Abstract
Early recognition and, where possible, avoidance of risk factors that contribute to the development of poststernotomy mediastinitis (PSM) form the basis for successful prevention. Once the presence of PSM is diagnosed, the known risk factors have been shown to have limited influence on management decisions. Evidence-based knowledge on treatment decisions, which include the extent and type of surgical intervention (other than debridement), timing and others is available but has not yet been incorporated into a classification on management decisions regarding PSM. Ours is a first attempt at developing a classification system for management of PSM, taking the various evidence-based reconstructive options into consideration. The classification is simple to introduce (there are four Types) and relies on the careful establishment of two variables (sternal stability and sternal bone viability and stock) prior to deciding on the best available reconstructive option. It should allow better insight into why treatment decisions fail or have to be altered and will allow better comparison of treatment outcomes between various institutions.
Highlights
Poststernotomy mediastinitis (PSM) is still one of the most complex and costly infectious processes to treat
Classification of the studies found As a result most studies were categorized as class II per procedure, while procedures for which no evidence existed were discarded
This study shows that, by careful application of the rating scheme recommended by the respected Society of Thoracic Surgeons (STS) workforce on Evidence-based Medicine (EBM), none of the current reconstructive options, with a few exceptions, available to the surgical team reaches a level of evidence higher than B
Summary
Poststernotomy mediastinitis (PSM) is still one of the most complex and costly infectious processes to treat. Data procured from 8 of the 16 centers from 2002 to 2007 revealed a cumulative incidence for surgical site sternal wound infection of 2.4% (95% confidence interval [CI], 1.9 to 3.1) following coronary artery bypass grafting (CABG) [2]. This figure rose to 3.2% (95% CI, 2.0 to 5.1) where CABG was combined. Even if the patient survives, the long-term mortality rate is significantly higher. In a 10-year follow-up study after CABG [5], the adjusted survival rate was 39% for patients who had suffered from PSM compared with 70% who did not. The study by Graf and colleagues [4] confirmed the findings of an earlier study from Uppsala, Sweden [6], with a similar length of follow-up
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