1Division of Cardiac Surgery, Department of
Surgery, University of Virginia, Charlottesville, VA
Disclosures: The authors have nothing to disclose
Word Count: 463
Data Availability Statement: This invited commentary does not include
any original data.
Funding Statement: This work was supported by a research grant from
NHLBI/NIH (T32HL007849). The content is solely the responsibility of the
authors and does not represent the official views of the National
Institutes of Health.
Conflict of Interest: none
IRB approval and informed consent: N/A
Corresponding Author:
Irving L. Kron, MD
Division of Thoracic and Cardiovascular Surgery
Department of Surgery
1215 Lee St., PO Box 800679
Charlottesville, VA 22908
Email: ILK@virginia.edu
Running Head:
Congenital Sternal Wounds
Abstract:
Some would argue that kids aren’t just little adults, but what about
their sternums? We are reviewing a manuscript by Horriat, McCandless,
and colleagues in the Journal of Cardiac
Surgery 1 describing their experience with managing
sternal wound infections (SWI) after congenital heart surgery. They
report encouraging results in 14 patients who required plastic surgery
consultation to manage their sternal wounds. The nature of congenital
cardiac abnormalities and the necessary steps to repair them leads to
physiologic derangements predisposing patients to SWI. Rates of SWI vary
and have been reported at 1.53% in this population. There is little
guidance on how the management of the congenital cardiac surgery patient
should differ from the adult patient.2
Commentary:
In this month’s Journal, Horriat, McCandless, and co-authors
present their outcomes in the management of SWI in congenital cardiac
surgery patients. 14 patients were evaluated and treated by their team.
The authors clearly describe their approach to the management of these
wounds as well as the demographics of their patients. They appear to
have favorable outcomes within the limitations of this limited case
series. In addition to several immediate SWIs, the authors successfully
managed several late SWIs, one at 133 days and another at 574 days. We
are interested in whether the authors modify their management in the
case of these delayed/chronic wounds.
We (Figure 1) commend the authors for their excellent outcomes. SWI is a
challenging problem, and the authors highlight some factors they
consider when approaching closure. Their step-wise approach to the
management of these wounds is clear and logical. We are interested in
how the authors decide which pedicled flap to use. The delicate nature
of the pectoralis major muscle is described in the manuscript, although
it is still the primary tissue used for closure. Is it a case of the
best of several poor options? The authors indicate they routinely use
incisional wound VAC therapy, which has strong support in literature for
adult sternal wounds and has been shown to be feasible in the pediatric
population.3,4 In the case described in their figure
2, the authors describe how a patient with sternal instability required
the wires to be left in place. This challenging situation required
interval wound VAC prior to reconstruction and despite best efforts
developed osteomyelitis, requiring prolonged IV
antibiotics.1
There may be benefits in continuous glucose monitoring and in sending
mediastinal wound cultures at the time of closure, but there is a lack
of consensus on how to manage SWI once they develop.2This manuscript and the cases described within illustrate the importance
of a multidisciplinary approach to these complicated wounds. From
critical care, to reconstruction, to wound care, to antibiotics, a team
approach is needed. We appreciate the authors’ description of their
processes and methods and wish them continued success.
References:
1. Narges L. Horriat MD, *Martin G. McCandless BS, Laura S. Humphries
MD, Mohammed Ghanamah MD, Brian E. Kogon MD, and Ian C. Hoppe.
Management of Pediatric Sternal Wounds following Congenital Heart
Surgery: The Role of the Plastic Surgeon in Debridement and Closure.Journal of Cardiac Surgery .
2. Woodward CS, Son M, Calhoon J, Michalek J, Husain SA. Sternal wound
infections in pediatric congenital cardiac surgery: a survey of
incidence and preventative practice. Ann Thorac Surg .
2011;91(3):799-804.
3. Song DH, Wu LC, Lohman RF, Gottlieb LJ, Franczyk M. Vacuum assisted
closure for the treatment of sternal wounds: the bridge between
débridement and definitive closure. Plast Reconstr Surg .
2003;111(1):92-97.
4. Costello JP, Amling JK, Emerson DA, et al. Negative pressure wound
therapy for sternal wound infections following congenital heart surgery.J Wound Care . 2014;23(1):31-36.
Figure:
Legend: Andrew M. Young, MD (left), Anthony Norman, MD (center) and
Irving L. Kron, MD (right)