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)