PROSPECTIVE TRIAL OF CATHETER IRRIGATION AND MUSCLE FLAPS FOR STERNALWOUND-INFECTION

Background. Sternal wound infection is a relatively rare but potential ly devastating complication of open heart operations. The most common treatments after debridement are rewiring with antibiotic irrigation a nd muscle flaps. Here we present the results of a prospective trial to determine the appropriate roles of closed-chest catheter irrigation a nd muscle flap closure for sternotomy infection and to assess the effe ct of internal mammary artery bypass grafting on the outcome of each t reatment modality. Methods. Between 1990 and 1994, 5,658 sternotomies were performed at the University of Washington Medical Center. Sternal dehiscence occurred in 43 patients, 25 of whom had infection (overall incidence, 0.44%). Because of the infrequency of this complication, a prospective, randomized trial was developed in which the initial appr oach to sternal dehiscence was rewiring and catheter irrigation. Muscl e flaps were used as the primary treatment if the sternum could not be restabilized or as secondary treatment if catheter irrigation failed. Wound resolution, length of hospital stay, and complications were eva luated. Results. Sterile dehiscences were successfully closed with irr igation in 17 of 18 patients; the other patient required flap closure. Of the 25 patients with infection, 19 had irrigation and 6, closure w ith flaps primarily. In the group of infected patients, 17 of the 19 w ho received irrigation also had internal mammary artery bypass graftin g. Irrigation failed in 15 (88.2%) of these 17 patients, and salvage w as accomplished with muscle flap closure. All 6 patients with infectio n who were closed primarily with muscle flaps had a successful outcome . Hospitalization averaged 10.2 days when muscle flaps were used prima rily and 14.3 additional days for unsuccessful irrigation. When irriga tion was successful, the hospital stay averaged 11.2 days. Conclusions . Catheter irrigation should be reserved for patients without infectio n or patients with infection but without internal mammary artery bypas s grafts in whom dehiscence occurs less than 1 month after sternotomy. All others should have closure with muscle flaps. (C) 1998 by The Soc iety of Thoracic Surgeons.