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Treatment of Mediastinitis by Ventrofil PlatesWithout Sternal RewiringAndrea Galanti, MD, Michele Triggiani, MD, PhD, Giordano Tasca, MD,Antonello Stefano Martino, MD, Floriana Giannico, MD, Pierfranco Ravizza, MD,Pietro Carboni, MD, and Amando Gamba, MDCardiac Surgery Unit, Cardiac Rehabilitation Unit, and Cardiac Intensive Care and Anesthesiology Unit, Cardiovascular Department,Manzoni Hospital, Lecco, Italy

Mediastinitis is a serious complication of cardiac surgicalprocedures, with high rates of morbidity and mortality.We describe a new simple surgical technique to treatdeep sternal infection based on the removal of all wiresand deep sutures, and reapproximation of the sternumwith four external plates without rewiring. Fourteen pa-tients were treated with this technique. No complications

Accepted for publication Sept 5, 2013.

Address correspondence to Dr Galanti, Via dell’Eremo 9/11-23900, Lecco,Italy; e-mail: a.galanti@ospedale.lecco.it.

� 2014 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

related to the procedure occurred, the infection was suc-cessfully treated in all patients, and only 1 patient un-derwent vacuum treatment to obtain healing of thewound.

(Ann Thorac Surg 2014;97:1816–8)� 2014 by The Society of Thoracic Surgeons

oststernotomy mediastinitis has a reported incidence

Pof 1% to 3% [1–3] and a morbidity/mortality rate of10% to 35% [4, 5], with a significant impact on hospitallength of stay and on cost of care. The established treat-ment is a combination of debridement, packing, delayedclosure, plastic reconstruction, rewiring, irrigation, andapplication of negative pressure, together with antibiotictherapy depending on the severity of the infection [6].

To reduce the invasiveness and complexity of thesetreatments, we have introduced a simple technique totreat deep sternal wound infection. The peculiarity ofthis technique is the approximation of the sternumby application of four external plates (Ventrofil sutureset, Aesculap Braun, Tuttlingen,Germany) after theremoval of all sternal wires and deep sutures to promotea favorable condition for the eradication of infection. Itshould be emphasized that once the plates are removed,no foreign materials remains under the skin.

Technique

From January 2010 to February 2013, 14 of 1,427 patients(1%; mean age, 72 years; range, 52 to 88 years) who un-derwent cardiac surgical procedures returned with deepsternal wound infection, as defined by the US Center forDisease Control and Prevention [7]. Mediastinitisoccurred within 60 days after operation (coronary arterybypass grafting [CABG] in 9/14 patients, aortic valvereplacement in 2/14 patients, mitral valve replacement in1/14 patients, aortic valve replacement associated withCABG in 1/14 patients, mitral repair and CABG in 1/14

patients). The microorganisms isolated were Staphylo-coccus aureus (7/14 patients, 50%), Staphylococcus epi-dermidis (6/14 patients, 43%), and Enterococcus faecalis(1/14 patients, 7%). Once the mediastinitis was diagnosed,the patients were treated with targeted antibiotic therapy,and only after 2 to 3 days were subjected to intervention.Postoperative pain was assessed three times a day duringthe first 4 days after operation by the visual analogue painscale (VAS).The scale ranged from 0 (no pain) to 10(maximum pain imaginable). In the first postoperativeday, patients were treated with paracetamol 1,000 mgthree times a day; thereafter, paracetamol was given ondemand if the VAS score was 5 or greater.Ventrofil is a suture set for the treatment and preven-

tion of wound dehiscence and for relief of strain onexisting wounds, generally used in abdominal surgicalprocedures. Every set is composed of two polyethyleneplates and one twisted stainless steel thread (90 cm long)with a large needle at either end (Fig 1). These retentionsutures, as far as we are concerned, are the only onestotally removable; strength and tension are applied a fewcentimeters far from the scar, preventing ischemia of thesubcutaneous tissue necessary to heal the wound.In the operating room, wires and all sutures are

removed, and extensive debridement of the sternumand soft tissues is performed immediately before theapplication to the skin of four Ventrofil plates, two oneither side of the wound, 4 to 5 centimeters away fromthe margin. The large needle should go deeply into thesubcutaneous tissue without entering the sternum; thethread fixes the plates to the skin thanks to specificindentation. (Fig 2). A small suction drain is positionedunder the suture. To obtain reapproximation of thesternal edges and subcutaneous tissue, the plates aregently approached by knotting the thick thread. To avoidischemia of the skin, this suture should not be tied too

0003-4975/$36.00http://dx.doi.org/10.1016/j.athoracsur.2013.09.043

Fig 1. Ventrofil set.

Fig 3. Procedure completed.

1817Ann Thorac Surg HOW TO DO IT GALANTI ET AL2014;97:1816–8 MEDIASTINITIS TREATED BY VENTROFIL

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tight. The skin is sutured with removable intradermalsuture (Fig 3). The entire procedure takes no more than30 minutes and, if the patient is not in a critical condi-tion, is performed with the patient in deep sedationwith a laryngeal mask. The drain is removed 24 to 48hours later. Antibiotic therapy is continued at least untilthe removal of the plates. Once the plates and the su-tures are removed, no foreign material remains underthe skin.

We did not observe adverse events in terms of organdamage or major bleeding related to the procedure. Theplates have been removed after a mean time of 17 days(range, 14 to 21 days). The mean length of hospital staywas 24 days (range, 15 to 34 days). The sternal woundshealed successfully (skin integrity, no sternal instability)in all patients but 1, in whom superficial dehiscence of theskin extended for less than 5 centimeters of the woundlength, related to rupture of the intradermal suture. Thispatient was discharged home 20 days after the operation,and the wound healed completely within 2 months withvacuum therapy. The sternal wound healed successfully

Fig 2. Application of four Ventrofil plates.

even in a very frail 85-year-old woman, but she died 34days after the procedure because of sequelae of acuterenal failure. The VAS rates scored from 1 to 5 (meanscore, 2.7). In particular, postprocedural pain was neversevere enough to disturb easy breathing and movementin any way. The 3-month follow-up examination revealedno fistulas or recurrent deep sternal wound infections.Three of 14 patients underwent computed tomographyscan 3, 21, and 22 months after operation, revealing goodcontact of the sternal edges and partial ossification ofthe sternal fracture in the patient with the shortestfollow-up time (Fig 4), and total ossification in the other 2patients (Fig 5).

Comment

The original technique described here seems to offer asafe and effective alternative treatment for mediastinitis,easily reproducible, with several potential advantages: (1)it is not technically demanding; (2) an intensive care unitstay is unnecessary; (3) once the plates and sutures areremoved, no foreign material is left under the skin (wehypothesize that this aspect is crucial to the treatment ofdeep sternal infections); and (4) early mobilization of thepatient is possible.

Fig 4. Computed tomographic scan early after correction.

Fig 5. (A) Computed tomographic scan of apatient 21 months after operation. (B)Computed tomographic scan of a patient 22months after operation.

1818 HOW TO DO IT GALANTI ET AL Ann Thorac SurgMEDIASTINITIS TREATED BY VENTROFIL 2014;97:1816–8

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We wonder whether fracture healing occurs throughnormal ossification or with sternal gaps covered by softtissue. In effect, we have observed good sternal stability inall patients, and mild sternal instability occurred in only afew cases in the immediate postoperative period buttended to disappear. This tendency toward normal heal-ing over time is also suggested by the results of computedtomography.

A limitation of this technique is that it is hard toperform in patients with a large amount of tissuedestruction. For this reason, we suggest early treatment,after only 2 or 3 days of antibiotic therapy. Thanks to thesternal stability, all patients experienced only mild pain,in a similar way to that observed after conventionalsternal wiring, and no impairment of respiratory functionwas observed. We removed the plates after a mean timeof 17 days (range, 14 to 21 days), but we suggest removalafter 3 weeks to ensure sternal stability and a goodhealing process.

In conclusion, the results of this experience seemencouraging. We believe that this new surgicaltechnique could be considered a reasonable alternative tothe current treatment of mediastinitis.

References

1. Ridderstolpe L, Gill H, Granfeldt H, Ahlfeldt H, Rutberg H.Superficial and deep sternal wound complication: incidence, riskfactors and mortality. Eur J Cardiothorac Surg 2001;20:1168–75.

2. Lu JC, Graysone AD, Jha P, Srinivasan AK, Fabri BM. Riskfactors for sternal wound infection and mid-term survivalfollowing coronary artery bypass surgery. Eur J CardiothoracSurg 2003;23:943–9.

3. Stahle E, Tammelin A, Bergstrom R, Hambreus A,Nystrom SO, Hansson HE. Sternal wound complication:incidence, microbiology and risk factors. Eur J CardiothoracSurg 1997;11:1146–53.

4. Milano CA, Kesler K, Archibald N, Sexton DJ, Jones RH.Mediastinitis after coronary artery bypass graft surgery: riskfactors and long-term survival. Circulation 1995;92:2245–51.

5. Borger MA, Rao V, Wiesel RD, et al. Deep sternal wound infec-tion: risk factors and outcomes. Ann Thorac Surg 1998;65:1050–6.

6. Sj€ogren J, Malmsj€o M, Gustafsson R, Ingemansson R. Post-sternotomy mediastinitis: a review of conventional surgicaltreatments, vacuum assisted closure therapy and presentationof the Lund University Hospital mediastinitis algorithm. Eur JCardiothorac Surg 2006;30:898–905.

7. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR.Guideline for Prevention of Surgical Site Infection, 1999.Centers for Disease Control And Prevention (CDC) HospitalInfection Control Practices Advisory Committee. Am J InfectControl 1999;27:97–132.