Comparative evaluation of the continuous and intermittent modes of vacuum therapy for the management of deep sternal wound infection after cardiac surgery

Purpose of the study – evaluate the immediate and midterm results of treatment of DSWI with vacuum drainage with intermittent and continuous modes in comparison to the open method of wound management.

Material and methods. We collect data for patient with vacuum therapy in prospectively. Data about patient with open wound management were obtained retrospectively. Study was non-randomized. Level of evidence – II. The patients were divided into the following clinical groups: 1st – vacuum drainage with intermittent mode (13 patients), 2nd – vacuum drainage in constant mode (14 patients), 3rd – open wound care as reference group (30 patients). There were 38 (66.7%) males and 19 (33.3%) females. The average age of patients was 63.2±7.8 years. The proportion of patients with diabetes mellitus was: 8 (57%) in clinical 1st group, 5 (38.5%) in 2nd group, and 8 (26.6%) in 3rd group.

Results. The time from the start of DSWI treatment to the healing of the post sternotomy wound in 1st group was 25.4±11.3 days; in 2nd group – 77.9±53.4 days; in 3rd group – 37.5±20 (p=0.004). Time from the start of treatment to the bacterial cleansing of the wound: 1st group – 11.9± 5.6 days; 2nd group – 28.8±20.1 and 3rd group – 29.9±17.4 days (p<0.05). Freedom from late complications (relapses/formation of chronic chest wall fistulas/development of chronic osteomyelitis of the sternum and ribs): 1st group – 100% (n=14), 2nd group – 85% (n=12) and 3rd group – 67% (n=20) (p=0.037). The case of a lethal outcome was noted only once in the constant vacuum group (II) and was not associated with complications of vacuum therapy (p<0.218). Dynamics of the level of leukocytosis: 1st group – from 15.3±2.8×109 (day of diagnosis) to 7.8±0.6×109 (30th days of treatment); 2nd group – from 12.6±3.8×109 to 9.8±2.7×109; 3rd group – from 10.7±2.8×109 to 7.7± 2.2 ×109 (p=0.197). ESR dynamics: 1st group – from 23.7±9.7 (day of diagnosis) to 22.8±15.8 mm/h (20th days of treatment); 2nd group – from 37.2±17.2 to 31.7±15.2 mm/h; 3rd group – from 41.8± 8.9 to 34.6±16.5 mm/h (p=0.197). Histologically 1st group was characterized by the lowest degree of intercellular edema and a higher growth rate of granulation tissue.

Conclusion. Vacuum therapy with intermittent mode reveal better clinical result in our study. Intermittent vacuum therapy application allows to achieve wound negative bacterial culture earlier. Provide faster wound closure. This mode of vacuum therapy minimizes risk of osteomyelitis and fistula formation and provide shortest hospitalization time.

2. Suntsov Yu.I., Bolotskaya L.L., Maslova O.V., et al. Epidemiology of diabetes mellitus and forecast of its distribution in Russian Federation. Sakharnyy diabet [Diabe- tes]. 2011; (1): 15–8. (in Russian)

3. Milano C.A., Kesler K., Archibald N., et al. Me- diastinitis after coronary artery bypass graft surgery. Risk factors and long term survival. Circulation. 1995; 92: 2245–51.

4. Loop F.D., Lytle B.W., Cosgrove D.M., et al. J. Maxwell Chamberlain memorial paper. Sternal wound complication after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg. 1990; 49: 179–86.

5. Holenbeak C.S., Murphy D.M., Koeng S., et al. The clinical and economic impact of deep chest surgical site infections following coronary artery bypass graft surgery. Chest. 2000; 118: 397–402.

6. Eklund A.M., Lyytikainen O., Klemets P., et al. Mediastinitis after more than 10,000 cardiac surgery procedures. Ann Thorac Surg. 2006; 82: 1784–9.

7. Crabtee T.D., Codd J.E., Fraser V.J., et al. Multivariate analysis of risk factors of deep and superficial sternal infection after coronary artery bypass grafting at a tertiary care medical center. Semin Thorac Cardiovasc Surg. 2004; 16: 53–61.

8. Braxton J.H., Marrin C.A., McGrath P.D., et al. Me- diastinitis and long-term survival after coronary artery bypass graft surgery. Ann Thorac Surg. 2000; 70: 2004–7.

9. Sjogren J., Malmsjo M., Gustafsson R., et al. Post-sternotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm. Eur J Cardiothorac Surg. 2006; 30: 898– 905.

10. Furgal A.A., Schava S.P., Kapustin M.A., Pol- kina L.N., Silaev A.A., Sorokin V.A. The use of vacuum therapy in the treatment of post-surgery sternomediastinitis: the first practice. Pacific Medical Journal. 2017; 2: 77–9. (in Russian)

11. Morykwas M.J., Argenta L.C., Shelton-Brown E.I., et al. Vacuumassisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg. 1997; 38: 553–62.

12. Damiani G., Pinnareli L., Sommella L., et al. Vacuum-assisted closure therapy for patients with infected sternal wounds: a meta-analysis of current evidence. J Plast Reconstr Aesthet Surg. 2011; 64: 1119–23.

13. De Feo M., Vicchio M., Sante P., et al. Evoution in the treatment of mediastinitis: single-center experience. Asian Cardiovasc Thorac Ann. 2011; 19: 29–43.

14. Steingrimsson S., Gottfredsson M., Gudmundsdottir I., et al. Negative-pressure wound therapy for deep sternal wound infections reduces the rate of surgical interventions for early re-infections. Interact CardioVasc Thorac Surg. 2012; 15: 17–21.

15. Vos R.J., Yilmaz A., Sonker Y., et al. Vacuum-assisted closure of post-sternotomy mediastinitis as compare to open packing. Interact CardioVasc Thorac Surg. 2012; 14: 17–21.

16. De Feo M., Della Corte A., Vicchio M., et al. Is post-sternotomy mediastinitis stil devastating after the advent of negative-pressure wound therapy? Tex Heart Inst J. 2011; 38: 375–80.

17. Petzina R., Hoffmann J., Navasardyan A., et al. Negative pressure wound therapy for post-sternotomy mediastinitis reduces mortality rate and sternal re-infection rate compared to conventional treatment . Eur J Cardiothorac Surg. 2010; 38: 110–3.

18. De Feo M., Vicchio M., Nappi G., et al. Role of vacuum in methicillin-resistant deep sternal wound infection. Asian Cardiovasc Thorac Ann. 2010. Vol. 18. P. 360–363.

19. Furgal A.A., Reva I.V., Reva G.V., Sorokin V.A., Garmash R.A., Garmash A.I., Kupatadze D.D., Odintsova I.A., Verin V.K. Vakuumnoye drenirovaniye pri provedenii posleoperatsionnykh sternomediastinitov v kardiokhirurgii // Sovremennyye problemy nauki i obrazovaniya. 2018; 6. URL: http://www.science-education.ru/ru/article/view?id=28381. (in Russian)

20. Anger J., Dantas D.C., Arnori R.T., et al. A new classification of poststernotomy dehiscence. Rev Bras Cir Cardiovasc. 2015; 30: 114–8.

21. Meszaros K., Fuehrer U., Grogg S., et al. Risk factors for sternal wound infection after open heart operations vary according to type of operation. Ann Thorac. Surg. 2016; 101: 1418–25.

22. Wackenfors A., Gustafsson R., Sjögren J. et al. Blood flow responses in the peristernal thoracic wall during vacuum-assisted closure therapy. Ann Thorac Surg. 2005; 79 (5): 1724–30.