The median sternotomy has long been the preferred approach for cardiac surgery since it was first described in 1957.¹ Sternal wound infection is a known complication of this approach. These infections are often difficult to treat as they invariably lead to dehiscence and may result in cardiac exposure.
In the past 45 years, treatment of sternal wound infections has evolved from debridement with open granulation, to rewiring with closed catheter irrigation, and finally to flap reconstruction. Omental flaps, rectus advancement flaps, and pectoralis advancement flaps have all been used to close these defects, usually with either a 1-stage or 2-stage procedure.^2,3 As the treatment of sternal wound infections evolved, it is generally regarded that a 1-stage operation with pectoralis advancement flap carries the lowest morbidity and is associated with the shortest hospital stay.^2–5
Much has been written about the risk factors associated with morbidity and mortality in patients undergoing flap reconstruction for sternal wound infection. Though some of these studies vary in their results, most experts agree that advanced infection with the presence of systemic infection denotes a poor prognosis. Most clinicians agree that early diagnosis with aggressive antibiotic therapy, debridement, and reconstruction are essential to mortality reduction.^2–7

Methods

All patients who underwent bilateral pectoralis flap reconstruction (BPF) from 1996–2004 were identified using the Birmingham, Alabama Veterans Affairs Hospital OR database. A similar database was used at the University of Alabama, Birmingham Hospital to identify patients who underwent the pectoralis advancement flap procedure. Data were obtained through electronic chart review and analyzed with respect to patient demographics, operation, reconstruction, risk factors, and outcome.
The UAB cohort group was comprised all patients at UAB who underwent flap reconstruction for sternal wound infection from 1996 to 2004 (n = 93). All female, organ transplant, pediatric, aortic dissection, and unilateral pectoralis flap patients, as well as those who had undergone their third or fourth sternotomy were excluded. This resulted in 2, all-male cohort groups who had been treated with bilateral pectoralis flap reconstruction for sternal wound infection. All patients’ wounds were from either primary or secondary coronary artery bypass graft surgery (CABG), with or without valve replacement. The same surgeons at both centers performed the cardiac and reconstructive procedures. The UAB group contained 29 patients and the VA group 21 patients.
Age describes age at the time of operation and lab values were within 5 days of reconstruction. Other details regarding operative complications, pre-reconstruction debridement, and cause of death are outlined in Tables 1–4. Mortality was defined as any death that occurred during the same admission as the reconstruction operation or a death that occurred as the direct result of a postoperative infection or complication.
Data were collected with the approval of the BVA institutional review board and the UAB institutional review board. Fisher’s exact test with 2-sided P values was used to determine odds ratios and P values. For value data, an unpaired t-test with a 2-tailed P value was used.