A technique for the treatment of sternal infections using the Vacuum Assisted Closure™ device

Background: Sternal infections after median sternotomy remain a serious cause of postoperative morbidity and mortality. The treatment of sternal infections has evolved over the past few decades, and now aggressive surgical debridement with rotational muscle flap closure has provided an acceptable means of managing this complication. However, there are several disadvantages with this approach, mainly related to the morbidity associated with serial debridements with dressing changes and open packing until the wound is closed. Other disadvantages include potential morbidity and mortality associated with the shearing forces between the beating heart and the debrided sternal edges, and the need to paralyze the patient during the period after debridement. Methods: Our method of managing sternal infections is based on the triad of prompt surgical debridement, serial quantitative wound cultures, and the use of the Vacuum Assisted Closure™ (VAC) device (KCI International, San Antonio, TX). Following debridement and irrigation, a biopsy of the healthy appearing bone is sent for quantitative culture. If culture results are favorable, the wound is then fitted with the VAC™ device, which consists of a non-collapsible, open-cell, polyurethane sponge with embedded vacuum tubing, a vacuum pump, and transparent adhesive dressing. When systemic signs of infection and quantitative cultures indicate the resolution of the local infection, regional muscle flap or primary wound closure is performed. Conclusions: The VAC™ serves as a bridge to sternal wound closure and is a safe and effective therapeutic strategy for patients with impaired physiologic reserve and/or highly contaminated wounds. We feel that it is also reasonable to consider the VAC™ as a preventive strategy against right ventricular rupture. Furthermore, because the firmness of the vacuum sponge apparatus acts as an impressive sternal stabilizer, post-debridement extubation is possible, reducing the need for prolonged paralysis and mechanical ventilation. This stabilization also allows early postoperative ambulation with the VAC™ in place. In summary, we believe that the VAC™ device offers an effective means of managing patients with sternal infections.