— In open heart surgery, a serious complication that sometimes occurs is stenomediastinitis, an infection of the sternum and the soft tissues around the chest wall. Here is a clearer explanation of what this condition entails and how it is managed today.
– Stenomediastinitis is an inflammatory process that can progress to infection of the sternum and anterior chest structures. It may present as a localized sternum abscess or extend to involve the sternum, adjacent ribs, and surrounding soft tissues.
In modern practice, this complication most often follows open cardiac procedures where the sternum is divided midline to access the heart. For operations on other organs, such sternotomy is rarely required.
Statistics in current literature show that mortality associated with this complication can be significant, and reported rates have varied across regions and time periods. While official data from some countries may be limited, international experience indicates occurrences in a minority of post-cardiac surgery cases. In about one in five patients with stenomediastinitis, extensive sternum destruction is a potential challenge that requires aggressive, multidisciplinary care.
Why does this complication occur? A key factor is the natural movement of the chest during breathing, which can cause the sternotomy edges to separate slightly after surgery. This mobility, combined with the patient’s activity and the presence of postoperative inflammation, can allow bacteria to invade the wound. When the wound remains open or dehisces, infection can spread through the chest wall and bone, making recovery more difficult.
– How are patients treated when this complication arises?
– Traditional management typically begins with removing all sutures from the wound and performing thorough wound irrigation with antiseptics. Bacteriological cultures guide antibiotic selection, and treatment often lasts several weeks to months. After ensuring the wound is clean, a new reconstruction is performed using sterile grafts, followed by careful resuturing. Long-term immobilization of the chest and protection of the repair are essential. In some cases, recurrent breakdown of the sternum requires repeating the entire process.
If the infection is not adequately controlled, large portions of the anterior chest wall may become necrotic, necessitating debridement of nonviable tissue and careful wound care until healing occurs.
– Is there any possibility to fundamentally improve outcomes and reduce the risk of this complication?
– Advances in surgical technique and decisive early intervention have shifted the approach. At the first signs of trouble, surgeons may perform targeted debridement of infected bone and soft tissue, remove biofilm, and then restore the sternum with vascularized tissue flaps. These flaps can come from inside the chest wall or from the chest wall’s outer surface, providing a well-nourished bed for healing and delivering robust blood supply to deliver antibiotics directly to the infection site.
Compared with traditional methods, these biologically reinforced repairs can shorten hospital stays and lower recurrence rates. In some centers, the typical stay after sternum infection treatment has shrunk from about eight weeks to roughly three weeks, with fewer infectious episodes.
– What kinds of biological tissues are used to cover the wound?
– Several options exist. The omentum, a thick fatty apron from the abdomen, is sometimes mobilized to fill the chest defect. This requires careful dissection to mobilize tissue while preserving its blood supply. Nearby muscle flaps, such as pectoralis major or rectus abdominis, are commonly rotated into the chest to provide bulk and vascularity. In extreme cases, back muscles may be transposed to the anterior chest wall to achieve robust coverage. Each choice depends on the defect’s size and the patient’s overall condition.
– If the sternum is already severely compromised, what then?
– In advanced cases, partial or complete removal of the sternum may be necessary. The resulting space is then rebuilt using muscle flaps that gradually integrate and gain strength. Muscular tissue, with its rich blood supply, is particularly effective because antibiotics penetrate well to the infected site and the tissue can become fibrous over time, resembling a tendon-like structure that provides durable support.
— Are there any patient criteria or timing considerations for these procedures?
– Operability must be assessed carefully. After initial evaluation, 3 to 5 days are typically needed to identify the responsible bacteria and tailor antibiotic therapy accordingly. Empiric antibiotics are started based on regional patterns until culture results guide refinement. This targeted approach helps reduce relapse risk and supports faster recovery.
– Has the advent of less invasive techniques changed the incidence of stenomediastinitis?
– In some situations, endovascular approaches can avoid opening the chest, but they cannot replace open surgery in every case. For certain heart procedures, such as complex valve interventions or transplants, chest access remains necessary. The choice between methods depends on the cardiac condition, the extent of disease, and technical feasibility. Cost and overall risk also influence the decision, with endovascular options generally offering less trauma but not universally applicable.
– Hybrid approaches combining traditional and endovascular techniques have emerged. Are they more effective?
– Hybrid strategies, used in specialized centers, open new pathways for treating difficult arterial and cardiac conditions. They tend to be less invasive, with smaller incisions and quicker recoveries, though their superiority depends on patient selection and specific anatomy.
– There was mention of a risk-stratification tool for postoperative complications. How does that work?
– A recent program uses data analytics to predict which interventions are most likely to lead to complications in atherosclerosis patients. By entering patient information, clinicians obtain recommendations on the optimal sequence of treatments with the aim of minimizing adverse events. The tool is still under evaluation, but it represents a step toward more personalized surgical planning.
What are the goals for the next several years?
– The priorities include better logistics so patients with stenomediastinitis are not left without guidance and a clear framework for surgeons facing this complication. There is also ongoing interest in preventing infection by improving aseptic technique, optimizing tissue coverage strategies, and refining antibiotic stewardship in cardiovascular surgery.
– On a related front, there is attention to infections of artificial vessels connected during procedures. Bacteria can invade prosthetic walls and lead to serious sepsis. Though relatively uncommon, this complication remains a meaningful concern in modern cardiovascular care and underscores the need for vigilant infection control and timely intervention.