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ICVTS on-line discussion A Definitions of sternal wound complications

Mansoura University, Mansoura 35511, Egypt

Factors associated with deep sternal wound infection and haemorrhage following cardiac surgery in Victoria

eComment: I read with interest the article [1] and I am astonished by your effort to collect these data. However, I do have some comments. I) Definitions of sternal wound complications are as follows:- (1) Mediastinal dehiscence: median sternotomy wound breakdown in the absence of clinical or microbiologic evidence of infection. (2) Mediastinal wound infection: clinical or microbiologic evidence of infected presternal tissue and sternal osteomyelitis, with or without mediastinal sepsis and with or without unstable sternum. Subtypes include: (A) superficial wound infection: wound infection confined to the subcutaneous tissue; and (B) deep wound infection (mediastinitis): wound infection associated with sternal osteomyelitis with or without infected retrosternal space [2].

Deep sternal wound infections, or mediastinitis, is classified into four subtypes based on the time of the first presentation, the presence or absence of risk factors, and whether previous attempts at treating the condition have failed [3]. Type I: Mediastinitis presenting within 2 weeks after operation in the absence of risk factors. Risk factors identified in three or more major studies. Currently accepted incremental risk factors for mediastinitis are diabetes, obesity, and the requirement of immunosuppressive agents.

Type II: Mediastinitis presenting at 2 to 6 weeks after operation in the absence of risk factors.

Type IlIA: Mediastinitis type I in the presence of one or more risk factors.

Type IIIB: Mediastinitis type II in the presence of one or more risk factors.

Type IVA: Mediastinitis type I, II, or III after one failed therapeutic trial.

Failed therapeutic trial includes any surgical intervention with intent to treat mediastinitis.

Type IVB: Mediastinitis type I, II, or III after more than one failed therapeutic trial.

Type V: Mediastinitis presenting for the first time more than 6 weeks after operation.

II) I think that the collection of DSWI and haemorrhage following cardiac surgery in one article is not satisfactory as every one of them in regard to the risk factors should be titled as a separate one. III) I am not convinced of the results as regard to the case of urgent operations which was found not significant either with haemorrhage or DSWI. I think that urgent operations made it possible for both of them to happen.

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1. Robinson PJ, Billah B, Leder K, Reid CM. Factors associated with deep sternal wound infection and haemorrhage following cardiac surgery in Victoria. Interact CardioVasc Thorac Surg 2007; 6:167–171.[Abstract/Free Full Text]
2. Loop FD, Lytle BW, Cosgrove DM, Mahfood S, McHenry MC, Goormastic M, Stewart RW, Golding LA, Taylor PC. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity and cost of care. Ann Thorac Surg 1990; 49:179–186.[Abstract]

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