Treatment of mediastinitis following cardiac surgery-still in discussion.

Dear Editor,

it is a pleasure for me to comment on Doctor Gursoy’s Letter to the Editor.

Osteosynthesis, whichever method you chose (plates, screws, pins, compression systems and all the other orthopedic paraphernalia) have not shown superiority but add further trauma to the patient  [1].

We do follow another approach. A therapeutic algorithm including debridement, vacuum assisted closure therapy and subsequent myoplastic reconstruction if necessary is recommended [2,3,4]. In our opinion it is important to get rid of all foreign material while the infection is still ongoing. Doctor Gursoy describes a radical debridement before performing the titanium plasty in combination with antibiotics and VAC Therapy meaning he operates in an area still contaminated where foreign material should be avoided.

In the presence of suitable local tissue, most of the sternal infections can be reconstructed with these. In the majority of cases with a bilateral M. pectoralis flap with or without desinseration at the humerus [5]. This is with no doubt a more beneficial procedure compared to synthetic material. The muscle plasty will guarantee a firm tissue layer and stable conditions. The complication rate concerning flap plasties Dr. Gursoy mentioned is not high when performed by an experienced and skilled surgeon [2,5]. It goes without saying that performing an osteosynthesis has its own complications. If an osteosynthesis is performed the pectoralis muscles have to be removed on both sides carefully to cover the devices.

So it should not be a problem to create a pectoralis plasty. It could be done in an interdisciplinary approach with a plastic surgeon. This cooperation is also applicable to procedures such as the omental- or latissimus dorsi flaps [2].

The literature Dr. Gursoy mentioned is not suitable to promote osteosynthesis:

Voss et al reports of one series of 6 patients in which a transverse plate fixation was used. In three patients the device had to be removed due respiratory discomfort, one patient died.

Sahin et al published a case report on this topic. No universally validity can be postulated.

Mitra et al did not use this system in cases of infection and mediastinitis, but in the primary closure of expected complicated sterna.

It might be an option in special individual cases, but surely not for the majority of patients suffering from mediastinitis.

What is the experience of Doctor Gursoy with this technique described by him, how many patients did he operate on, what are his results and follow up?

Best wishes

Ina Carolin Ennker, MD, PhD