الفهرس 
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Abstract
Sternal wound infection (SWI) is an infrequent but potentially life threatening complication following cardiac surgery with increase morbidity, mortality and hospital stay . The overall reported incidence for SWI ranges from .9 % to 10%, and the incidence for deep sternal wound infection is 1% to 2% in most studies. The reported mortality ranges from 9.8 to 14% in different studies.
The risk factors for the development of sternal wound infection includes: preoperative risk factors as old age, the obesity ( BMI > 30 kg/m2), NYHA class >3 , recent MI, diabetes, COPD, smoking, peripheral arterial disease. Intraoperative risk factors as use of bilateral mammary arteries, long operative time, long duration of cardiopulmonary bypass, use of intraaortic balloon pump counterpulsation. Postoperative risk factors as longer mechanical ventilation times, more blood loss in intensive care unit (ICU) and re-explorations for bleeding.
Sternal wound infection can be divided into superficial infections and deep sternal wound infection. superficial sternal wound infection is infection that involves skin and subcutaneous tissues . Deep sternal wound infections (DSWIs) or mediastinitis is wound infection associated with sternal osteomyelitis with or without retrosternal space affection .DSWIs is classified into four subtypes. Type I, mediastinitis presenting within 2 weeks after operation in absence of risk factors. Type II, mediastinitis presenting within 2 to 6 weeks after operation in absence of risk factors. Type IIIa, mediastinitis type I in presence of one or more risk factors. Type IIIb, mediastinitis type II in presence of one or more risk factors. Type IVa,
mediastinitis type I, II or III after one failed therapeutic trial. Type IVb, mediastinitis type I, II or III after failed more than one therapeutic trial.
The treatment of SWI remains controversial. These include, conservative treatment with antibiotic therapy, surgical debridement and open packing or closed suction and irrigation systems. Other surgical options includes radical debridement and closure of defect with pedicle omental transposition , pectoral muscle flap or other muscle flap.
Vacuum-assisted closure therapy is a novel treatment employed to aid wound healing in different areas of the body and recently also in sternal wound infection after cardiac surgeries. The purpose of this study is to evaluate the effectiveness and clinical outcome of VAC therapy in the treatment of sternal wound infections as either a sole therapy or as a bridge for other reconstructive procedure.
By maintaining a moist environment, this therapy stimulates granulation-tissue formation in combination with an increased blood flow in the adjacent tissue . Furthermore, VAC therapy approximates the wound edges and provides a mass filling effect with a low degree of surgical trauma. Finally, due to sternal stabilization and wound isolation, patients can be mobilized early and receive physiotherapy in order to minimize further complications.
Our study was conducted upon 30 patients who developed either superficial or deep sternal wound infection after cardiac surgeries. These patients were treated with VAC therapy as a sole therapy or as a bridge for other reconstructive procedure. This study done from March 2013 until February 2016, at Nasr City insurance hospital in Cairo.
The mean age of the patients was 60.8 years. , 16 patients were males (53%) and 14 patients were females (47%). 24 patients had ischemic heart disease with percentage (80%), 16 patients were diabetics with percentage of (53.33%), 13 patients were hypertensive with percentage (43.33%), 10 patients had COPD with percentage (33.33%), 21 patients had BMI > 30 with percentage (70%), prolonged ICU stay was present in 13 patients with (43.33 %) and re-exploration to control bleeding occurred in 7 patients (23.3%)
The mean duration of VAC therapy was 12.7 days ± 6.26 days (SD) and range (4 _ 27 days). The mean length of hospital stay was 27 days ± 9.32 days (SD) and range (14 _ 65 days).Twenty nine patients (95 %) were treated successfully. Hospital mortality was one patient (3.33 %) due to septic shock and multiple organ failure. At the end of the duration of VAC therapy, the mean percentage in reduction of wound size was 34.3 % ± 12.2 (SD). The mean percentage in granulation tissue formation was 64 % ± 18.68 (SD). VAC therapy was used as definitive therapy in 63.33% also as a bridge to conventional methods in 33.3%.
With VAC therapy freedom from sternal wound microbiological cultures was achieved early, C-reactive protein level declined rapidly, in-hospital stay was short, sternal closure was achieved early and long-term survival tended to be high.
VAC therapy markedly reduced required surgical intervention and reoperations for persistent infections, even in the group of high-risk patients. Traditionally, timing of the following surgical closure is based on the appearance of the wound, negativity of wound cultures and general patient condition.
Vacuum assisted closure therapy is a safe, reliable and a relatively new option for treatment of devastating sternal wound infection after cardiac surgery. It is important to find a strategy which may be used as a ”standard VAC therapy approach” if identified in the future. Finally, we conclude that VAC therapy should be considered as a first-line treatment for most SWI.