Tissue Saving Approach with Cold Atmospheric Plasma: Subject-Specific Strategy for a Critical Ill Patient with Deep Sternal Infection

Background: Deep sternal infection is still a life threatening complication following cardiac surgery. Current guidelines recommend radical debridement of the infected area with removal of the sternal wires and partial or complete resection of the sternum. Most of these patients are in need for plastic surgery afterwards. However short and long term results of this radical approach with regard to mortality and quality of life remain unsatisfactory. A tissue saving approach using cold atmospheric plasma and advanced negative pressure therapy (aNPWT) has already proven its ability in the management of sternal infection. Herein we report the case of a critically ill patient suffering from deep sternal infection in which radical resection of the sternum was avoided in favor of an individualized treatment strategy.

Method: A 69-year-old female patient referred for urgent mitral valve replacement. EuroSCORE II 15: EF 37%, NYHA Class III, previous myocardial infarction and RIVA stenting, pulmonary hypertension, severe COPD and impaired renal function. Minimal invasive mitral valve replacement was performed. Urgent resternotomy was mandatory due to acute bleeding on the day of operation. Secondary wound closure was done on the first postoperative day. Infection of the sternal wound occurred ten days later. Operative Debridement with application of aNPWT was necessary leaving the sternal wires in place. The first attempt after a treatment period of 24 days and an exchange of sternal wires for sternal plates failed. An avulsion of the lower sternal plate due to the ailing bone structure required again aNPWT treatment. Infection was caused by Candida albicans and Enterobacter cloacae. Application of cold plasma was performed during every change of the aNPWT dressing.

Results: Resection of the sternum was avoided. The upper sternal plate was removed on postoperative day 68 when the bony structure had already healed. Overall 15 operative procedures were required including the first failed attempt. Duration of wound treatment (initial debridement to final wound closure) was 127 days.

Conclusion: The treatment strategy in this case consisting of cold atmospheric plasma and aNPWT has the ability to control the infection process and maintain chest wall stability. Considering the results of the current literature on the open chest treatment this strategy may improve patient's outcome in terms of mortality and quality of life.

This tissue saving approach should be considered as an alternative pathway for critical ill patients suffering from sternal infection.

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Artikel online veröffentlicht:
03. Februar 2022