Chasing Full Recovery
Overcoming an adamant problem after Coronary
Artery Bypass Grafting
A 56-year old diabetic man had undergone Coronary Artery Bypass
Grafting (CABG) with Left Internal Mammary Artery (LIMA). After
being released from hospital the patient reported back on day 14 with
history of pus discharge from the sternal suture line. He was readmitted
under CTVS care at another hospital where initial debridement and
sternal resuturing was done. The patient subsequently developed
sternal osteomyelitis and was taken up for debridement where the
entire sternum was excised and bilateral pectoralis fl aps were used
for closure of the defect over the drains.
The patient did well post-operatively and was discharged after 10
days post-surgery and almost 8 weeks post CABG. However, the
patient again reported having breakdown of the wound leading to pus
discharge and was shifted to Department of Plastic and Reconstructive
Surgery at Nanavati for further treatment.
On admission, the patient was reviewed by a team of various
specialists including CTVS, Intensivist, Physician and Microbiologist.
The patient had a large gap at the lower end of the sternum with necrosis
of skin, soft tissue and muscle at the lower end with a large tunnel
between the upper overlying skin and underlying pericardium. Cultures
showed klebsiella sensitive to colistin and a rare fungus, candida famata.
Candida famata (also known as debaryomyces hansenii and torulopsis
candida) is a commensal yeast found in cheese, dairy products and the
environment and accounts for 0.2%-2% of invasive candidiasis.
The patient was again at high risk as he had a single kidney. He was
started on colistin, voricanozole and micafungin along with regular
debridement and dressing of the wound. It took approximately
15 days to control the progressive necrosis of wound. Once the wound
condition began to improve the next focus was to get the wound
closure. Though doing another fl ap was an option but it was decided
to go conservatively and used Vacuum-Assisted Closure (VAC) device
extensively to further improve the wound condition. The next challenging
task was to get the mediastinal tunnel to close for which a novel idea
was tried. The VAC dressing sponge was just placed on the lower wound
crater and not inserted in the cavity. Instead, a large foam was placed
on the skin over the tunnel. Hence, on application of negative pressure
by the device the foam would compress and press the overlying skin fl ap
to meet the pericardium.
Five weeks of constant observation and management resulted in
closure of the mediastinum from lower wound which was skin grafted
to achieve complete healing; thereafter the patient was discharged.
Dr. Parag Vibhakar
and Cosmetic Surgeon
Nanavati Super Speciality