Chasing Full Recovery

Overcoming an adamant problem after Coronary
Artery Bypass Grafting

THE CASE

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.

THE PROCEDURE

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.

THE RESULT

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
Sr. Consultant
Plastic, Reconstructive,
Microvascular
and Cosmetic Surgeon
Nanavati Super Speciality
Hospital, Mumbai