Sternal Wound Infection After Heart
Transplantation: Incidence and Results With
Aggressive Surgical Treatment
Michel Carrier, MD, Louis P. Perrault, MD, Michel Pellerin, MD,
Richard Marchand, MD, Pierre Auger, MD, Guy B. Pelletier, MD, Michel White, MD,
Normand Racine, MD, and Denis Bouchard, MD
Department of Surgery and Medicine and the Microbiology Laboratory, Montreal Heart Institute and University of Montreal,
Montreal, Quebec, Canada
Background. Sternal wound infection remains a signif-
icant complication. We reviewed the incidence and the
treatment of sternal wound infection after heart
transplantation.
Methods. Of 226 patients who had a heart transplanta-
tion, 20 (8.8%) underwent postoperative wound debride-
ment for superficial or deep sternal wound infection. The
incidence and the survival of patients with sternal
wound infection were analyzed.
Results. The incidence of sternal wound infection was
similar among patients treated with four protocols of
immunosuppressive drugs: cyclosporine and prednisone
(0 of 22; 0%); cyclosporine, prednisone, and azathioprine
(2 of 24; 8.3%); cyclosporine, prednisone, azathioprine,
and antithymocyte globulin (15 of 139; 10.8%); and cyclo-
S ternal wound infection remains a serious complica-
tion after cardiac operations, with rates ranging from
1% to 10% [1– 4]. Although most wound infection epi-
sodes are superficial and self limited, deep sternal infec-
tion and acute mediastinitis can be life-threatening, es-
pecially in heart transplantation recipients to whom
immunosuppressive agents are administered during the
postoperative period. Not only was sternal wound infec-
tion not reported in the most recent clinical trials com-
paring newer immunosuppression agents after heart
transplantation [5, 6], but the incidence of wound infec-
tion was almost never analyzed in single-center studies
on clinical results after heart transplantation. Yet, sternal
wound infection is a major cause of morbidity and
occasionally of mortality among these patients.
The objective of the present study was to review the
variation in the incidence of sternal wound infection
according to different protocols of immunosuppressive
drugs immediately after heart transplantation. The clin-
ical outcome of sternal wound infection treatment after
heart transplantation was also reviewed.
Accepted for publication May 3, 2001.
Address reprint requests to Dr Carrier, Department of Surgery, Montreal
Heart Institute, 5000 Belanger St East, Montreal, QB, H1T 1C8, Canada;
e-mail: carrier@icm.umontreal.ca.
© 2001 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc
sporine, prednisone, mycophenolate mofetil, and anti-
thymocyte globulin (3 of 41; 7.3%) (p ⴝ 0.4). Six-month
and 5-year survival of patients with sternal wound infec-
tion averaged 85% ⴞ 8% and 74% ⴞ 10% compared with
92% ⴞ 2% and 82% ⴞ 3% in patients without wound
infection (p ⴝ 0.15). Patients with deep sternal wound
infection, debridement, and reconstruction had a 5-year
survival averaging 80% ⴞ 10%.
Conclusions. The incidence of sternal wound infection
remains similar between patients treated with the triple
drug therapy. Surgical debridement and reconstruction
can result in long-term survival after heart transplanta-
tion.
(Ann Thorac Surg 2001;72:719 –24)
© 2001 by The Society of Thoracic Surgeons
Material and Methods
Heart Transplantation Program
From 1983 to September 2000, 237 patients underwent
heart transplantation at the Montreal Heart Institute.
Eleven patients died during or immediately after their
surgical procedures, precluding any significant analysis
of the risk of wound infection. All patients were followed
prospectively and data were collected in a computerized
database. Four protocols of immunosuppressive agents
were used during the study period. Cyclosporine and
prednisone were administered to patients who under-
went heart transplantation between 1983 and 1987. Cy-
closporine, prednisone, and azathioprine were used in
1988; the combination of cyclosporine, prednisone, aza-
thioprine, and rabbit antithymocyte globulin from 1989 to
1997; and cyclosporine, prednisone, mycophenolate
mofetil, and antithymocyte globulin was used from 1997
to 2000 [7, 8].
Patients who underwent open heart operations be-
tween 1983 and 2000 were administered preoperative and
postoperative antibiotic prophylaxis with either cefazolin
or vancomycin for penicillin-allergic patients. The anti-
biotics were administered during the first 48 hours after
operation in heart transplantation patients.
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720 CARRIER ET AL
STERNAL WOUND INFECTION
Definition of the Type of Infection
Sternal wound infection was classified as superficial
infection characterized by purulent drainage from the
wound limited to cutaneous and subcutaneous involve-
ment. Deep wound infection involved deep fascial and
muscular tissue. Acute mediastinitis was defined as pu-
rulent drainage involving the sternal bone and surround-
ing mediastinal tissue. Cultures of drainage of all sus-
pected surgical wound infections were obtained and
analyzed routinely.
Statistical Analysis
Data are expressed in mean and standard deviation.
Differences between means were analyzed with the Stu-
dent’s t test, and the Fisher exact test was used for
categorical variables. The actuarial method was used to
analyze survival and event-free survival in our groups of
patients. A logistic regression analysis was used to study
the risk factors correlated with wound infection after
heart transplantation. Factors included in the analysis
were recipient age, sex, pretransplant diabetes, mechan-
ical support before transplantation, and the protocols of
immunosuppressive drugs.
Results
Patient Population
Among 226 patients who had a heart transplantation,
preoperative diagnoses included 118 (52%) with end-
stage ischemic cardiomyopathy, 50 (22%) with congestive
cardiomyopathy, and 38 (17%) with various forms of
end-stage heart disease. Of the 226 patients, 20 (8.8%)
showed evidence of sternal wound infection: 9 (of 226;
3.9%) had superficial wound infections, 4 (of 226; 1.8%)
had deep wound infections, and 7 (of 226; 3%) had acute
mediastinitis. Of these 20 patients, 3 (15%) were women
and 17 (85%) were men; of the 206 free from sternal
infection, 37 (18%) were women and 169 (82%) were men
(p ⫽ 0.7). Patients with sternal wound infection averaged
52 ⫾ 9 years of age compared with 46 ⫾ 10 years in
patients free from sternal infection (p ⫽ 0.01). Diabetes
was noted in 1 of the 20 patients (5%) who developed a
sternal wound infection and in 12 of 206 patients (6%)
without wound infection after transplantation (p ⫽ 0.9).
Superficial wound infections were treated with local
debridement and dressing changes in an outpatient
clinic. Deep wound infections were treated with surgical
debridement and sternal rewiring including Robiscek
weave in 3 patients and local debridement in another
patient. Acute mediastinitis was treated with surgical
debridement, drainage, and sternal rewiring in 5 pa-
tients. Omentoplasty and pectoralis muscle flaps were
used in 2 other patients.
Sixteen patients (of 20; 80%) who developed sternal
wound infections after transplantation were followed at
our outpatient clinic while waiting for heart transplanta-
tion (recipient UNOS status 2) compared with 116 (of 206;
56%) UNOS status 2 recipients without wound infection
after transplantation. Four patients (of 20; 20%) with
Ann Thorac Surg
2001;72:719 –24
sternal wound infection after transplantation were hos-
pitalized before transplantation (recipient UNOS status
1) compared with 89 (of 206; 43%) UNOS status 2 recip-
ients who remained free from wound infection after
transplantation.
Twenty-five patients were mechanically supported be-
fore heart transplantation, 5 with the CardioWest total
artificial heart, 3 with a Thoratec (Pleasanton, CA) left
ventricular assistance, and 17 with an intraaortic balloon
pump. All other mechanically supported patients did not
show any evidence of sternal infection throughout the
periods of support and transplantation. One patient (of
20; 5%) was on mechanical assistance with the Cardio-
West (Tucson, AZ) total artificial heart and developed an
episode of acute mediastinitis after heart transplantation.
Patients who developed sternal wound infection after
transplantation waited 15 ⫾ 23 weeks for a donor heart
compared with 24 ⫾ 38 weeks for patients who did not
show any evidence of wound infection after transplanta-
tion (p ⫽ 0.13). Donor ischemic time in these two groups
averaged 139 ⫾ 49 minutes and 134 ⫾ 63 minutes,
respectively (p ⫽ 0.5).
Sternal Wound Infection and Regimens of
Immunosuppressive Drugs
There was no sternal wound infection among the 22
patients treated with cyclosporine and prednisone. Evi-
dence of sternal wound infection after heart transplanta-
tion was found in 2 of 24 (8.3%) patients who were
administered cyclosporine, prednisone, and azathio-
prine; 15 of 139 patients (10.8%) who were administered
cyclosporine, prednisone, azathioprine, and antithymo-
cyte globulin; and 3 of 41 patients (7.3%) who were
administered cyclosporine, prednisone, mycophenolate
mofetil, and antithymocyte globulin (p ⫽ 0.4).
Of the 20 sternal wound infections after heart trans-
plantation, most were superficial (9; 45%), 4 (20%) were
deep, and 7 (35%) were episodes of acute mediastinitis.
The acute mediastinitis was caused by various bacterial
agents in various combinations: bacteroides (n ⫽ 1),
Escherichia coli (n ⫽ 2), Staphylococcus epidermidis (n ⫽ 5),
Staphylococcus aureus (n ⫽ 6), methicillin-resistant S au-
reus (n ⫽ 2), Aspergillus fumigans (n ⫽ 1). For superficial
and deep wound infections, S aureus (8 of 20; 40%) and S
epidermidis (5 of 20; 25%) were the most common bacteria
responsible.
Survival and Rejection
Six-month and 5-year survival of patients with sternal
wound infection averaged 85% ⫾ 8% and 74% ⫾ 10%,
compared with 92% ⫾ 2% and 82% ⫾ 3% in patients
without wound infection (p ⫽ 0.15) (Fig 1). Eleven pa-
tients with deep sternal wound infection or acute medi-
astinitis underwent aggressive surgical debridement,
drainage, and reconstruction with 6-month and 5-year
survival rates averaging 91% ⫾ 9% and 80% ⫾ 10%,
respectively (Fig 2). One patient with acute mediastinitis
died from uncontrolled sternal wound infection after
implantation of a total artificial heart and transplantation
and another patient died from massive hemorrhage sec-
Ann Thorac Surg CARRIER ET AL 721
2001;72:719 –24 STERNAL WOUND INFECTION

Fig 1. Actuarial survival of patients with superficial, deep, and

acute mediastinitis (infection) compared with patients without ster-
nal wound infection. Survival was lower among patients with ster-
nal wound infection, but the difference is not statistically significant
(p ⫽ 0.15).

ondary to erosion of the ascending aorta. Two patients

underwent successful reconstruction of the ascending
aorta, with a Dacron (C. R. Bard, Haverhill, PA) graft in 1
and a cryopreserved homograft in the other after the
appearance of infected false aneurysms of the ascending
aorta (Fig 3). Omentoplasty and pectoralis muscle flaps
were also used in these 2 patients to control the infected
mediastinal space (Fig 4). Three patients recovered suc-
cessfully after surgical debridement, mediastinal drain-
age, and sternal reclosure associated with the proper
antibiotic treatment.
The freedom rate from acute rejection averaged 47% ⫾
4% 6 months after transplantation in patients who did not
show evidence of sternal wound infection, compared
Fig 3. Computed tomography scan showing (A) a false aneurysm of
the ascending aorta (arrow) and (B) a mediastinal abscess behind
the ascending aorta (arrow). The patient was treated for a deep ster-
nal wound infection immediately after heart transplantation but
showed evidence of mediastinal infection 6 months later. Cultures of
the abscess isolated a methicillin-resistant Staphylococcus aureus
bacteria.

with 43% ⫾ 11% in patients with sternal wound infections

(p ⫽ 0.5). The number of treated acute rejection episodes
averaged 1.1 ⫾ 1.2 per patient in those who did not show
evidence of sternal wound infection compared with 1.0 ⫾
0.9 episode per patient in those with sternal wound
infections (p ⫽ 0.8).

Fig 2. Actuarial survival of patients with deep sternal wound infec-
tion and acute mediastinitis compared with patients without deep
wound and mediastinal infection. Survival was similar in the two
groups.
Multivariate Analysis
Recipient age (odds ratio 1.08, 95% confidence interval,
1.05 to 1.1) was the only risk factor significantly correlated
with the appearance of wound infection after heart trans-
plantation. The use of mycophenolate mofetil, azathio-
prine, and antithymocyte globulin was not associated
with wound infection, nor was the presence of diabetes
before transplantation.
722 CARRIER ET AL
STERNAL WOUND INFECTION
Fig 4. A patient underwent resection of the false aneurysm, drainage
of the retroaortic abscess, reconstruction of the ascending aorta with
a cryopreserved homograft, omentoplasty to control mediastinal dead
space, and pectoralis muscle flap to secure the sternal closure. The
patient had a successful outcome and remains free from recurrence 6
months after the operation.
Comment
Heart transplantation is an established treatment for
patients in end-stage heart failure. Although rejection
and systemic infections episodes have been well charac-
terized among transplant patients, sternal wound infec-
tion is seldom reported and rarely discussed. Yet, sternal
wound infection after standard cardiac operations and
after heart transplantation is the major source of morbid-
ity and mortality. The present study showed that sternal
wound infection after heart transplantation correlates
directly with patient age. There was no significant rela-
tionship between the incidence of sternal wound infec-
tion and protocols of immunosuppressive drugs used in
the present experience, although the incidence was
slightly higher among patients with the quadruple drug
therapy. There was no sternal infection in patients with
the double drug therapy of cyclosporine and prednisone,
but the later protocol was used in the earliest part of our
experience with heart transplantation enrolling only
young patients. Moreover, survival of patients with ster-
nal wound infection remains similar to those without
wound infection after transplantation suggesting that, in
most cases, aggressive surgical debridement and appro-
priate reconstructive approaches were successful.
Ann Thorac Surg
2001;72:719 –24
From 1992 to 2000, including 13,199 patients undergo-
ing cardiac operation in our institution, the annual inci-
dence of acute mediastinitis varied from 0.13% to 1.33%.
Our experience with acute mediastinitis occurring in
transplant patients showed a high rate of 3%. Although
recipient age was the only risk factor associated with
sternal wound infection in the present study, a larger
cohort of patients could show the effect of pretransplant
general nutritional status, mechanical support, and im-
munosuppressive drugs.
Nine patients in the present study had superficial
wound infections and were treated at the outpatient
clinic without significant morbidity. Eleven patients had
deep sternal wound infections or acute mediastinitis
requiring prolonged hospital stay and multiple surgical
procedures of mediastinal drainage, debridement, reop-
eration, and in 2 cases reconstruction of the ascending
aorta (Dacron graft in 1 case and cryopreserved ho-
mograft in another) associated with pectoralis muscle
flaps and omentoplasty to control the mediastinal in-
fected space. Other authors have also reported the use of
muscle flaps and of omentoplasty in patients with medi-
astinal infection after conventional operation [9] or heart
transplantation [10, 11].
Coselli and colleagues [12] described the use of cryo-
preserved homografts in patients with thoracic aortic
graft infections, an approach that we used in combination
with omentoplasty and pectoralis muscle flaps in patients
who showed evidence of infected pseudoaneurysms of
the ascending aorta at the site of the aortic anastomosis
[13]. Although Argenziano and colleagues [14] showed
that wound infection in patients with left ventricular
assist support does not adversely affect survival, local
infection surrounding a total artificial heart carries a
dismal prognosis [15], as was the case with 1 of our
patients.
There is no clear guideline as to the level of immuno-
suppression that should be maintained in patients with
significant sternal wound infection after transplantation.
Our practice has been to rely on cyclosporine and pred-
nisone while azathioprine or mycophenolate mofetil
were stopped until we were confident that the sternal or
mediastinal infection was controlled. The use of cyclo-
sporine and prednisone was effective in preventing the
rejection process during these episodes of sternal wound
infection.
Sternal wound infection and acute mediastinitis re-
main a serious complication after heart transplantation.
Although there was no significant difference in the inci-
dence of sternal wound infection among the four proto-
cols of immunosuppressive agents used, older patients
and those with quadruple drug treatment had the high-
est rate of wound complications. Although old age was
shown to increase the incidence of wound infection, the
selection criteria remain based on risks and benefits of
the transplantation procedure. Immediate and aggres-
sive surgical debridement of all infected sternal tissue is
mandatory with cultures and proper antibiotic treatment.
Mediastinal drainage, debridement of all infected and
necrotic tissue, and closure is most often successful, but
Ann Thorac Surg
2001;72:719 –24
omentoplasty and pectoralis muscle flaps may be neces-
sary whenever sternal or mediastinal dead space needs
to be controlled. Cryopreserved homograft appears to be
a suitable conduit for aortic reconstruction in the pres-
ence of acute mediastinitis and infected pseudoaneurysm
of the aorta; prosthetic material should probably be
avoided. Aggressive surgical treatment of sternal wound
complications results in good short- and long-term sur-
vival after heart transplantation.
References
1. Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound
complications after isolated coronary artery bypass grafting:
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Thorac Surg 1990;49:179– 86.
2. Mossad SB, Serkey JM, Longworth DL, Cosgrove DM, Gor-
don SM. Coagulase-negative staphylococcal sternal wound
infections after open heart operations. Ann Thorac Surg
1997;63:395– 401.
3. Harbath S, Samore MH, Lichtenberg D, Carmeli Y. Pro-
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INVITED COMMENTARY
Sternal wound infections following cardiac surgery have
been well defined. Subscribing to the CDC definition of
surgical wound infection (SWI) a “deep” infection is
characterized by a subfascial location or involving the
bone or retrosternal space (mediastinitis). The incidence
is generally well below 1% for valve procedures and
increases to 1% to 2% for coronary artery bypass grafting.
Risk factors are consistent across series and include older
age, diabetes, obesity, chronic obstructive pulmonary
disease, current smoking, use of bilateral internal tho-
racic arteries and surgical techniques that traumatize the
tissue or interfere with wound healing. Mortality is
significant at 10% to 20%.
Heart transplantation SWI rate should be similar to
that of a valve procedure. In fact, one could expect an
even lower incidence because many of the risk factors for
SWI are contraindications to transplantation and the
sternum is not acutely devascularized. So on initial read-
ing, the 3.9% superficial SWI and 4.9% deep infection
rates reported by Carrier and colleagues appear quite
high. However as they point out there is very little
information published to compare these rates with. A
quick (unconfirmed) review of our transplant database
(excluding left ventricular assist device [LVAD] patients)
found a 5% SWI rate and a separate database managed
by the Infectious Disease Department found a 2% inci-
© 2001 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc
CARRIER ET AL 723
STERNAL WOUND INFECTION
results at six months after transplantation. Transplantation
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7. Carrier M, White M, Perrault LP, et al. A 10-year experience
with intravenous thymoglobuline in induction of immuno-
suppression following heart transplantation. J Heart Lung
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8. Mathieu P, Carrier M, White M, et al. Effect of mycopheno-
late mofetil in heart transplantation. Can J Surg 2000;43:
202– 6.
9. Jurkiewicz JG, Bostwick J, Wood R, et al. Management of the
infected median sternotomy wound with muscle flaps. The
Emory 20-year experience. Ann Surg 1997;225:766–76.
10. Ascherman JA, Hugo NE, Sultan MR, Patsi MC, Smith CR,
Rose EA. Single-stage treatment of sternal wound complica-
tions in heart transplant recipients in whom pectoralis major
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diovasc Surg 1995;110:1030– 6.
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12. Coselli JS, Koksoy C, LeMaire SA. Management of thoracic
aortic graft infections. Ann Thorac Surg 1999;677:1990–3.
13. Katsumata T, Moorjani N, Vaccari G, Westaby S. Mediasti-
nal false aneurysm after thoracic aortic surgery. Ann Thorac
Surg 2000;70:547–52.
14. Argenziano M, Catanese KA, Moazami N, et al. The influ-
ence of infection on survival and successful transplantation
in patients with left ventricular assist devices. J Heart Lung
Transplant 1997;16:822–31.
15. Griffith BP, Kormos RL, Hardesty RL, Armitage JM, Dummer
JS. The artificial heart: infection-related morbidity and its
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dence of superficial SWI and a 3.3% deep SWI rate. Not
that much different than Carrier’s incidence.
Could it be that different risk factors play a role in SWI
after heart transplantation? Malnutrition, cardiac ca-
chexia, chronic low cardiac output state, anemia, pro-
longed hospitalization on inotropic support through cen-
tral lines, and infections or colonization with nosocomial
flora followed immediately by intense immunosuppres-
sion may put these patients at increased infection risk.
Unfortunately, very few variables were investigated in
this series. Inexplicably, 80% of the SWI occurred in what
would appear to be a low risk population of United
Network for Organ Sharing status II patients waiting on
average only 4 months for transplantation, and, unlike
SWI in nontransplant patients, mortality was not signif-
icantly increased (although a trend was suggested). This
undoubtedly reflects the small numbers affected.
Their management paradigm supports an aggressive
diagnostic and therapeutic approach, which I support.
Prevention is the best. All nonpermanent central venous
lines are replaced at the time of transplant and in LVAD
patients the pump pocket and mediastinum are debrided
of all necrotic material and copiously irrigated before
implanting the heart. If a deep SWI occurs, especially in
the patient who has had multiple previous operations
and a fixed mediastinum, obliteration of the infected
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