Ammar Mustafa Head of Wound Care Service Heart Hospital, Doha, Qatar

1. GUIDELINES FOR THE USE OF
NEGATIVE PRESSURE WOUND THERAPY (NPWT)
FOLLOWING CARDIAC SURGERY
Dr. Ammar Mustafa
Head of Wound Care Service
Heart Hospital, Doha, Qatar
EWMA Meeting, Copenhagen, Denmark, May 2013

2. INTRODUCTION
 Postoperative wound
complications post cardiac
surgery, deep sternal
infections in particular, are
associated with increased
morbidity and mortality.
Negative Pressure Wound
Therapy (NPWT) is a well
established modality in the
management of infected
sternal wounds. However, it is a
relatively new modality of
treatment for clean and closed
surgical incisions.

3. INCISION MANAGEMENT SYSTEM (PREVENA)
Definition:
Powered Negative Pressure dressing
designed for clean & closed surgical
incisions in patients at risk for developing
post-operative wound complications.
Mechanisms of action:
1. Holding incision edges together 
reduces chance of wound dehiscence.
2. Promoting wound tissue perfusion
& improving lymph flow.
3. Redistributing skin strain 
reduces lateral tension.
4. Reducing hematoma, seroma & edema
 via Negative Pressure suction.
5. Protecting the surgical site from infection
 wound interface layer contains silver
which reduces microbial colonization of
the wound.

4. METHODOLOGY
 We utilized NPWT over a period of
6 months in the treatment of
sternotomy incisions in patients
considered high risk for
complications such as surgical
site infection and wound
dehiscence.
 There are no specific clinical
indications in the literature for the
use of NPWT for clean closed
sternotomy wounds following
Cardiac Surgery.
 We have looked at our 6 months
experience with this type of
dressing to check if we can define
some indications.

5. GUIDELINES
1. Obesity (BMI > 30 kg/square meter).
2. Uncontrolled diabetes (HbA1c > 8%).
3. Bilateral Internal Mammary Arteries harvesting.
4. Heavy smoking and COPD.
5. Fragile substance of sternal bone .
6. Delayed primary closure of sternal wounds.
7. Secondary closure of sternal wounds.
8. Repeat median sternotomies for “Redo” operations.

6. DISCUSSION
 NPWT has been applied to 47 patients with one or more of the above
criteria immediately after closure of sternotomy wounds.
 The dressing was removed after 6-7 days. The primary end point was the
development of wound complications within 30 days.
 Only 1 patient developed sternal wound infection (2.1%) compared to 5
patients (10.6%) from a similar control group of 47 patients with no
postoperative NPWT.
 We have also used NPWT (Prevena) after secondary closure of 3 thigh
wounds that had to have haematomas evacuated at the sites of long
saphenous vein harvesting for Coronary Artery Bypass Grafting (CABG) with
good results.

7. CASE PRESENTATION: 1- MORBID OBESITY
History:
43 year old (morbidly obese)
gentleman (BMI of 52).
He had resection of a huge
Thymoma through Median
Sternotomy incision.
Procedure:
ZipFix System of sternal closure has
been used because of the high BMI.
NPWT (Prevena) has been used for
7 days.
Result:
No wound problems.

8. CASE PRESENTATION: 2- FRAGILE STERNUM
History:
74 years old diabetic gentleman
with severe Aortic Stenosis.
He underwent Biological Aortic
Valve Replacement. His sternal
bone was fragile.
Procedure:
His sternum was closed using
Modified Robicsek technique.
NPWT (Prevena) was applied for
7 days.
Result:
Good wound healing, stable
sternum and no complications.

9. CASE PRESENTATION: 3- DELAYED STERNAL CLOSURE
History:
52 years old gentleman with severe 3 vessel
Coronary Artery Disease, poorly controlled
diabetes and morbid obesity.
He had CABG with good wound healing
initially but he was readmitted with
Mechanical Dehiscence of the lower half of
the sternum after one month.
Procedure:
Modified Robicsek closure of Pseudoarthrosis
of the lower half of the sternum. NPWT
(Prevena) for 2 weeks.
Superficial wound infection treated with IV
antibiotics for 2 weeks.
Result:
Good wound healing subsequently.

10. CASE PRESENTATION: 4- SECONDARY STERNAL CLOSURE
History:
72 years old diabetic lady with poor left
ventricular function. CABG for 3 vessel
Coronary Artery Disease with Bilateral
Internal Mammary Arteries harvesting.
Hemodynamic instability upon sternal
closure. Therefore the chest was left open
(covered with dressing) for 48 hours for the
myocardial edema to subside.
Procedure:
Sternum was then closed with wound
tension sutures and good hemodynamics.
NPWT (Prevena) was applied for 7 days.
Result:
Excellent wound healing result.

11. CASE PRESENTATION: 5- INFECTED THIGH HEMATOMA
History:
58 year old obese and diabetic lady  she
developped an infected left thigh
hematoma post CABG at the site of long
saphenous vein harvesting.
Procedure:
Evacuation of the hematoma PLUS
V.A.C. therapy & Antibiotics for 2 weeks.

12. CASE PRESENTATION: 5- INFECTED THIGH HEMATOMA
After 2 weeks:
Space filled with granulation tissue and
Infection cleared.
Procedure:
Secondary wound closure PLUS
Prevena dressing for one week.
Result:
Good healing with no wound complications.