The management of sternal mediastinitis in heart and lung transplant patients: An 8-year experience and application of reconstructive algorithm.

Abstract

Sternal mediastinitis, the most severe form of deep sternal wound infection (DSWI), following heart and lung transplantation is uncommon but associated with substantial morbidity. Chronic immunosuppression, complex microbiological profiles and altered chest wall anatomy pose distinct reconstructive challenges. We present our experience from our tertiary transplant centre and evaluate the applicability of our reconstructive algorithm in this population. A retrospective review was conducted of all heart and lung transplant recipients who were surgically managed for DSWI at a tertiary cardiothoracic transplant centre between June 2017 and December 2025. Demographic data, microbiology, operative details, reconstructive interventions and outcomes were analysed. A PRISMA-compliant systematic review was performed alongside. Ten patients were identified (7 lung and 3 heart transplant recipients). Median time from transplant to DSWI diagnosis was 95 (4-1486) days. Following diagnosis, median time to definitive reconstruction was 90 (32-722) days, during which patients underwent a median of 4 (1-10) debridements and received prolonged antimicrobial therapy. Negative pressure wound therapy was used for a median of 42.5 days (8-122 days; n=9). Median DSWI-related length of stay was 147 (62-321) days. Reconstructive strategy was guided by previous incision type: reverse abdominoplasty predominated following clamshell thoracotomy (5/7), whereas bilateral pectoralis major advancement flaps were most employed following median sternotomy (2/3). All patients were successfully discharged. There was no perioperative mortality. Transplant-associated DSWI is characterised by prolonged treatment courses and complex microbiology. Aggressive source control within a multidisciplinary framework, combined with considered reconstructive planning, facilitates durable results and successful discharge in this high-risk population.