Sternal dehiscence: oxygenated gel and TPN duo in newborns

Surgical complexity and neonatal wound management: a multidisciplinary challenge

The management of newborns with complex congenital heart diseases, combining in this case a type A interrupted aortic arch, a ventricular septal defect, and mitral stenosis, constitutes a high-risk surgical challenge. This case reports the journey of a one-month-old infant whose recovery was compromised by severe mitral regurgitation, requiring extracorporeal membrane oxygenation (ECMO) support and a succession of three thoracic interventions, including valve replacement with a Melody bioprosthesis.

The main objective of this study is to demonstrate the feasibility and effectiveness of an innovative healing strategy for a sternal dehiscence occurring on the 33rd postoperative day. In a critical context marked by Pseudomonas aeruginosa sepsis and Staphylococcus haemolyticus bacteremia, the authors evaluate the impact of a protocol combining negative pressure wound therapy (NPWT) and the application of an oxygen-enriched topical gel.

The hypothesis tested is based on the synergy of these two modalities to promote complete healing by secondary intention. This report aims to prove that this multidisciplinary approach achieves tissue resolution without neurological or scarring sequelae, despite prolonged hemodynamic instability and severe infectious complications in a fragile neonatal patient.

Study design and clinical profile

This clinical case report details the management of a one-month-old female infant of Romanian origin, presenting with a rare constellation of complex congenital heart diseases: a type A interrupted aortic arch, a ventricular septal defect (VSD), and mitral valve stenosis.

Operative protocol and extracorporeal support

The therapeutic strategy involved three successive surgical procedures and prolonged life support:

• Initial intervention: Aortic arch reconstruction, VSD closure with a bovine pericardium patch and mitral valve repair.
• ECMO support: Due to severe residual mitral regurgitation, veno-arterial ECMO was initiated immediately, followed by valve replacement with a Melody bioprosthesis.
• Reintervention at D19: Urgent thrombectomy of the obstructed prosthesis, allowing for ECMO weaning.

Wound management and healing

The sternal closure and soft tissue care protocol followed a specific schedule following a dehiscence that occurred on the 33rd postoperative day:

• Delayed sternal closure: Performed at D26.
• Combined phase (33 days): Joint application of negative pressure wound therapy (NPWT) and an oxygen-enriched topical gel.
• Monotherapy phase (38 days): Continuation of treatment with oxygen-enriched gel alone.
• Follow-up: Evaluation of complete healing by second intention achieved after 73 days of localized care.

L'analyse de l'issue clinique a intégré la surveillance des complications infectieuses, notamment un sepsis à Pseudomonas aeruginosa et une bactériémie à Staphylococcus haemolyticus.

Surgical Chronology and Clinical Evolution

This case study reports the complex management of a one-month-old neonatal patient presenting with a rare constellation: interrupted aortic arch (type A), ventricular septal defect (VSD), and mitral stenosis. The therapeutic journey required three major surgical interventions and extracorporeal membrane oxygenation (ECMO) support.

• Initial intervention: Aortic arch reconstruction, VSD closure with bovine pericardial patch and mitral valvuloplasty.
• Second intervention: Due to severe residual mitral regurgitation, immediate veno-arterial ECMO support was required, followed by mitral valve replacement with a Melody bioprosthesis.
• Third intervention (D19): A thrombotic obstruction of the prosthesis required a surgical thrombectomy, subsequently allowing for ECMO weaning.

Results of Sternal Wound Management

Delayed sternal closure was performed on day 26. Following a dehiscence that occurred on day 33, an innovative combined strategy was implemented. As this is a single case report, no statistical analysis (p-values) or group comparisons are applicable.

Infectious Complications and Clinical Outcome

Despite the complexity of the site and the invasive devices, qualitative observations confirm the resilience of the protocol:

• Infectious profile: The patient survived Pseudomonas aeruginosa sepsis and late-onset Staphylococcus haemolyticus bacteremia.
• Neurological status: Full recovery with no objective neurological deficit.
• Skin follow-up: Total healing achieved after 73 days of specific care, without wound-related sequelae despite prolonged ECMO support and systemic infection.

Clinical analysis and therapeutic interest

This case report demonstrates that multidisciplinary management, combining major surgical techniques with an innovative wound care strategy, can lead to a favorable outcome in a very high-risk newborn. The success of secondary intention healing in 73 days, despite a critical condition (interrupted aortic arch, prolonged ECMO, and Pseudomonas aeruginosa sepsis), highlights the potential effectiveness of the combination of negative pressure wound therapy (NPWT) and oxygen-enriched topical gel.

From a clinical perspective, the integration of topical oxygen appears to have compensated for the limitations of NPWT alone in the face of complex sternal dehiscence. The study shows that the combined NPWT phase (33 days) followed by gel monotherapy (38 days) achieved complete closure without neurological sequelae or long-term scarring complications, where conventional surgical reintervention would have presented an immediate fatal risk.

Limits and perspectives

The interpretation of these results is inherently limited by the study design (n=1). As a single clinical case, the reproducibility of this therapeutic synergy remains to be confirmed in larger cohorts. Furthermore, the total healing time (over two months) reflects the complexity of the case but imposes a prolonged care burden in a hospital setting.

Nevertheless, compared to classic literature data on neonatal mediastinitis, this approach offers a less invasive alternative to muscle flaps or iterative sutures on infected tissues, particularly in fragile patients under extracorporeal circulatory support.

Summary of results

This case demonstrates the complete healing of a sternal dehiscence in a one-month-old infant within 73 days, thanks to the combination of negative pressure wound therapy (NPWT) and an oxygen-enriched gel. Despite a critical course including three cardiac surgeries, prolonged ECMO, and P. aeruginosa sepsis, this combined strategy allowed for total healing by secondary intention without neurological or functional sequelae.

In concrete terms, for the practitioner:

• Surgical alternative: Prioritize the combo of NPWT and topical oxygen therapy for complex neonatal sternal dehiscences to avoid another invasive re-intervention on tissues already weakened by ECMO.
• Management of septic environments: Do not give up on secondary intention healing in the event of bacterial infection (Pseudomonas, Staphylococcus); this protocol maintains its granulation potential even in the context of severe sepsis.
• Optimization of NPWT weaning: A transition to oxygen-enriched gel monotherapy (after 33 days of NPWT in this case) allows for the completion of skin closure while simplifying nursing care at the patient's bedside.

Technical lexicon of the study

Interrupted aortic arch (Type A): Rare congenital malformation characterized by a lack of continuity between the ascending and descending aorta, with type A located distally to the origin of the left subclavian artery.

ECMO (Extracorporeal Membrane Oxygenation): Extracorporeal circulatory support technique of the veno-arterial type (VA-ECMO) temporarily ensuring cardiac and pulmonary functions, used here following severe post-surgical mitral regurgitation.

Melody bioprosthesis: Bovine biological valve originally designed for percutaneous pulmonary valve replacement, used here in an adapted manner for surgical mitral replacement in a one-month-old infant.

NPWT (Negative Pressure Wound Therapy): Negative pressure wound therapy applied to the sternal wound to stimulate granulation and promote healing by secondary intention after tissue dehiscence.

Oxygen-enriched topical gel: Innovative medical device for local wound care applied to increase tissue oxygenation, used in combination with NPWT to treat complex sternal dehiscence.

Sternal dehiscence (Wound dehiscence): Postoperative complication manifesting as a separation of the surgical incision edges, occurring here on the 33rd day of life after delayed sternal closure.

Delayed sternal closure: Post-cardiotomy surgical strategy consisting of delaying the closure of the chest wall to prevent or treat hemodynamic instability or myocardial edema.

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