Omental Flap as Primary Surgical Treatment in Post-Operative Mediastinitis After Cardiac Surgery

Introduction: A 43-year-old man developed a mediastinal abscess after a redo aortic valve along with an ascending aorta replacement and also a sub-aortic membrane resection. He was surgically revised: as there were no signs of involvement of the valve and vascular prosthesis, a pedunculated tract of the greater omentum was mobilized and positioned around the aortic prosthesis. During a 10-month follow-up, it has been revealed that the patient is doing well and has no recurrence of the infection. Use of the great omentum could be considered in the selected mediastinitis cases. Case Presentation: A 43-year-old man was referred to our institution for a severe aortic regurgitation and an ascending aorta enlargement associated with a relapsing sub-aortic membrane, which had been treated in his childhood. He underwent a redo ascending aorta replacement and an aortic valve replacement (mechanical prosthesis) along with a resection of the relapsing sub-valvular membrane. Some weeks after he was admitted to another hospital for fever, arthromyalgias and chest pain. After a few days, he developed an inflammatory jugular swelling and underwent a chest CT scan showing a bulky anterior mediastinal abscess in the direct continuity with the sternum. A further chest CT scan showed a mediastinal para-aortic capsulated mass, 135 × 85 × 90 mm in dimension, well delimited over the surrounding plans. At the top of the lesion, a further fluid collection was appreciated, extending through the sternum over the subcutaneous tissues, 30 × 20 mm in dimension. Re-sternotomy was performed and the mediastinal mass was opened and drained. After an extension of the median sternotomy through the epigastrium, a pedunculated tract of the greater omentum was mobilized and positioned around the vascular prosthesis to fill the empty space left by the abscess. Conclusions: The greater omentum is well known in cardiothoracic surgery for its valuable features such as plasticity, immune competence, good blood supply and neovascularization-potential. Dead space can be obliterated by omental flap because of its plasticity qualities. It contains a large number of immunologically active cells likely to be responsible for its anti-infective properties. We can affirm that use of the great omentum could be considered in selected post-operative mediastinitis cases after cardiac surgery.