Between 1978 and 1987, 15,595 median sternotomies were performed at Emory University Hospitals. Sternal wound infections developed in 246 patients (1.6 percent). Mediastinitis was present in 211 patients, while superficial infections were detected in the remaining 35 patients. Debridement and muscle or omental flap closure were performed in all instances of mediastinitis, with an overall mortality rate of 5.3 percent. The results of this treatment are reviewed, and the evolution of current therapeutic guidelines is described. When compared with closed-catheter irrigation and open granulation techniques, flap closure is shown to result in a fourfold decrease in mortality, an increased success of primary therapy, and a diminished length of hospitalization following treatment. This evidence supports the conclusion that debridement and flap closure should be considered the primary therapy for patients with poststernotomy mediastinitis.