Ann Thorac Surg 1996;61:1245-1246
© 1996 The Society of Thoracic Surgeons
Case Report
Resinous Plate for Permanent Sternal Splinting in Patients With Extracardiac Conduits
Motohiro Kawauchi, MD,
Akira Furuse, MD,
Yutaka Kotsuka, MD,
Minoru Ono, MD
Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan
Accepted for publication September 6, 1995.
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Abstract
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During operations on patients with extracardiac conduits, sternal reapproximation occasionally results in critical compression of the conduit and serious deterioration in hemodynamic function. Permanent splinting of the sternum with a methyl methacrylate resinous plate provides an adequate substernal space for the extracardiac conduit.
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Introduction
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Difficulties in closing the sternal incision are occasionally encountered in patients with extracardiac conduits, especially patients receiving such a conduit at reoperation. This may be because the positioning of the new conduit is somewhat restricted by the placement of the previous proximal and distal anastomoses. In 2 such patients, we used a permanent resinous plate to provide adequate substernal space for the new conduits.
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Case Reports
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Patient 1
A 14-year-old girl 146 cm tall and 26 kg in weight underwent reoperation because of conduit stenosis 1 year after intracardiac repair of pulmonary atresia with an extracardiac valved pericardial-roll conduit. The conduit was compressed between the heart and the sternum (Fig 1a
). After normothermic extracorporeal circulation had been established, the extracardiac conduit was longitudinally incised and enlarged with a Dacron patch, 50 x 18 mm + 45 x 35 mm. The native right ventricular outflow tract was also enlarged. After bypass, approximation of the sternum caused severe deterioration in hemodynamic function.
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Fig 1. . (a) Preoperative computed tomogram from patient 1 showing compressed extracardiac conduit (white arrows) and (b) postoperative computed tomogram. The concave arch in the splint (white arrows) provides adequate substernal space for the extracardiac conduit. (c) Postoperative computed tomogram from patient 2. The splint (small white arrows) prevents the rib cage from compressing the allograft and the additional bypass graft (large white arrow).
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A methyl methacrylate splint, 15 x 2.5 x 1.5 cm, was made from Cranioplastic acrylic resinous material (CMW Laboratories Ltd, Blackpool, England) at the operating table (Fig 2). After the resinous material was mixed, a flexible metal plate was applied to the posterior surface of the sternum so as to fit the curvature. A piece of gauze was placed on the metal plate where, at a later procedure after the splint was molded and set hard, the posterior surface of the splint facing the conduit was shaved off with a pneumatic drill to create a concave shape and, hence, room for the conduit (Fig 3a). The resinous splint was molded in a plastic sheet on the metal plate (Fig 3b). Anterior flanges were made on both sides of the splint to keep it in the correct position on the sternum. Five holes were drilled in the center of the plate for wires, and the splint was fixed to the sternum with wire sutures. The subcutaneous tissues of the bilateral pectoral regions were undermined to allow skin closure.
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Fig 2. . (A, B) Anterior flanges on both sides of the splint keep it correctly positioned in the sternum. (C) The surface of the splint facing the conduit was shaved off to make a concave shape.
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Fig 3. . (a) A flexible metal plate was applied to the posterior surface of the sternum so as to fit the curvature. A piece of gauze (white arrow) was placed on the metal plate where, at a later procedure after the splint was molded and set hard, the posterior surface of the splint facing the conduit was shaved off. (b) The resinous splint was molded in situ on the metal plate.
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The patient made a satisfactory recovery and was weaned from artificial ventilation 3 days after operation. Postoperative computed tomographic examination revealed that the concave arch provided adequate substernal space for the extracardiac conduit (Fig 1b
). To the time of writing, 6 months after the operation, the patient has done well with the splint.
Patient 2
A 31-year-old man 160 cm tall and weighing 46 kg was admitted to the hospital 14 years after a Rastelli procedure with a porcine xenograft conduit. At this admission, the conduit, which was stenosed by neointima, was replaced with a pulmonary allograft, and an additional bypass graft was positioned between the right ventricle and the right pulmonary artery. Although weaning from bypass was uneventful, the patient required a splint of resinous material, 15 x 3 x 1.5 cm, to provide space for the new extracardiac conduit. Postoperative respiratory function was satisfactory, and he was extubated on the third postoperative day. He has been in good condition for 2 months with the stent preventing compression of the conduit (Fig 1c).
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Comment
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Abnormal cardiac swelling occasionally encountered after a cardiac operation is usually due to cardiac edema and is therefore transient. Closure of the skin without sternal closure or sternal splinting, at most, is enough for temporary use [1]. However, the difficulty in reapproximating the sternum in our patients was due to the size and the position of the extracardiac conduit, and they needed a permanent splint.
Use of a methyl methacrylate plate as a temporary splint has been reported [2, 3] on occasion, but most often it is for permanent placement. The cranioplastic kit containing resinous methyl methacrylate is manufactured for the repair of cranial defects, and therefore is made for permanent use. This material must not be applied at a site of active infection; alternatives such as a muscle flap or an omental pedicled flap are indicated in that situation. On the other hand, unlike other procedures such as delayed sternal closure, a permanent resinous splint does not require removal by reoperation. The splinted and hence rigidly fixed sternum allows satisfactory respiratory motion and early extubation. The material can be mixed and set within 20 minutes at the operating table. During setting, the splint can be shaped to fit the curvature of the sternum. After polymerization, the plate is so firm and rigid that a portion can be shaved off to create a space for the underlying conduit or heart. Further, as methyl methacrylate is radiolucent, the splints do not interfere with the postoperative chest roentgenographic study.
Both of our patients are doing well with the splint without any obvious problems. We conclude that a resinous plate of methyl methacrylate is an effective splint for permanent use to prevent chest wall compression in patients with extracardiac conduit repair, especially patients having reoperation.
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Footnotes
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Address reprint requests to Dr Kawauchi, Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113, Japan.
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References
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- Shore DF, Capuani A, Lincoln C. Atypical tamponade after cardiac operation in infants and children. J Thorac Cardiovasc Surg 1982;83:449–52.[Abstract]
- Jazzar AS, Dalton WE, Bradley NE, Cooper DKC, Zuhdi N. Methyl methacrylate plate to prevent compression after heart transplantation. Ann Thorac Surg 1993;55:1242–3.[Abstract/Free Full Text]
- Yokoyama H, Togo T, Murata S, et al. Cardiac dilatation after cardiopulmonary bypass: ceramic plate technique for sternal splinting. Ann Thorac Surg 1993;56:971–2.[Abstract/Free Full Text]
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Abstract
Introduction
