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Ann Thorac Surg 1997;63:1834
© 1997 The Society of Thoracic Surgeons

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Correspondence

Delayed Tamponade After MIDCABG

New England Heart Institute Catholic Medical Center, 100 McGregor St, Manchester, NH 03102

To the Editor:

Minimally invasive surgery is increasingly popular in many surgical centers, including ours. We recently operated on a 34-year-old man for tamponade and hypotension after a minimally invasive coronary artery bypass grafting procedure done in another facility 3 days before admission. He had a history of stent placement in the circumflex system and recent minimally invasive direct coronary artery bypass grafting with left internal mammary artery to the left anterior descending artery through a small transverse left anterior thoracotomy, medial to the breast. He did well and was discharged on the second postoperative day. The next day the patient was admitted in the emergency room of a third center with hypotension. Physical examination and electrocardiography suggested tamponade, and this was confirmed by echocardiography. He was emergently transferred on vasopressors to our facility and brought to the operating room on arrival. A median sternotomy was performed. To our surprise the left internal mammary artery was intact, in place, and without any tension but there was bleeding from two side branches. A large hemopericardium was evacuated (250 mL) and a smaller hemothorax as well, with good hemodynamics thereafter. The side branches were repaired with a clip and suture. A regular chest tube drain was left in place, and the sternotomy was closed as routine. Doppler echocardiography of the left internal mammary artery showed excellent flow with nice diastolic phase. Cardiac enzymes levels were not elevated postoperatively. The patient recovered well and went home on the fourth day.

Delayed tamponade after minimally invasive direct coronary artery bypass grafting is very rare. We had presumed a diagnosis of avulsed mammary artery (Salerno T, personal communication), which is why we used a sternotomy; this is more important in an unstable patient. An argument could be made for using the original incision if the diagnosis is known ahead of time, although there is concern for complete pericardial blood evacuation through that limited thoracotomy. The large hemopericardium is somewhat surprising in view of a small pericardial incision and the pleural opening, but can be explained by the very distal site of the bleeders and compression by the lung. Minimally invasive surgery is rapidly evolving in cardiac surgery, and we are still in a learning phase. Delayed tamponade should be considered in the face of hypotension and recent minimally invasive direct coronary artery bypass grafting but differentiation from avulsion may be difficult in the acutely unstable patient.

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yvon R. Baribeau Benjamin M. Westbrook David C. Charlesworth Christopher T. Maloney Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Baribeau, Y. R. Articles by Maloney, C. T. Search for Related Content PubMed Articles by Baribeau, Y. R. Articles by Maloney, C. T.