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Ann Thorac Surg 1998;66:304-306
© 1998 The Society of Thoracic Surgeons
, MDa
a Siyami Ersek Thoracic and Cardiovascular Surgery Center, Haydarpaa, 
stanbul, Turkey
To the Editor
We read with great interest the letter written by Dr Opie [1] and Dr Stoney’s reply [2].
Sternal wound complications, sternal instability, dehiscence, and nonunion prolong the postoperative course of open heart procedures and predispose patients in some cases to mediastinitis or respiratory failure or long-term mechanical ventilatory support [3]. On the other hand, mediastinitis, long-term mechanical ventilatory dependence, emphysema, advanced age, osteoporosis, sliding maladjustment of the sternal parts, incomplete twisting of the sternal wires, and poor general condition of the patients (low cardiac output state, diabetes mellitus, chronic renal disease, hypoproteinemia) increase the risk of sternal detachment and play an essential role in the augmentation of the morbidity, mortality, and hospital expenses.
We share Dr Opie’s [1] and Dr Stoney’s [2] viewpoints concerning the use of no. 7 wires and the simplified concept of one wire per 10 kg.
Hendrickson and colleagues [4] defined sternal nonunion as sternal pain with clicking, instability, or both for more than 6 months in the absence of infection, and they reported its correction by sternal plating. We propose here to use cyanoacrylate glue as an adjunct to the standard sternal wiring in high-risk patients to avoid sternal detachment or nonunion, and we report 2 cases of Hendrickson type III sternal instability treated by wiring and gluing.
A 42-year-old man with rheumatic mitral and aortic valve disease underwent mitral and aortic valve replacement with prosthetic heart valves (CarboMedics 23 mm and 31 mm; CarboMedics, Inc, Austin, TX) on October 10, 1997. Cardiac tamponade developed on the 8th postoperative day, with enlargement of the mediastinum, elevation and equalization of the right- and left-sided pressures, and low cardiac output state. The patient underwent urgent revision, and 800 mL of defibrinated blood was aspirated. An important amount of coagulum was evacuated from the retrocardiac space. Hemostasis was reestablished. Multiple bilateral transverse sternal fractures were present. To ensure stabilization of the sternum, no. 7 sternal wires (Davis + Geck, Wayne, NJ) were applied in standard fashion with seven single loops in this patient weighing 65 kg. But before the wires were twisted, commercially available cyanoacrylate glue (cyanacrylacidethylester; Lely Turbo Ltd, Istanbul, Turkey) was applied to all fractured and split sternal edges. Then all parts were reapproximated by bilateral handling. After that, the wires were tightened. Stabilization was completed in a few minutes. Subcutaneous and cutaneous layers were closed by traditional suture methods. The postoperative course was uneventful without any sign of infection or sternal detachment, and the patient was discharged on the 8th day after the revision. The follow-up is 4 months.
The second patient was 62-year-old man with chronic obstructive pulmonary disease weighing 110 kg operated on for coronary artery bypass grafting with a left internal thoracic artery graft to the left anterior descending artery. Three days of prolonged ventilatory support was necessary postoperatively. Hendrickson type III sternal detachment and mediastinitis with Staphylococcus aureus developed. The revision procedure consisted of debridement, drainage, and sternal stabilization. Nine single loops of no. 7 sternal wires were applied, and all sternal parts were glued with cyanoacrylate before the wires were twisted. Mediastinal drainage continued for 40 days without a major alteration of the patient’s general condition, and the sternum stayed stable. Vancomycin was used as parenteral antibiotic therapy. Hospital discharge was on the 55th day.
Bacteriologic studies of the commercially available cyanoacrylate that we used showed no bacterial growth on soybean-casein digest broth, on endo-agar, and on Sabouraud-dextrose agar. Robicsek and colleagues [5] also showed that commercially available cyanoacrylate glue does not have bacteriologic contamination. Quinn and associates [6] showed its in vitro antimicrobial effect when standard disc sensitivity tests are used.
However, care must be taken to avoid gluing of the understernal drains and epicardial surface of the heart to the sternum.
References
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