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Ann Thorac Surg 1998;66:2115-2116
© 1998 The Society of Thoracic Surgeons

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How To Do It

Repair of right ventricular rupture complicating mediastinitis

^a Division of Cardiothoracic Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, USA

Accepted for publication June 15, 1998.

Address reprint requests to Dr Barner, 3108 Queeny Tower, One Barnes-Jewish Hospital Plaza, St. Louis, MO 63110-1041
e-mail: (Barnerh{at}msnotes.wustl.edu)

	Abstract

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A treatment strategy for rupture of right ventricle complicating mediastinitis is presented. We used two strips of anterior rectus sheath to buttress the ventricular closure during femoral-femoral bypass.

	Introduction

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Right ventricular rupture is a rare but potentially fatal complication of open mediastinal drainage of mediastinitis. Successful outcome depends on understanding the pathology and having a well-organized treatment plan.

One to 2 weeks after median sternotomy for cardiac operation, the anterior surface of the heart becomes adherent to the sternum and adjacent chest wall. Removal of the sternal wires for open drainage of purulent mediastinal infection with debridement of necrotic tissue allows lateral motion of the two halves of the sternum to be transmitted to the right ventricular wall. At times of sudden increase in intrathoracic pressure (eg, coughing or vomiting), the diaphragm moves upward pushing the heart forward and the two halves of sternum abruptly separate. We have found that this separation results in lateral stress on the anterior wall of the right ventricle and a linear tear that is essentially parallel to the interventricular septum.

	Technique

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Hypotension associated with right ventricular rupture is frequently associated with cessation of bleeding as a clot forms to seal the site of rupture. Whether bleeding has stopped or is continuing, a bulky dressing should be placed in the wound and hand held until bleeding is controlled. The dressing is then taped in position. Closed chest compression should not be performed because it might result in continued bleeding or an extension of the right ventricular tear. Open cardiac massage is not an option because the heart is firmly adherent to surrounding structures. Volume resuscitation is necessary, as well as sedation, paralysis, and mechanical ventilation to stabilize the patient and to prevent uncontrolled chest wall movement. Vasoconstrictor and inotropic agents might be required. The patient should be transferred to the operating room while firm pressure (hand or tape) is maintained on the sternotomy wound dressing and continued until cannulation for femoral-femoral cardiopulmonary bypass can be established. When bleeding has stopped, the outer portion of the dressing can be removed to allow preparation and draping of the chest. The heart can be inspected to assess the lesion after initiating bypass followed by rectus fascia harvest, or the fascia can be harvested without bypass before inspecting the heart.

The initial sternotomy incision is extended 8 to 10 cm inferiorly and the right or left anterior rectus sheath exposed (Fig 1). Two strips of anterior rectus fascia 5 to 8 cm long and 1 cm wide are harvested. Depending on the width of the rectus sheath one or both sides may be used. Cardiopulmonary bypass requires a soft cardiotomy suction tube to be placed in the right ventricular cavity through the ventricular tear and a second firm suction tube placed in the operative field (Fig 2). The heart is then mobilized from the chest wall by using electrocautery to relieve all lateral stress, which allows sternal spreading for adequate exposure of the defect. The fascia strips are placed parallel to the defect and five to eight horizontal mattress sutures of 4-0 polypropylene are placed through the full thickness of the ventricular wall and through the fascial strips (Fig 2). After placing all sutures they are tied with partial release of the sternal retractor if any lateral stress is present. Additional mattress sutures are placed if leaks are present, and the repair can be completed with a running 4-0 suture that incorporates the adjacent fascial edges. The repair is then tested by discontinuation of bypass. If further sutures are needed they should be placed and tied after resumption of maximal bypass.

View larger version (27K): [in this window] [in a new window]   Fig 1. Packing remains in the chest wound to control right ventricular bleeding. The incision has been extended inferiorly, and the rectus sheath exposed with harvest of rectus fascia.

View larger version (60K): [in this window] [in a new window]   Fig 2. Horizontal mattress sutures have been placed through the full thickness of the right ventricular wall and the fascial strips. A soft cardiotomy suction tube is positioned within the right ventricular cavity and a second suction tube is placed inferiorly.

	Comment

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This technique has been used successfully in four patients over 6 years. All patients had closure with pectoral muscle flaps 3 to 10 days postoperatively with primary healing and hospital discharge 8 to 16 days later, except for the last patient. This 80-year-old man developed focal areas of skin and subcutaneous necrosis on the right side despite healing of the muscle flaps and remained ventilator dependent and in a long-term care facility 3 months later.

Others reported the use of an onlay patch of anterior rectus sheath after primary repair with Teflon felt pledgeted sutures failed [1] or reinforcement of primary closure with a piece of fascia lata or Teflon felt [2]. Our method is a simpler one-stage method that avoids the use of foreign material (Teflon felt) in an infected field.

Ventricular rupture is usually seen when the sternotomy wound is opened for 10 days or more after the initial operation, when the heart is more likely to be adherent to the posterior surface of the chest wall. It has been suggested that the patient should be kept intubated, sedated, and ventilated until wound closure is carried out [3]. However, some of these wounds might require a significant period of debridement before they are clean enough to close, so that continued intubation becomes a liability. An alternative approach is to dissect the heart from the chest wall when the sternal wires are removed to prevent this occurrence, an approach we now recommend but have not yet practiced.

The senior author did not experience this complication in the first 25 years of the practice of cardiothoracic surgery, which included the era when all mediastinal infections were treated by open drainage and debridement and allowed to heal by secondary intention. Most of our patients with mediastinal infection now undergo muscle flap closure. Ventricular rupture occurred 1 to 4 days after mediastinal drainage and debridement, while the wound was being prepared for muscle flap closure.

	References

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1. Slater A.D., Gott J.P., Tobin G.R., II, Gray L.A. Management of extensive right ventricular injury or rupture. Ann Thorac Surg 1990;49:810-813.[Abstract/Free Full Text]
2. Cartier R., Diaz O.S., Carrier M., Leclerc Y., Castonguay Y., Leung T.K. Right ventricular rupture. A complication of postoperative mediastinitis. J Thorac Cardiovasc Surg 1993;106:1036-1039.[Abstract]
3. Cartier R. Right ventricular rupture after mediastinitis [Reply to the Editor]. J Thorac Cardiovasc Surg 1995;109:594-595.[Free Full Text]

This article has been cited by other articles:

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hon Chi Suen Hendrick B. Barner Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Suen, H. C. Articles by Barner, H. B. Search for Related Content PubMed PubMed Citation Articles by Suen, H. C. Articles by Barner, H. B.