Ann Thorac Surg 1999;68:1085-1086
© 1999 The Society of Thoracic Surgeons
Case Reports
Indwelling catheter-induced right ventricular rupture
Ismael N. Nuño, MD, FACSa,
Kenneth A. Ashton, MDa,
Kanti M. Uppal, MDa,
Patricia W. Leea,
Vaughn A. Starnes, MDa
a Department of Cardiothoracic Surgery, University of Southern California School of Medicine, Los Angeles, California, USA
Address reprint requests to Dr Nuño, Cardiac Surgery Service, LAC + USC Medical Center, 1200 North State St, Rm 10-250, Los Angeles, CA 90033
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Abstract
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We describe a case of a 68-year-old man who, because of postoperative mediastinitis, underwent a multiple muscle flap closure of the mediastinum. A chronic indwelling catheter led to erosion and rupture of the anterior wall of the right ventricle. The near exsanguinating hemorrhage was corrected under circulatory arrest. A pericardial patch repair was performed with good results.
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Introduction
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Rupture of the right ventricle is a catastrophic event regardless of its etiology. There are only a few reports in the national and international literature describing such cases. Postoperative mediastinitis has been reported to cause erosion of a ventricular wall with near exsanguinating hemorrhage. The inflammatory reaction, fibrosis, and tissue edema may make cannulation in the mediastinum extremely difficult, especially in the face of severe bleeding. We describe a patient in whom, because of the severe mediastinal inflammation, femoro-femoral cannulation was undertaken instead, and under circulatory arrest, the ventricular rupture was repaired.
A 68-year-old man underwent a successful two-vessel bypass for symptomatic coronary artery disease. Postoperatively, the patient developed an acute and severe mediastinitis with mediastinal cultures yielding Staphylococcus epidermidis. He was returned to the operating room for mediastinal debridement and drainage, partial sternectomy, and bilateral pectoral muscle flap closure of the mediastinal defect. Four Jackson-Pratt (JP) drains were left in place anterior to the muscle flaps. Two drains were removed on the 6th postoperative day, while the remaining two were left in place because they persistently produced greater than 100 mL of serosanguinous fluid per day. The patient was then discharged home with the two indwelling drains and oral antibiotics. Both the Cardiac Surgery and the Plastic Surgery Services followed him as an outpatient.
Approximately 2 months later, the patient returned to the Cardiac Surgery Service because he had suddenly drained 0.5 L of blood from the suction pear of the remaining indwelling JP drain. His median sternotomy wound was therefore emergently explored. At this time, severe mediastinal inflammation was encountered. The tissues were fibrotic and edematous. The pectoral muscle flaps had retracted and the drainage catheter had fallen to lie against the anterior wall of the right ventricle. A computed axial tomographic scan of the chest obtained the day before demonstrated the drain eroding into the right ventricle (Fig 1). On the antero-apical aspect of the right ventricle was an area of disintegration caused by the catheter measuring approximately 5 x 3 cm with torrential bleeding. Because dissection of the right ventricle was difficult due to the severe inflammatory tissue reaction, we opted to cannulate the femoral vessels and go on partial cardiopulmonary bypass. However, venous return into the right side of the heart made visualization nearly impossible. In order to visualize completely the wound edges, total circulatory arrest was undertaken. A double-bovine pericardial patch was then utilized to close the defect with running 3-0 Prolene. The total circulatory arrest lasted 18 minutes. Subsequently, the patient was rewarmed and successfully weaned off cardiopulmonary bypass. He underwent further muscle flap closure with pectoralis and rectus abdominis muscles by the Plastic Surgery Service and was discharged home on the 17th postoperative day. Follow-up has been benign at this point.
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Fig 1. Computed axial tomographic scan of the chest demonstrating the JP drain (arrow) eroding into the anterior aspect of the right ventricle (R).
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Comment
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Rupture of the heart with exsanguinating hemorrhage from postoperative mediastinitis has been previously reported [1]. Muscle flap coverage of the rupture and closure of the mediastinum for salvage have been also documented [2]. Reports of right ventricular disruption are scanty within the national and international literature. On the other hand, left ventricular rupture is more frequently reported with etiologies such as ischemic necrosis, trauma, and iatrogenic causes. The utilization of cardiopulmonary bypass and the use of bovine pericardium for repair of the ventricular rupture have previously been successfully attempted [3]. However, there is no mention of the use of circulatory arrest in any of the publications.
The cannulation of a heavily fibrotic and inflamed mediastinum for cardiopulmonary bypass in the face of massive hemorrhage is very difficult. Erratic dissection can lead to further cardiac tissue disruption causing increased bleeding and death. We submit cardiopulmonary bypass and complete circulatory arrest as a possible addition to the existing armamentarium of techniques.
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References
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Yellin A. Right ventricular rupture after mediastinitis. J Thorac Cardiovasc Surg 1995;109:594-595.[Free Full Text]
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Yuen J.C., Hochberg J., Cruzzavala J., et al. Immediate muscle flap coverage for repair of cardiac rupture associated with mediastinitis. Ann Plast Surg 1991;27:358-360.[Medline]
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Kalangos A., Jornod N., Rognon R., et al. Successful repair of a right ventricular rupture at the atrioventricular groove. Ann Thorac Surg 1996;61:995-997.[Abstract/Free Full Text]
Accepted for publication March 4, 1999.
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Abstract
Introduction
