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Ann Thorac Surg 2002;73:1629-1631
© 2002 The Society of Thoracic Surgeons
a Department of Cardiovascular Surgery, Osaka City University Medical School, Osaka, Japan
Accepted for publication October 16, 2001.
* Address reprint requests to Dr Fukui, Department of Cardiovascular Surgery, Osaka City University Medical School, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
e-mail: tm-fukui{at}gem.hi-ho.ne.jp
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Abstract |
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Introduction |
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A 73-year-old man with triple-vessel coronary disease was scheduled to undergo a coronary artery bypass operation. Preoperative risk factors included diabetes mellitus and severe chronic obstructive lung disease. Preoperative computed tomography revealed severe calcification of the ascending aorta, and three-vessel off-pump coronary artery bypass grafting was planned. A median sternotomy was performed and anterior pericardial traction sutures were placed. The three deep pericardial sutures were inserted in the pericardium anterior to the left superior and inferior pulmonary veins, halfway between the left inferior pulmonary vein and the inferior vena cava, and near the inferior vena cava. No bleeding into the pericardial cavity was seen. The left internal thoracic artery was anastomosed to the left anterior descending artery, and the radial artery was sequentially anastomosed to the obtuse marginal branch and the posterior descending artery. Exposure and stabilization of these arteries were achieved easily by using the deep pericardial sutures and the Octopus stabilizer (Medtronic, Inc, Anaheim, CA). The proximal end of the radial artery was anastomosed to the side of the internal thoracic artery. Both pleural cavities were entered to harvest the internal thoracic artery or expose the lateral heart vessels. The patient was returned to the intensive care unit after complete hemostasis was achieved.
Immediately after the operation, the patient was hemodynamically stabilized on low-dose dobutamine (3 µg/kg/min). The cardiac output was more than 7.0 L per minute. The postoperative blood loss was 457 mL during the first 24 hours and 170 mL over the next 24 hours. The mediastinal drainage tube was removed on the second postoperative day. Continuous infusion of low molecular weight heparin (10,000 U/day) was started to prevent graft occlusion on postoperative day 3 because the patient’s poor pulmonary function precluded extubation. The hemodynamics began to degenerate on postoperative day 4. Cardiac output decreased to 2 L/minute despite the administration of dopamine (5 µg/kg/min), dobutamine (5 µg/kg/min) and epinephrine (0.07 µg/kg/min). Transesophageal echocardiography (TEE) was performed to assess cardiac function. The TEE demonstrated a retropericardial hematoma that was compressing the left atrium anteriorly (Fig 1). Computed tomography showed the existence of an extensive hematoma behind the left atrium and bilateral pleural effusion (Fig 2). The infusion of heparin was stopped, and bilateral thoracostomy drainage tubes were inserted immediately that produced 800 mL of serosanguineous fluid. The hematoma was smaller the next day, and the hemodynamics improved.
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The TEE is a useful diagnostic tool for assessing cardiac function and identifying abnormal findings in surgical patients [5]. When the patient’s hemodynamic condition deteriorated, we performed TEE immediately and readily detected the hematoma behind the left atrium. Furthermore, findings on TEE and computed tomography led us to believe that the hematoma may have resolved with pleural drainage alone, which turned out to be what occurred.
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