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Ann Thorac Surg 2003;75:1311-1313
© 2003 The Society of Thoracic Surgeons
a Heart and Lung Division, Section of Cardiothoracic Surgery, University Hospital, Lund, Sweden
Accepted for publication October 3, 2002.
* Address reprint requests to Dr Sjögren, Heart and Lung Division, University Hospital, SE-221 85 Lund, Sweden
e-mail: johan.sjogren{at}thorax.lu.se
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The vacuum-assisted closure (VAC) technique is a safe method of achieving negative pressure in the mediastinum. Polyurethane foam and cannulas are placed in the wound and fixed to the surrounding tissue with sutures. The wound is completely covered with a transparent, self-adhesive plastic sheet and the cannulas are connected to a negative pressure of 125 mm Hg. In patients with postoperative mediastinitis, this technique provides a well-drained, mechanically stable wound.
Normally, the VAC technique should be avoided in patients with ongoing bleeding. However, in this report, we describe the use of a modified VAC technique to control severe postoperative bleeding due to coagulopathy. Coagulation dysfunction appeared after the implantation of a biventricular cardiac assist device in a patient with end-stage heart failure.
A 61-year-old woman with dilated cardiomyopathy and severe heart failure was admitted to our department and accepted for heart transplantation. Echocardiography demonstrated a left ventricular ejection fraction of less than 20% with both mitral valve and tricuspid valve insufficiency due to dilatation. At the time of admission, the patient was treated with intravenous diuretics and extensive inotropic support (frusemide, ethacrynic acid, phosphodiesterase inhibitor, dobutamine, dopamine). Despite aggressive pharmacologic treatment, cardiac function deteriorated and additional symptoms of liver (spontaneous INR was 2.2) and kidney dysfunction (oliguria) appeared.
Because of the worsening situation, we decided to implant a left ventricular assist device as a bridge to heart transplantation. A HeartMate VE LVAS (Thoratec Corporation, Pleasanton, CA) was implanted during extracorporeal circulation and cardioplegic arrest, with the inflow graft in the apex and the outflow graft in the ascending aorta. After 20 minutes of reperfusion on bypass, the hemodynamic situation was stable with a cardiac output of 4 L-1 min-1. Two hours after arrival at the intensive care unit, low-output syndrome developed in the patient, and acute echocardiography verified right ventricle failure. The patient was immediately returned to the operating theater and a right ventricular assist device, Abiomed BVS 5000 (Abiomed Inc, Danvers, MA), was implanted with the inflow cannula from the right auricle and the outflow cannula to the pulmonary artery.
No anticoagulant was given to the patient postoperatively, as blood samples indicated coagulopathy. The patient experienced thrombocytopenia (Trc 46 x 109/L) with an increased D-dimer level (0.9 mg-1L-1) and a normal antithrombin III level (86%).
On postoperative day 3, the patient was successfully weaned from the right ventricular assist device. During the explantation procedure, approximately 1,500 mL of sanguineous fluid and blood clots were removed from the mediastinum and pleural cavities. In addition, almost 500 mL of blood was drained from the chest tubes the same day.
During postoperative day 4, the patient developed clinical and echocardiographic signs of acute heart tamponade. The bleeding could not be controlled in the intensive care unit, despite treatment with fresh frozen plasma, platelet concentrates, aprotinin, desmopressin, and tranexamic acid. Therefore, the patient underwent emergent reoperation.
Further surgery was necessary on postoperative day 5 because of diffuse bleeding. This time, we implanted a negative pressure system. Separate chest tubes (Argyle, Sherwood Medical, Tullamore, Ireland) were placed in the pleural cavities and the mediastinum was opened bilaterally. To achieve hemostasis, several surgical sponges (Mölnlycke, Gothenburg, Sweden) were placed around the heart and the cardiac assist device. A transparent, self-adhesive plastic sheet (KCI, Copenhagen, Denmark) was draped over the wound and a negative pressure of 20 cm H2O was applied to the pleural cavities. Because the mediastinal pleura had been opened bilaterally, the negative pressure of 20 cm H2O sucked the self-adhesive plastic sheet inward over the surgical sponges and into the mediastinum. The purpose of the negative pressure was to establish a tamponade effect between the mediastinal tissue and the surgical sponges. This action was successful, and the bleeding decreased promptly from more than 300 mL-1h-1 to less than 40 mL-1h-1.
Two days later, there were no signs of bleeding. Because the patient had undergone surgery several times, we decided to implant the VAC system to avoid postoperative infection. The chest tubes in the pleural cavities were removed and the surgical sponges replaced with polyurethane foam (KCI, Copenhagen, Denmark). The foam was placed in front of the heart covering the inflow and outflow cannulas of the HeartMate. Two transparent, self-adhesive plastic sheets (KCI, Copenhagen, Denmark) were placed over the wound as an external cover. Two noncollapsible plastic tubes (KCI, Copenhagen, Denmark) were fixed to the foam through the plastic sheets. Because of the foam adjacent to the heart, a negative pressure of 50 mm Hg was applied. After 3 more days, the polyurethane foam was explanted and the sternum was closed. The VAC system was now applied subcutaneously in front of the sternum. Four days later, the presternal VAC system was removed and the wound closed. At the 90-day follow-up, the patient was placed on the transplant list and her physical condition continued to improve.
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  T. Fleck, B. Kickinger, R. Moidl, F. Waldenberger, E. Wolner, M. Grabenwoger, and W. Wisser Management of open chest and delayed sternal closure with the vacuum assisted closure system: preliminary experience Interactive CardioVascular and Thoracic Surgery, October 1, 2008; 7(5): 801 - 804. [Abstract] [Full Text] [PDF]
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