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Ann Thorac Surg 2003;76:956-958
© 2003 The Society of Thoracic Surgeons

How to do it

Rectus abdominis myocutaneous flap after unsuccessful delayed sternal closure

Toshihiko Shibata, MDa*, Koji Hattori, MDa, Hidekazu Hirai, MDa, Hiromichi Fujii, MDa, Takanobu Aoyama, MDa, Shigefumi Seuhiro, MDa

a Department of Cardiovascular Surgery, Osaka City University Medical School, Osaka, Japan

Accepted for publication February 14, 2003.

* Address reprint requests to Dr Shibata, Department of Cardiovascular Surgery, Osaka City University Medical School, 1-4-3, Asahi-machi, Abeno, Osaka 545-8585, Japan
e-mail: shibata{at}msic.med.osaka-cu.ac.jp


   Abstract
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 Abstract
Introduction
 Technique
 Comment
 References
 
Open chest management is one of the best options for severely impaired hearts after open-heart surgery. Reapproximation of sternal edges compresses the heart, so a less compressive method of chest wall reconstruction should be considered when sternal closure must be delayed. We applied a rectus abdominis myocutaneous flap approach in 3 patients after difficulties with delayed sternal closures. Two patients were weaned off intraaortic balloon pumping and survived without respiratory troubles or wound complications. This alternative method of chest reconstruction is useful in patients after an unsuccessful delayed sternal closure.


   Introduction
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 Abstract
 Introduction
Technique
 Comment
 References
 
Sternal closure after cardiac surgery can be difficult when cardiac function is severely impaired. Sometimes the best option is to leave the sternum open to avoid compressing the heart. Although delayed sternal closure is possible in most cases, sternal approximation is sometimes impossible when cardiac dilation is sustained. We attempted to close the wound with a rectus abdominis myocutaneous flap and hoped to avoid cardiac compression.


   Technique
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 Abstract
 Introduction
 Technique
Comment
 References
 
Between January 1999 and May 2002, edges could not be approximated for sternum closure in 7 (1.4%) of 523 patients who underwent open-heart surgery with cold blood cardioplegic arrest. In these patients, the sternum was left open with separators and a scaphoid-shaped Esmarch bandage (Currie Laboratory, Monrovia, CA) was used as a skin substitute. In 3 patients, sternal approximation was impossible due to continued hemodynamic instability (Table 1).


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  		Table 1. Patient Characteristics

 
A 67-year-old woman suffered from mitral stenosis with cardiac cachexia. The chest wall could not be closed due to the marked cardiac edema after mitral valve replacement. Moreover a large hematoma developed on the right ventricle at the site of the epicardial pacing lead. The sternal edges could not be reapproximated, and so remained open with the separators. On postoperative day (POD) 7, an attempt at delayed sternal closure again failed, and so we applied a rectus abdominis myocutaneous flap. Postoperative hemodynamics were stable, and the intraaortic balloon pump was removed the next day. Though tracheostomy was carried out 12 days after the myocutaneous flap procedure, the patient could be weaned off the respirator 6 weeks later.

A 70-year-old woman had acute myocardial infarction of the left anterior descending artery. An emergent triple coronary artery bypass grafting was performed with an intraaortic balloon pump. Because of the broad myocardial infarction of the anterior septal wall, extreme dilation of the heart developed. On the POD 4, delayed sternal closure failed due to hemodynamic instability and arrhythmia. Delayed sternal closure failed once again on POD 7, so application of a rectus abdominis myocutaneous flap was undertaken. Because the left internal thoracic artery was used for the coronary artery bypass graft, the right rectus abdominis muscle was used.

A 73-year-old woman had severe aortic stenosis. She had a severe interstitial pneumonia with pulmonary hypertension (70 mm Hg). Aortic valve replacement was performed, but intraaortic balloon pumping was required because of biventricular failure and the patient left the operating room with her chest wall remaining open. On POD 2, delayed chest closure failed. A rectus myocutaneous flap procedure was successfully undertaken on POD 8, but the patient died on POD 14; severe interstitial pneumonia was demonstrated at autopsy.

Before the flap procedure, the integrity of the internal thoracic artery to the rectus abdominis muscle was confirmed using duplex echocardiographic scanning. The sternum was partially removed to avoid compressing the heart. Debridement of nonviable tissue and irrigation of mediastinum were performed. Mediastinal cultures were not performed. Skin and soft tissue were incised down to the anterior rectus abdominis fascia. The inferior epigastric artery was incised, and the presence of blood flow in the internal thoracic artery was verified. The rectus abdominis myocutaneous flap was carefully rotated to avoid kinking, and subcutaneous tissue was approximated with absorbable sutures. After a myocutaneous flap procedure, the chest wall was tightened with a chest band.

The two surviving patients are doing well without respiratory trouble at 18 and 13 months after their operations (Fig 1).



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  		Fig 1. Rectus abdominis myocutaneous flap rotated into position to reconstruct anterior chest wall in patient 2 (13 months after operation).

 

   Comment
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 Abstract
 Introduction
 Technique
 Comment
References
 
The reported incidence of open chest management after cardiac surgery ranges from 1.2% to 2% [1–5], and outcomes are often poor. Direct rewiring and skin closure is the usual method of delayed chest closure; however, chest closure inevitably compresses the heart to some extent. Given the grave consequences of cardiac compression, a method of chest wall reconstruction that does not compress the heart is required in these cases. The rectus abdominis myocutaneous flap provides better and wider coverage than does the pectoralis flap.

The use of rectus abdominis myocutaneous has been reported for the management of postoperative mediastinitis. Success in that clinical situation provided us with the basis for using this flap for delayed chest reconstruction. Francel and Kouchoukos [1] reported rectus abdominis myocutaneous flap for the reconstruction of the chest in 4 patients. The myocutaneous flap affords thick coverage and a variety of options for tailoring the skin segment to meet specific needs. A myocutaneous flap provides skin coverage without tension, and contributes to wound healing and protects against infection. Before raising the flap, the surgeon needs to ensure that the internal thoracic artery, on which the flap is based, is intact. If any question exists as to the integrity of the pedicle, duplex scanning should be undertaken.

Because an unfixed chest wall, one without sternal rewiring, may flail, we were concerned whether respiratory complications would develop. However, both survivors have had no significant respiratory trouble postoperatively.

We believe that the rectus abdominis myocutaneous flap is a useful method for reconstructing chest walls in patients with impaired cardiac function when the usual delayed sternal closure procedures have been unsuccessful.


   References
Top
 Abstract
 Introduction
 Technique
 Comment
 References
 

  1. Francel T.J., Kouchoukos N.T. A rational approach to wound difficulties after sternotomy: reconstruction and long-term results. Ann Thorac Surg 2001;72:1419-1429.[Abstract/Free Full Text]
  2. Anderson C.A., Filsoufi F., Aklog L., Farivar R.S., Byrne J.G., Adams D.H. Liberal use of delayed sternal closure for postcardiotomy hemodynamic instability. Ann Thorac Surg 2002;73:1484-1488.[Abstract/Free Full Text]
  3. Furnary A.P., Magovern J.A., Simpson K.A., Magovern G.J. Prolonged open sternotomy and delayed sternal closure after cardiac operations. Ann Thorac Surg 1992;54:233-239.[Abstract]
  4. Mubeen M., Dan S., Agarwal S.K., Srivastava A.K., Kanhere V.M. Delayed sternal closure after cardiac operations. Asian Cardiovasc Thorac Ann 2001;9:82-85.[Abstract/Free Full Text]
  5. Mestres C.A., Pomar J.L., Acosta M., et al. Delayed sternal closure for life-threatening complications in cardiac operations: an update. Ann Thorac Surg 1991;51:773-776.[Abstract]



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This Article
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