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Ann Thorac Surg 2003;76:974
© 2003 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK
e-mail: yabuomar{at}doctors.org.uk
To the Editor:
We read with interest the article by Fleck and colleagues [1] describing their experience with the vacuum-assisted wound closure system. Poststernotomy mediastinitis after a cardiac surgical procedure carries substantial morbidity and mortality. A safe and effective strategy involving reexploration and debridement followed by application of high-pressure suction drainage through polyurethane foam for a period prior to delayed primary wound closure has been reported from our center [2]. Since adopting this method of management, we have encountered the rare complication of right ventricular (RV) rupture in 2 patients. The cases of these patients are summarized to highlight this serious complication and to discuss the lessons learned.
The first patient developed sternal instability with discharge 8 days after coronary artery bypass grafting. Reexploration, debridement, and application of high-pressure suction drainage were performed. The patient’s condition stabilized until on the 11th postoperative day, when acute hemodynamic compromise associated with a large output of blood from the mediastinal drains warranted emergent reexploration. This demonstrated rupture of the anterior RV wall, which was repaired with Teflon-pledgeted 3-0 Prolene (Ethicon) sutures.
The second patient manifested signs of poststernotomy mediastinitis on the seventh postoperative day, and his condition failed to improve with conservative management. Debridement and application of high-pressure suction drainage were undertaken. The patient was returned to the intensive therapy unit in a stable condition. As the level of sedation was reduced, RV wall rupture occurred when he coughed. Repair was carried out using cardiopulmonary bypass with circulatory arrest. The condition of both patients improved after repair. The dressings on the mediastinal wound were changed regularly, and ultimately pectoral flap reconstruction was performed.
Reported in only a handful of cases in the literature [3–7], RV rupture is a rare but potentially catastrophic event complicating poststernotomy mediastinitis. In our experience, two cases of RV rupture associated with the use of the high-pressure suction drainage system have occurred. We propose that RV wall rupture results from the overstretching of the right ventricle (RV), which is adherent to the sternum and adjacent chest wall, during a sudden increase in intrathoracic pressure (eg, coughing or vomiting), as suggested in previous reports [3, 8]. We have long thought that this suction drainage system splints the sternum, thereby reducing movement and potentially reducing the risk of RV rupture. This may be true in instances where there is considerable sternal destruction and when the heart is effectively free from the sternum. However, this was not the case in our 2 patients. The sternum was essentially intact, and the RV was adherent to its deeper aspect. Coughing led to separation of the sternal edges and thus to stretching and tearing of the RV.
Right ventricular rupture after poststernotomy mediastinitis is a rare complication of an infrequent condition. However, given that the cause of this complication is most likely mechanical coupled with the presence of adhesions between the RV and the posterior aspect of the sternum, we recommend mobilization of the RV on initial debridement and application of polyurethane foam. In theory, this should allow independent movement of the sternum and prevent shearing forces on the RV during sudden chest wall movements. We also recommend modifying the technique by reducing the suction from 125 mm Hg to 70 mm Hg after 72 hours of treatment. In addition, routine placement of paraffin gauze over the surface of the RV before applying the suction dressing may help reduce adhesions and minimize trauma between dressing changes.
References
This article has been cited by other articles:
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  M. Malmsjo, S. Lindstedt, and R. Ingemansson Effects of foam or gauze on sternum wound contraction, distension and heart and lung damage during negative-pressure wound therapy of porcine sternotomy wounds Interact CardioVasc Thorac Surg, March 1, 2011; 12(3): 349 - 354. [Abstract] [Full Text] [PDF]
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J. Sjogren, R. Gustafsson, J. Nilsson, S. Lindstedt, S. Nozohoor, and R. Ingemansson Negative-pressure wound therapy following cardiac surgery: bleeding complications and 30-day mortality in 176 patients with deep sternal wound infection Interact CardioVasc Thorac Surg, February 1, 2011; 12(2): 117 - 120. [Abstract] [Full Text] [PDF]
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A. Sachithanandan Negative pressure vacuum assisted closure therapy following cardiac surgery: safe and effective Interact CardioVasc Thorac Surg, February 1, 2011; 12(2): 120 - 120. [Full Text] [PDF]
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 R. Petzina, M. Malmsjo, C. Stamm, and R. Hetzer Major complications during negative pressure wound therapy in poststernotomy mediastinitis after cardiac surgery J. Thorac. Cardiovasc. Surg., November 1, 2010; 140(5): 1133 - 1136. [Abstract] [Full Text] [PDF]
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M. Malmsjo, R. Petzina, M. Ugander, H. Engblom, C. Torbrand, A. Mokhtari, R. Hetzer, H. Arheden, and R. Ingemansson Preventing heart injury during negative pressure wound therapy in cardiac surgery: Assessment using real-time magnetic resonance imaging J. Thorac. Cardiovasc. Surg., September 1, 2009; 138(3): 712 - 717. [Abstract] [Full Text] [PDF]
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C. Torbrand, A. Wackenfors, S. Lindstedt, R. Ekman, R. Ingemansson, and M. Malmsjo Sympathetic and sensory nerve activation during negative pressure therapy of sternotomy wounds Interact CardioVasc Thorac Surg, December 1, 2008; 7(6): 1067 - 1070. [Abstract] [Full Text] [PDF]
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 C. Anslot, S. Hulin, and Y. Durandy Postoperative Mediastinitis in Children: Improvement of Simple Primary Closed Drainage Ann. Thorac. Surg., August 1, 2007; 84(2): 423 - 428. [Abstract] [Full Text] [PDF]
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A. Mokhtari, R. Petzina, L. Gustafsson, J. Sjogren, M. Malmsjo, and R. Ingemansson Sternal stability at different negative pressures during vacuum-assisted closure therapy. Ann. Thorac. Surg., September 1, 2006; 82(3): 1063 - 1067. [Abstract] [Full Text] [PDF]
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L. F. L. Almodovar, A. C. Canas, P. P. Lima Canadas, and M. C. Hernandez Vacuum-assisted therapy with a handcrafted system for the treatment of wound infection after median sternotomy Interact CardioVasc Thorac Surg, October 1, 2005; 4(5): 412 - 414. [Abstract] [Full Text] [PDF]
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U. Fuchs, A. Zittermann, B. Stuettgen, A. Groening, K. Minami, and R. Koerfer Clinical Outcome of Patients With Deep Sternal Wound Infection Managed by Vacuum-Assisted Closure Compared to Conventional Therapy With Open Packing: A Retrospective Analysis Ann. Thorac. Surg., February 1, 2005; 79(2): 526 - 531. [Abstract] [Full Text] [PDF]
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J. Sjogren, R. Gustafsson, A. Wackenfors, M. Malmsjo, L. Algotsson, and R. Ingemansson Effects of vacuum-assisted closure on central hemodynamics in a sternotomy wound model Interact CardioVasc Thorac Surg, December 1, 2004; 3(4): 666 - 671. [Abstract] [Full Text] [PDF]
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