Ann Thorac Surg 2005;80:2360-2362
© 2005 The Society of Thoracic Surgeons
Case report
Repair of Right Ventricular Free Wall Defect With a De-Epithelized Pedicled Myocutaneous Latissimus Dorsi Muscle Flap
Tapio Hakala, MD, PhD
a
,
*
,
Leena Berg, MD, PhD
a
,
Ensio Berg, MD
a
,
Kimmo Makinen, MD, PhD
a
,
Petri Sipola, MD
b
a Department of Surgery, Kuopio University Hospital, Kuopio, Finland
b Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
Accepted for publication July 9, 2004.
* Address correspondence to Dr Hakala, Department of Surgery, Kuopio University Hospital, PO Box 1777, FIN-70210 Kuopio, Finland (Email: tapio.hakala{at}kuh.fi).
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Abstract
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Rupture of the right ventricle may occur because of sternal dehiscence or mediastinitis after cardiac surgery. Direct suture, polytetrafluoroethylene patch, fasciae, and muscle flaps have been used to close a right ventricular rupture. A unique occurrence of repair of a full-thickness right ventricle defect with a de-epithelized myocutaneous flap is presented. Our patient experienced a rupture of the right ventricle complicating sternal wound infection. The rupture was reconstructed with a polytetrafluoroethylene patch, but the patch needed to be removed because of infection. The defect was reconstructed with a de-epithelized myocutaneous latissimus dorsi flap. The patient indicated no signs of complication during follow-up.
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Introduction
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Mediastinitis or sternal dehiscence after cardiac surgery can lead to a rupture of the right ventricular wall. We herein report the findings with regard to a patient who experienced a full-thickness right ventricular rupture that was repaired using a de-epithelized myocutaneous latissimus dorsi flap.
Our patient is a 67-year-old diabetic male with a history of hypertension and progressive angina pectoris. He underwent coronary artery bypass grafting with left internal mammary artery and saphenous vein grafts. Postoperative recovery was favorable and the patient was discharged on postoperative day 6.
Fever, drainage from the sternotomy wound, and sternal instability developed on postoperative day 14. The patient underwent debridement, sternal rewiring, and catheter irrigation. Intraoperative gram-stained and subsequent culture samples, including a bone specimen, consistently revealed S epidermidis. On postoperative day 28 the patient was returned to the operating room (OR) because the sternum was again unstable and drainage from the sternotomy wound continued. A sternectomy was performed and the median sternotomy wound was covered with a pedicled right latissimus dorsi myocutaneous flap.
On postoperative day 34 massive hemorrhaging occurred under the myofascial flap and the patient was urgently returned to the OR. A 3-cm-wide full-thickness rupture was identified on the anterior aspect of the right ventricle. The patient was placed on a normothermic femoral–femoral bypass and the rupture was repaired using a polytetrafluoroethylene (PTFE) patch. Thereafter the patient required prolonged mechanical ventilation and temporary hemodialysis. He also exhibited acalcylous cholecystitis, which was complicated by pseudomonas sepsis and he underwent a cholecystectomy using a right subcostal incision. After 8 weeks in the intensive care unit he, was transitioned to the surgical ward.
Three months after the repair of the right ventricle rupture, a fistula appeared beneath the latissimus dorsi flap. A computerized tomography (CT) scan revealed several fistulas continuing to the PTFE patch of the right ventricular wall and culture results of the drainage revealed multiresistant pseudomonas. Six weeks of conservative treatment with antibiotics and wound care failed to cure the fistula and the patient once again was returned to the OR for operative treatment. Initially the patient was positioned in the straight lateral decubitus position and a left myocutaneous latissimus dorsi flap was harvested. An elliptical island of skin and subcutaneous fat attached to the latissimus dorsi muscle were harvested, then the pedicle with the thoracodorsal vessels was dissected, and finally the flap was subcutaneously transposed to the sternotomy wound. The donor site was directly closed and the patient was situated into a supine position. Then he was placed on a hypothermic femoral–femoral bypass and the sternotomy wound was explored. The PTFE material was removed from the anterior right ventricle surface. The fascia of the harvested myocutaneous flap was very thin and thus not usable for the reconstruction of the defect. The skin of the myocutaneous latissimus dorsi flap was de-epithelized with a scalpel and scissors [1] and the de-epithelized skin was sutured with a continuous monofilament suture to reconstruct the defect in the right ventricle wall. Finally the muscle portion of the latissimus dorsi flap visible in the wound edge was skin grafted. Figure 1
illustrates the operative technique.
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Fig 1. Myocutaneous latissimus dorsi flap is harvested and the flap is subcutaneously transported to the sternotomy wound. The skin is de-epithelized. Next the de-epithelized skin will be sutured to reconstruct the defect on the right ventricle wall (thick arrow). (PTFE = polytetrafluoroethylene.)
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Postoperative recovery was favorable and the patient was discharged on postoperative day 28. There have been no signs of infection or thromboembolic complication during the 17 months of follow-up. Figure 2
illustrates a CT image of the chest 1 year after the final reconstruction.
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Fig 2. Sagittal computed tomography image 12 months postoperatively. The arrow indicates the de-epithelized patch of the right ventricular anterior wall. (LA = left atrium; LD = latissimus dorsi; LVOT = left ventricular outflow tract; PA = pulmonary artery; RV = right ventricle.)
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Comment
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Right ventricular rupture caused by mediastinitis or sternal dehiscence after cardiac surgery is a serious complication. Direct suture, PTFE patch, fasciae latae, and de-epithelized free dermal skin grafts as well as rectus abdominis and pectoralis major muscles have all been used to close full-thickness right ventricular ruptures [2–6]. A myocutaneous latissimus dorsi muscle flap has been used for the reconstruction of the infected sternotomy wound after cardiac surgery [7]. We used a PTFE patch for the primary closure of a right ventricle rupture, but it was later infected by multiresistant pseudomona bacteria. It would have been more suitable to use autogenous tissue to repair the right ventricular rupture in the presence of a staphylococcal infection, but the PTFE patch was used in an emergency operation as there were no signs of an active infection. Pseudomonas infection cannot be cured without graft excision [8], so we replaced the PTFE patch with autogenous tissue.
The use of a rectus abdominis flap in the reconstruction was contraindicated because a right side laparotomy through the subcostal incision had been performed and the left internal mammary artery had been harvested for graft. If full-thickness defects are reconstructed with muscle alone, without the muscle fascia, the initial hemostatic closure is difficult and the skeletal muscle exposed to circulation is highly thrombogenic [5]. We determined that hemostatic closure of the full-thickness defect was easy to obtain with de-epithelized skin. During 17 months of follow-up there has been no thrombus formation in the right ventricular cavity.
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References
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- Arnold PG, Pairolero PC. Intrathoracic muscle flaps in the surgical management of life-threatening hemorrhage from the heart and great vessels Plast Reconstr Surg 1988;36:831-837.
- Cohen M, Marshall MA, Goldfaden DM, Silverman NA. Repair of right ventricular free wall defect with a pedicled muscle flap Ann Thorac Surg 1987;44:651-652.[Abstract/Free Full Text]
- Ladin DA, Smith DP, Izenberg PH, Deschner WP. Acute repair of a full-thickness right ventricular defect with a composite myofascial pedicle flap Plastic Reconstruct Surg 1992;90:310-313.[Medline]
- Higgins RSD, Stahl R, Baldwin JC. Skin grafting for repair of cardiac laceration Ann Thorac Surg 1991;52:1161-1163.[Abstract/Free Full Text]
- Fansa H, Handstein S, Schneider W. Treatment of infected median sternotomy wounds with a myocutaneous latissimus dorsi muscle flap Scand Cardiovasc J 1998;32:33-39.[Medline]
- Calligaro KD, Veith FJ, Schwartz ML, Savarese RP, DeLaurentis DA. Are gram-negative bacteria a contraindication to selective preservation of infected prosthetic arterial grafts? J Vasc Surg 1992;16:337-346.[Medline]
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Abstract
Introduction
