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Ann Thorac Surg 2006;82:1110-1111
© 2006 The Society of Thoracic Surgeons

Case report

Cardiac Rupture During Vacuum-Assisted Closure Therapy

Ulrik Sartipy, MDa,*, Ulf Lockowandt, MD, PhDa, Jakob Gäbel, MDb, Lena Jidéus, MD, PhDc, Göran Dellgren, MD, PhDa

a Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Karolinska Institutet, Stockholm
b Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg
c Department of Cardiothoracic Surgery, Uppsala University Hospital, Uppsala, Sweden

Accepted for publication January 13, 2006.

* Address correspondence to Dr Sartipy, Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, SE-171 76 Sweden (Email: ulrik.sartipy{at}karolinska.se).


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Vacuum-assisted closure therapy is a recently introduced technique for treatment of deep sternal wound infections after cardiac surgery. We present five cases of vacuum-assisted closure therapy-related major bleeding complications due to rupture of the right ventricle. This potentially lethal complication may be avoided by covering the heart with protective layers of paraffin gauze dressings.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
The best treatment for deep sternal wound infections after cardiac surgery has yet to be determined. Vacuum-assisted closure (VAC) therapy is a new and promising alternative to conventional treatment and is easy to apply. However, life-threatening complications may arise, and possible actions to prevent these are discussed.

Institutional review board approval was obtained and informed consent was waived for the patients in this study. Five patients underwent reoperations 10 to 26 days after cardiac surgery due to deep sternal wound infection (Table 1). In all patients the wound was surgically revised and VAC therapy was initiated. A continuous negative pressure of 125 mm Hg was applied. Every 2 to 3 days, the wound was revised, the polyurethane foam was changed, and VAC therapy was re-started. Paraffin gauze was placed in the wound cavity underneath the polyurethane foam to protect the heart. However, in these cases an insufficient number of layers were used or the paraffin gauze was only partially covering the right ventricle. After 2 to 10 days of VAC treatment, severe bleeding from a rupture in the right ventricle occurred. In case 4, the bleeding occurred only 30 minutes after initiation of VAC therapy. Even though the lacerations in the right ventricle were repaired in all patients, the outcome was fatal in three cases due to massive blood loss. All cases were performed in Sweden at three institutions between 2003 and 2005.


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  		Table 1. Characteristics, Course and Consequence in 5 Patients With Vacuum-Assisted Closure Therapy Related Right Ventricular Rupture
 

   Comment
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 Abstract
 Introduction
 Comment
References
 
Vacuum-assisted closure therapy is a new and promising alternative to conventional treatment of deep sternal wound infections after cardiac surgery [1–3]. This therapy is easy to apply but there are pitfalls, as illustrated by this collection of case reports from three different institutions in Sweden, as well as those reported in two cases by Abu-Omar and colleagues [4]. There are at least two key issues that are important to avoid this dreaded complication in the future. First it is essential to cover the heart. Second, it is necessary to fixate the sternum. As with all devices approved for clinical practice, it is important to adhere to the manufacturer's (KCI Medical AB, Solna, Sweden) instructions for use. In order to effectively prevent direct exposure of the heart, lung, or grafts to the VAC therapy polyurethane foam, it is the manufacturer's recommendation to place three or four protective layers of paraffin gauze as described by Gustafsson and colleagues [2]. Meticulous inspection of the sternal edges is warranted to discover any sharp edges that may damage the underlying right ventricle. In all of the reported cases, failure to correctly cover the heart with paraffin gauze may have contributed to the tearing of the right ventricle.

Gustafsson and colleagues [2] also describe a two-layer technique of placing the polyurethane foam. The first layer was cut as a strip and trimmed to fit between the sternal edges. This layer was used to seal the gap between the bone edges. The second layer of foam was used to cover the wound and was placed subcutaneously. This method is supposed to effectively fixate the sternal edges when a vacuum is applied. In addition, it may reduce the risk of shearing stress and displacement of sternal halves that otherwise may result in tearing of the adherent right ventricle.

Properly applied VAC therapy has been demonstrated to be a safe treatment option. More than 80 patients have subsequently undergone VAC therapy without major bleeding complications at our institutions. In the recently published largest series of VAC therapy for poststernotomy mediastinitis [3], there were no major bleeding complications reported.

The importance of covering the heart with paraffin gauze is illustrated by this report. The ease of performing VAC revisions may be deceptive and could make one forget the risks and the need for surgical experience and continuity in handling the VAC therapy. It was also noted in our series that VAC revision was commonly performed after hours by different junior on-call surgeons.

In conclusion, we present five cases with VAC therapy-related major bleeding complications due to rupture of the right ventricle. This potentially lethal complication may be avoided by covering the heart with protective layers of paraffin gauze dressings and ensure fixation of the sternal halves.


   References
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 Abstract
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 Comment
 References
 

  1. Cowan KN, Teague L, Sue SC, Mahoney JL. Vacuum-assisted wound closure of deep sternal infections in high-risk patients after cardiac surgery Ann Thorac Surg 2005;80:2205-2212.[Abstract/Free Full Text]
  2. Gustafsson RI, Sjogren J, Ingemansson R. Deep sternal wound infectiona sternal-sparing technique with vacuum-assisted closure therapy. Ann Thorac Surg 2003;76:2048-2053.[Abstract/Free Full Text]
  3. Sjogren J, Gustafsson R, Nilsson J, Malmsjo M, Ingemansson R. Clinical outcome after poststernotomy mediastinitisvacuum-assisted closure versus conventional treatment. Ann Thorac Surg 2005;79:2049-2055.[Abstract/Free Full Text]
  4. Abu-Omar Y, Naik MJ, Catarino PA, Ratnatunga C. Right ventricular rupture during use of high-pressure suction drainage in the management of poststernotomy mediastinitis Ann Thorac Surg 2003;76:975.[Free Full Text]



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