Spontaneous right ventricular rupture after sternal dehiscence: a preventable complication?

Abstract

Mediastinitis and/or sternal dehiscence developed in 143 out of 10,263 patients (1.4%) who underwent cardiac surgery between January 1979-December 1993. Mediastinal drainage, sternal debridement and early wound closure with pectoralis major and/or rectus abdominalis muscle flaps was the treatment employed. Between these two stages of treatment, massive hemorrhage developed in seven patients (0.07%) from a tear of the anterior wall of the right ventricle (RV). Six patients survived. Temporary control of the bleeding was achieved with digital or full palm pressure control of the ventricular tear. This was followed by immediate repair in the operating room (OR). The only death was due to exsanguination in the intensive care unit. The other six patients were taken to the OR. The anterior RV was freed from the underside of the sternum and the RV tear repaired with or without the aid of femoral-femoral bypass. These six then had muscle flap wound closures at that time or shortly after. All six were hospital survivors and are currently alive. We believe that RV rupture results from the sternal edges pulling the anterior surface of the RV apart, since the RV is stuck to the underside of the sternum. This experience indicates that the RV must be freed in all cases during initial sternal debridement. Hopefully this simple maneuver will prevent this horrendous complication.

Experience with Vacuum-Assisted Closure of Sternal Wound Infections Following Cardiac Surgery and Evaluation of Chronic Complications Associated with its Use

“…Another advantage attributed to the use of VAC system is stabilization of the sternal halves 15 . This reduces the shear forces between the beating heart and the sternum, and may prevent the rare but fatal complication of right ventricular rupture 24 . We have observed one case of right ventricular rupture in a patient with VAC system in place.…”

Profuse Mediastinal Hemorrhage due to Mediastinitis after a Sternal Infection

“…[2][3][4][5] However, no case similar to ours was found in the English literature in a PubMed search (available at http://www.ncbi.nlm.nih.gov/pubmed/), using "rupture" and "hemorrhage" connected with "mediastinitis" as index words. This is the first report of an ascending aorta hemorrhage due to recurrent mediastinal infection after irradiation for sternal bone metastasis from breast cancer.…”

Post-Mediastinitis Ventricle Rupture:. Closing the Chest Without Closing the Heart?

“…Most of the time, right ventricle rupture occurs after a coughing effort because of chest wall adhesions from the anterior wall of the right ventricle. Several authors suggest that the initial surgical debridement should include an extensive slitting up of the left side of the sternum to free the right ventricle from any chest wall adhesions and to decrease the pulling tension during chest wall movement 2,4 . When right ventricle rupture occurs, the previously described surgical management is complex and includes a four‐step procedure: first, use of femoral‐femoral cardiopulmonary bypass; second, mediastinum exploration and release of chest wall adhesions; third, repair of the right ventricle tearing, and fourth, wound closure 5,6 .…”

“…debridement should include an extensive slitting up of the left side of the sternum to free the right ventricle from any chest wall adhesions and to decrease the pulling tension during chest wall movement. 2,4 When right ventricle rupture occurs, the previously described surgical management is complex and includes a fourstep procedure: first, use of femoral-femoral cardiopulmonary bypass; second, mediastinum exploration and release of chest wall adhesions; third, repair of the right ventricle tearing, and fourth, wound closure. 5,6 However, detaching the heart from the chest wall may be hazardous in case of a coronary artery bypass graft using the mammary artery, which is frequent.…”