Selective approach to sternal closure after exploration for hemorrhage following coronary artery bypass

Thirty-six (4.6%) patients required exploration for hemorrhage after 788 coronary artery bypass grafting procedures. Twenty-three (64%) patients with a specific site of bleeding that was surgically controlled or with improving coagulopathy were managed by immediate sternal closure. Continued hemorrhage or tamponade necessitated reexploration in 5 of these patients. All 5 patients were then treated by open sternotomy and delayed sternal closure. There were no deaths or sternal wound infections in this subgroup. Thirteen (36%) patients explored for hemorrhage were initially treated by open sternotomy and delayed sternal closure because of ongoing coagulopathy with refractory bleeding. Twelve patients recovered without further complication. One patient died 30 days after delayed sternal closure. There were no sternal wound infections. This experience supports a selective approach to sternal closure after exploration for hemorrhage following coronary artery bypass grafting. Immediate closure is recommended if a specific site of bleeding can be located and corrected. However, in the presence of refractory hemorrhage due to coagulopathy, delayed sternal closure should be considered to avoid the subsequent morbidity of continued bleeding, including cardiac tamponade, multiple reexplorations with sternal trauma, and retained mediastinal hematoma.     

Mediastinal hematoma due to thymoma hemorrhage--a case report

A 70-year-old man came to our hospital complaining mainly of acute dyspnea. A chest X-ray, echocardiogram, and chest CT showed a mediastinal mass, and pericardial and pleural effusions. A thoracotomy revealed a cystic tumor along the thymus. The tumor contained bloody fluid, coagula, and fibrin calculi. Rapid specimens showed no tumor cells and the hematoma was assumed to have been caused by the thymus. Therefore, a thymectomy was performed and as much of the hematoma as possible was removed. After the operation, a careful pathological examination revealed a thymoma with a diameter of about 7 mm. In addition, coagula and fibrin calculi contained some tissue from the thymoma, and the diagnosis was made that a mediastinal hematoma had formed due to hemorrhage from the thymoma. Several cases of mediastinal tumor of cyst hemorrhages in the thorax have been reported. However, only a few cases of thymomal hemorrhages in the thorax have been reported; one case each of mediastinal hematoma, hemothorax, and cardiac tamponade. Great care is necessary when dealing with atraumatic mediastinal hematomas if malignant tumors such as thymoma are present.     

Survival after blunt traumatic rupture of the left ventricle

There have been 11 reported survivors from blunt-trauma-induced right ventricular rupture and only three from left ventricular rupture. We report the fourth case of a survivor of blunt left ventricular rupture. This patient presented with hypotension from both hemorrhage into the left chest and pericardial tamponade. The tamponade was relieved via an emergent left thoracotomy, the bleeding from the rent in the left ventricle was easily controlled, and repair was straightforward.     

Influence of primary closure of the pericardium after open-heart surgery on the frequency of tamponade, postcardiotomy syndrome, and pulmonary complications.

Experiences with primary closure of the pericardium in a series of 100 patients undergoing open-heart operations are described. The pericardium was kept under tension during the operation to minimize shrinkage and permit closure at the end of the procedure. In 28 patients one pleural space was opened for drainage, whereas in 72 patients intra- and extrapericardial sumps alone were used for drainage. Measurements of sump drainage revealed that most postoperative bleeding originates from outside the pericardium. There were no instances of cardiac tamponade although 19 patients lost more than 1 L. of blood after operation and 5 required reoperation for hemorrhage. Transpleural drainage tubes were shown to be ineffective and in addition were associated with a fourfold increase in postcardiotomy syndrome and a significantly greater frequency of pleural effusion and atelectasis when compared to the use of mediastinal sump drainage alone. We have concluded that closing the pericardium and using mediastinal sump drainage minimizes the risk of cardiac tamponade and allows early localization of the site of postoperative bledding. Another advantage of pericardial closure and drainage is that postoperative adhesions and postcardiotomy syndrome will be less significant. As a consequence the danger of injuring the heart in a subsequent operation is lessened.     

Resection of mediastinal teratoma in a patient with cardiac tamponade due to pericardial perforation

Benign teratoma of the mediastinum causes a variety of complications if left untreated, but reports of pericardial perforation have been rare. We report a case of mediastinal teratoma that perforated the pericardium and induced clinical cardiac tamponade. The patient was a 46-year-old male, who was admitted due to sudden chest pain. Since chest CT and echocardiography suggested perforation of the pericardium by a mediastinal teratoma, pericardial drainage was carried out. However, heart failure could not be resolved, and the tumor was resected on the 5th hospital day. From the intraoperative and pathologic findings, mature type mediastinal teratoma was found to have perforated the pericardium, causing massive influx of yellowish fluid from the cyst of the tumor. There have been only 10 cases reported to date in Japan and abroad in which mediastinal teratoma was complicated by cardiac tamponade.     

Intrapericardial teratoma presenting as recurrent pericardial tamponade: Report of a case

Intrapericardial teratomas are rare after infancy. An accurate diagnosis can only be made with a high index of suspicion. Most of the time, a mediastinal teratoma ruptures/perforates the pericardial cavity, thus causing either pericardial effusion or life-threatening tamponade. These factors emphasize the importance of an early surgical excision even for extrapericardial locations. This report presents the case of a 16-year-old girl with intrapericardial teratoma who presented with cardiac tamponade which is a rare complication of this rare tumor with only eight cases reported so far beyond infancy. This patient presented with recurrent tamponade, and underwent multiple procedures of pericardiocentesis and developed pyopericardium and polyserositis. This intrapericardial teratoma was not detected by imaging modalities.     

Postoperative care of the adult cardiac surgical patient

Most patients are ready to be transferred to a ward after 24–48 hours on a cardiac intensive care unit (CICU); however, several potential complications can occur during this period. The risks during transfer from theatre to CICU increase if a long distance is involved. A thorough handover to nursing staff is mandatory. Problems with blood pressure and arrhythmias are common on the CICU. Patients undergoing hypothermic cardiopulmonary bypass are at greater risk of hypothermia postoperatively. Multiple factors can cause postoperative cardiac surgical bleeding. Despite efforts to correct clotting abnormalities, patients occasionally need to return to theatre because of mediastinal bleeding or cardiac tamponade. The avoidance of multiorgan failure by maintaining good tissue perfusion and oxygenation is the main aim of perioperative care and through the initial postoperative period. Avoidance or treatment of a low cardiac output state often necessitates cardiac output monitoring and the use of inotropes, vasoactive drugs or mechanical assist devices such as an intra-aortic balloon pump. Established organ failure leads to a longer stay on a CICU, a growing proportion of patients having a protracted critical care stay.     

Catheter drainage of symptomatic postoperative mediastinal effusion guided by computed tomography. A nonoperative approach

Postoperative mediastinal effusion after cardiac operations is a common phenomenon and has a potential for serious complications, such as tamponade necessitating urgent drainage. Computed tomography of the chest provides excellent postoperative visualization of the mediastinum. Catheter insertion or paracentesis guided by computed tomography has been used to accomplish nonoperative drainage of symptomatic postoperative mediastinal effusion in six cases. This technique offers simplicity, safety, and cost effectiveness.     

Postoperative care of the adult cardiac surgical patient

Most patients are ready to be transferred to a ward after 24–48 hours on a cardiac intensive care unit (CICU); however, several potential complications can occur during this period. The risks during transfer from theatre to CICU increase if a long distance is involved. A thorough handover to nursing staff is mandatory. Problems with blood pressure and arrhythmias are common on the CICU. Drugs or pacing can be used to manipulate heart rate. Patients undergoing hypothermic cardiopulmonary bypass are at greater risk of hypothermia postoperatively. Active and passive warming methods are imperative to avoid complications of hypothermia. Multiple factors can cause postoperative cardiac surgical bleeding. Despite efforts to correct clotting abnormalities, patients occasionally need to return to theatre because of mediastinal bleeding or cardiac tamponade. The avoidance of multiorgan failure by maintaining good tissue perfusion and oxygenation is the main aim of perioperative care. Avoidance or treatment of a low cardiac output state often necessitates cardiac output monitoring and the use of inotropes, vasoactive drugs or mechanical assist devices such as an intra-aortic balloon pump. Established organ failure leads to a longer stay on a CICU; respiratory, renal, neurological and gastrointestinal complications account for a very few patients having a protracted critical care stay.     

Reversible total esophageal exclusion

A 23-year-old man with miliary tuberculosis had severe esophageal hemorrhage secondary to eroding tuberculous nodes. Balloon tamponade and packing with gauze did not alter the profuse bleeding. Empyema of the right thorax, massive mediastinal nodes, an unknown site of bleeding in the esophagus, and diffuse pulmonary involvement with tuberculosis precluded a thoracotomy. Because of widespread peritoneal tuberculosis, permanent esophageal exclusion by ligation was rejected as bowel interposition would have been extremely difficult at a later time. Reversible total esophageal exclusion was successfully utilized.     

Rupture of the ascending aorta after surgical resection for lung cancer--a case report

A rupture of the ascending aorta which occurred in a woman on the 13th postoperative day following a right upper lobectomy with mediastinal lymph node dissection for lung cancer is reported herein. Fortunately, the patient was rescued from a cardiac tamponade and hemothorax by emergency operation. The operative findings suggested a traumatic rupture of the aorta, however, lymph node dissection of the mediastinum could not be excluded as a possible cause. Therefore, careful mediastinal lymph node dissection should be carefully performed in operations for lung cancer.     

Desmopressin control of surgical hemorrhage secondary to prolonged bleeding time

Desmopressin has been used as a hemostatic agent in numerous hematological and nonhematological diseases. We report a case of surgical hemorrhage secondary to prolonged bleeding time of unexplained origin controlled with desmopressin.     

Efficacy of intravascular volume resuscitation in dogs with acute cardiac tamponade

Whether cardiac tamponade causes myocardial ischemia and whether volume resuscitation can improve coronary perfusion pressure and myocardial blood flow were studied by hemodynamic responses to three blood infusions of 15 ml/kg in dogs with left ventricular hypovolemia produced by cardiac tamponade (N = 10) or hemorrhage (N = 10). Coronary perfusion pressure decreased to 37 +/- 2 mm Hg with tamponade and 39 +/- 1 mm Hg with hemorrhage, causing significant blood flow decreases in both ventricles. Myocardial oxygen extraction increased significantly in both groups without affecting lactate extraction. Volume resuscitation after hemorrhage progressively restored hemodynamic variables to baseline values. Volume resuscitation after tamponade did not increase stroke volume, whereas it increased coronary sinus pressure to 19.2 +/- 1.0 mm Hg (p less than 0.05). Coronary perfusion pressure increased to 53 +/- 5 mm Hg following the first infusion (p less than 0.05), but exhibited no further improvement. Tamponade did not produce myocardial ischemia. Coronary perfusion pressure and blood flow were not restored to baseline values with volume resuscitation since coronary sinus pressure rose incrementally with each volume infusion.     

Nonoperative emergency treatment of variceal hemorrhage

The nonoperative management of acute variceal hemorrhage can control acute hemorrhage and allow stabilization of the patient prior to definitive therapy to prevent further bleeding episodes. Balloon tamponade, endoscopic sclerotherapy, and pharmacotherapy can stop acute variceal bleeding. Endoscopic sclerotherapy has the highest reported success rate, decreases the incidence of early rebleeding, and is the recommended first method to control bleeding.     

Penetrating injuries of the mediastinum

This study reviews 47 patients who were operated on for acute penetrating mediastinal wounds. These included 40 cases of cardiac tamponade, 2 mediastinal hematomas, 1 contused myocardium, 3 esophageal wounds, and 1 VSD. Stab wounds were most common (73%) followed by gunshot wounds (23%), and shotgun wounds (4%). When measured, central venous pressure was 15 cm or greater in 28 out of 32 patients (87.5%) with proven tamponade. By contrast, Beck's criteria (distended neck veins, distant heart sounds, hypotension) were noted in only 19 (48%) of 40 cases of tamponade. Emergency room pericardiocentesis resulted in improvement in 20 of 22 cases (91%), affording time for definitive operative therapy. The majority of entrance wounds (85%) occurred in the anterior mediastinal region. Peritoneal lavage in 15 cases yielded 5 true positive, 9 true negative, and 1 false positive tests. Most commonly injured areas were right ventricle (20 patients), left ventricle (11 patients), pericardium (5 patients), and right atrium (4 patients). Isolated esophageal injuries occurred in 3 of 11 gunshot wounds (27%). Complications were numerous (70%) and mortality ranges as follows: GSW 27% SW 15% SGW 0%. Central venous pressure determination and early pericardiocentesis are useful in suspected cases of tamponade. In GSW, an esophagogram is indicated to rule out isolated injury. Median sternotomy is the operative exposure of choice for mediastinal injuries causing cardiac tamponade.     

Immediate hemodynamic consequences of MAST inflation in normo- and hypovolemic anesthetized swine

Use of the military antishock trouser (MAST) remains controversial in part because its mechanism(s) of action are poorly understood. We studied two aspects of the hemodynamic response to MAST inflation in 14 anesthetized swine. First, in six swine the relation that existed between inferior vena cava flow and aortic pressure/cardiac output was determined before and during inflation of the MAST, and then before and after removal of 30% of the calculated blood volume. Inflation of the MAST before hemorrhage had little effect on cardiac output but increased aortic pressure by 25%. Inflation of the MAST after hemorrhage increased cardiac output by 41% and increased aortic pressure by 62%. Three different inflation pressures were studied (40, 80, and 120 mm Hg) and were found to give equivalent results. Inflation of the MAST translocated about 3 ml/kg of blood to the heart. A second group of eight swine were instrumented so that the radiomicrosphere technique could be used to measure organ blood flow. Inflation of the MAST following hemorrhage increased coronary perfusion by 50% and cerebral perfusion by about one third. Flow to kidney, liver, and small intestine was not changed. We conclude that, in addition to tamponade of venous bleeding and the splinting of lower extremity fractures, use of the MAST might cause a clinically important increase in the perfusion of the heart and brain in some trauma patients.     

Rupture of the ascending aorta after surgical resection for lung cancer —A case report—

A rupture of the ascending aorta which occurred in a woman on the 13th postoperative day following a right upper lobectomy with mediastinal lymph node dissection for lung cancer is reported herein Fortunately, the patient was rescused from a cardiac tamponade and hemothorax by emergency operation. The operative findings suggested a traumatic rupfure of the aorta, however, lymph node dissection of the mediastinum could not be excluded as a possible cause. Therefore, careful mediastinal lymph node dissection should be carefully performed in operations for lung cancer.     

Enoxaparin associated with hugh abdominal wall hematomas: a report of two cases

Enoxaparin is a low-molecular-weight heparin used for prophylaxis against deep venous thrombosis. Indications include hip and knee replacement surgery, risk of deep venous thrombosis during abdominal surgery, and prevention of ischemic complications of unstable angina and non-Q-wave myocardial infarction. Its efficacy in the prevention of the above complications has been previously studied; however, the liberal use of enoxaparin is not without incident. Complications of enoxaparin include hemorrhage, thrombocytopenia, and local reactions. Since 1993 there have been more than 40 reports of epidural or spinal hematoma formation with the concurrent use of enoxaparin and spinal/epidural anesthesia or spinal puncture. Herein reported are two cases of abdominal wall hematomas in patients receiving prophylaxis with enoxaparin. Both patients sustained an unexplained fall in the hematocrit and abdominal pain. A CT scan confirmed the diagnosis. One patient recovered uneventfully; however, the other patient, on chronic hemodialysis, became hemodynamically unstable and hyperkalemic and sustained a fatal cardiac arrhythmia. An extensive review of the literature revealed no similar cases of abdominal wall hematomas associated with enoxaparin although other complications, including spinal and epidural hematomas, psoas hematomas, and skin necrosis have been reported. The extended use of enoxaparin as an anticoagulant requires the physician to be vigilant of these rare complications. Bleeding can occur at any site during therapy with enoxaparin. An unexplained fall in the hematocrit or blood pressure should lead to a search for a bleeding site.     

Aortic dissection and pericardial tamponade causing compression of the pulmonary arteries in a patient with prior cardiac surgery

A patient with prior aortic valve surgery presented with aortic dissection and pericardial tamponade, with subsequent compression of the pulmonary arteries. While both expanding pericardial effusions and aortic dissections have been reported to cause compression of other adjacent structures, compression of the pulmonary artery vasculature in a patient with prior cardiac surgery has never been described. In this case report, we highlight this situation, which may have occurred because of alterations in the pericardial and mediastinal spaces.     

Does more than a single chest tube for mediastinal drainage affect outcomes after cardiac surgery?

Background

The use of 1 or more mediastinal chest tubes has traditionally been routine for all cardiac surgery procedures to deal with bleeding. However, it remains unproven whether multiple chest tubes offer a benefit over a single chest tube.

Methods

All consecutive patients undergoing cardiac surgery (2005–2010) received at least 1 chest tube at the time of surgery based on surgeon preference. Patients were grouped into those receiving a single chest tube (SCT) and those receiving multiple chest tubes (MCT). The primary outcome was return to the operating room for bleeding or tamponade.

Results

A total of 5698 consecutive patients were assigned to 2 groups: 3045 to the SCT and 2653 to the MCT group. Patients in the SCT group were older, more often female and less likely to undergo isolated coronary artery bypass graft than those in the MCT group. Unadjusted outcomes for SCT and MCT, respectively, were return to the operating room for bleeding or tamponade (4.7% v. 5.0%; p = 0.50), intensive care unit stay longer than 48 hours (25.5% v. 27.9%; p = 0.041, postoperative stay > 9 days (31.5% v. 33.1%; p = 0.20) and mortality (3.8% v. 4.6%; p = 0.16). Logistic regression analysis, adjusted for clinical differences between groups, showed that the number of chest tubes was not associated with return to the operating room for bleeding or tamponade.

Conclusion

The use of multiple mediastinal chest tubes after cardiac surgery confers no advantage over a single chest tube in preventing return to the operating room for bleeding or tamponade.