Mediastinitis-related right ventricular (RV) rupture is a potentially life-threatening complication of cardiac surgery. Our experience with this complication is analyzed.
All the cases of mediastinitis recorded since the introduction of a prospective database for our cardiac surgery program were reviewed. All the patients with bleeding from the anterior surface of the heart during this interval were analyzed.
Among the 953 consecutive patients who underwent heart surgery between January 2003 and May 2005, mediastinitis occurred in 20 cases (2.1%). All 20 patients had coronary artery surgery, three of them combined with aortic valve replacement. Four patients developed RV bleeding while waiting for their secondary chest closure. In the four cases, bleeding occurred between 1 and 6 days after sternal debridement. One patient died immediately of exsanguination. The other three had limited bleeding which could be repaired at bedside with direct sutures. All 3 patients had subsequent successful closure with pectoral flaps, but one eventually died of multiple cerebral emboli. Notably, the four bleedings occurred among the 12 patients (33%) who had their pericardium left open at the time of the initial cardiac operation, while no rupture occurred among the 8 patients (0%) who had their pericardium closed.
In this series, RV bleeding developed exclusively among patients who had their pericardium left opened during their initial cardiac operation. The RV tear likely resulted from the distraction of the sternal edges which was transmitted directly to the fragile RV wall.
In order to prevent this severe complication, we recommend systematic closure of the pericardium at the primary operation. When the pericardium has been left open, we recommend that the RV should be widely freed from the sternal edges during the debridement and that the chest should be closed as soon as possible.
Xavier Mueller, None.