Asian Cardiovasc Thorac Ann 2006;14:90
© 2006 Asia Publishing EXchange Ltd
DIRECT COMPLICATIONS OF STERNAL RE-ENTRY
Nagarajan Muthialu, DNB
Department of Cardiac Surgery, Nottingham City Hospital, United Kingdom
This is in reference to the article titled "Direct Complications of Repeat Median Sternotomy in Adults" by Mr Elahi et al.1 I notice that they have dealt with various aspects of the direct complications and the value of femoro-femoral bypass in those situations. I wanted to add few points to them2 and ask the author if he has any experience in those situations. First of all, as Mr Elahi mentioned, hemostasis is vital in sternal re-entry. So, as a routine factor, we use Aprotinin (Trasylol; Bayer AG, Germany) in half Hammersmith dose in all patients (1 million KI unit during induction of anesthesia and a further 1 million KI unit during initiation of CPB) with ACT maintained at least 700 during CPB. The incidence of bleeding complications and coagulopathy were noticed much less with this protocol. Certain dissection manoeuvres were quite useful especially in reentry situations. All patients had their groin electively prepared and kept ready for access if needed. We had to use only once for an emergency femoral arterial access for establishing CPB in an inadvertent right atrial injury. After sternotomy as mentioned, thorough dissection underneath of sternum either side is mandatory before the application of the sternal retractor. Dissection at the pedicle viz., aorta and the innominate veins is mandatory before further dissections as adhesions make vascular injury imminent if chest is wide open without any dissection in those areas. Further access for CPB can also be obtained if necessary before the heart itself is released. Any fat noticed while dissection around the heart belongs to heart and is always left with it. This reduces injury to various chambers and surface vessels together. If difficult, a patch of pericardium can also be left as island over the heart so as to avoid chamber entry. This is quite useful over right atrium at the sites for venous cannulation, as it provides layered buffering for hemostatic suture. Apart from these, some special situations do arise especially in redo coronary surgery. Any graft encountered is considered as harbouring disease in it and so handled gently. The grafts are always protected with extreme care and venous grafts and doubly ligated once the corresponding territory has been revascularised if possible. A special mention about the defibrillator in these patients – all of them should have surface defibrillator pad fixed to their lateral chest and posterior aspect of thorax as well. This is useful to defibrillate them even before a plane could be created for internal defibrillator. Finally if not least, if an alternate route can be used for access to surgery like various forms of thoracotomy, that can be used to avoid those potential complications of sternal reentry.
REFERENCE
- Elahi M, Dhannapuneni R, Firmin R, Hickey M. Direct complications of repeat median sternotomy in adults. Asian Cardiovasc Thorac Ann 2005;13:135–8.[Abstract/Free Full Text]
- Cohn LH. Evolution of Redo Cardiac Surgery: review of personal experience. J Card Surg 2004;19:320–4.[Medline]
