Asian Cardiovasc Thorac Ann 2006;14:e19-e20
© 2006 Asia Publishing EXchange Ltd
Video-Assisted Thoracic Surgery for Hemothorax Following Coronary Artery Bypass
Shivpreet S Samra, FRCS,
Navdeep S Samra, MS,
Ajeet Jain, MCh,
Vipin Mehta, MS
Department of Cardiovascular and Thoracic Surgery, Fortis Heart Institute, Mohali, India
For reprint information contact: Shivpreet S Samra, FRCS Tel: 91 172 509 0928 Email: sssamra{at}rediffmail.com, 4493 Darshan Vihar, Sector 68, Mohali, Punjab, India.
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ABSTRACT
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A 56-year-old man complained of dyspnea and cough 9 days after coronary artery bypass grafting. Chest radiography showed opacity and left lung collapse. Following removal of clots from the pleural cavity by videothoracoscopy, he recovered without further incident. Video-assisted thoracic surgery is a feasible and safe option in the management of early hemothorax.
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INTRODUCTION
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Videothoracoscopy is a proven technique in the investigation, diagnosis, staging, and treatment of intrathoracic diseases. We report the use of the technology in a patient to manage hemothorax that developed after coronary artery bypass grafting (CABG).
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CASE REPORT
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A 56-year-old man underwent CABG using the left internal mammary artery (IMA) and the great saphenous vein. He was discharged on postoperative day 6 but presented with dyspnea and cough 3 days later. Clinical examination revealed silent chest on the left side. A chest radiograph showed opacification of the left hemithorax and collapse of the left lung (Figure 1
). Echocardiography showed no pericardial effusion and a left ventricular ejection fraction of 55%.
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Figure 1. Chest radiograph showing opacification of the left hemithorax and collapse of the left lung.
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Under general anesthesia, thoracoscopic evacuation was performed using a double-lumen endotracheal tube. The usual vital parameters, such as mean arterial pressure, arterial blood gases, and hourly urinary output, were registered and electrocardiography carried out. The patient was then placed in the right lateral decubitus position. The operating table was flexed downward to widen the intercostal spaces and to lower the shoulder and hip to allow 360-degree rotation of the scope and other instruments. The left hemithorax was prepared and draped for possible open thoracotomy. A 10 mm primary port was made in the 6th intercostal space along the anterior axillary line for introducing a zero-degree telescope and other auxiliary equipment (B. Braun Aesculap, Tuttlingen, Germany). Another 10 mm port was established in the 6th intercostal space 5 cm behind the posterior axillary line through which the telescope was introduced to inspect the hemothorax. Fibrinous adhesions were divided using blunt dissection with large biopsy forceps. A carbon dioxide insufflator was used at a pressure of 8 mm Hg to improve visualization. There was no active bleeding site. The blood clots were removed using tissue and swab forceps and a high-suction evacuator. Saline lavage was done subsequently and chest tubes were placed. Under direct vision, a chest tube was placed through the primary port and directed apically; another chest tube was placed through the 6th intercostal space in the mid-axillary line and directed basally. The posterior port was sutured. The chest tubes were removed on postoperative day 2, and the chest radiograph showed an expanded lung (Figure 2). The patient was discharged the following day. He continued to be asymptomatic at follow-up 1 month later.
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DISCUSSION
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Impaired hemostasis and bleeding complications are an inherent risk of CABG. Re-operation for bleeding is required in 2% to 5% of patients.1 The risk of bleeding increases with age, a smaller body surface area, re-operation, grafting using bilateral IMAs, as well as preoperative use of heparin, aspirin, and thrombolytic drugs. Our patient was taking aspirin preoperatively. Bleeding into the hemithorax most often arises from IMA harvest.2,3 Our patient’s left IMA was harvested. The bleeding usually is not substantial enough to disrupt hemodynamics, but occasionally a sizable hemothorax can result over time from insidious, persistent bleeding. Unrecognized, hypovolemia may develop and transfusions may be required in addition to chest tube drainage and often re-exploration. Hemothorax may result in reduced pulmonary function because of compression of the lung, increased risk of infection in the affected lung, and the development of a fibrinous peel that must be removed eventually. Decortication by thoracoscopic surgery is most easily done in the early stages, before the fibrinous peel is completely organized.4,5
Surgical treatment of hemothorax aims at achieving 3 objectives: arresting the bleeding source, evacuating the pleural cavity, and re-expanding the lung.6 An open thoracotomy is associated with higher morbidity, more postoperative pain, and longer hospitalization. Moreover, in patients whose left IMA graft has been harvested, thoracotomy is likely to entail difficult dissection through postoperative adhesions,7 as in our case. Video-assisted thoracic surgery for early hemothorax following CABG has proved to be a feasible approach. In comparison with thoracotomy, the results can be achieved with less operative trauma, lower costs, shorter hospitalization, better cosmesis, and early return to normal activities.
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REFERENCES
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- Tomas A. Empyema and hemothorax. In: Yim APC, Hazelrigg SR, Izzat BM, Landreneau RJ, Mack MJ, Naunheim KS, editors. Minimal access cardiothoracic surgery. Philadelphia: Saunders, 2000:48–57.
- Katara AN, Samra SS, Bhandarkar DS. Thoracoscopic window for a post-coronary artery bypass grafting pericardial effusion. Indian Heart J 2003;55:180–1.[Medline]
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ABSTRACT
INTRODUCTION
