MANAGEMENT AND PREVENTION OF CARDIOVASCULAR HEMORRHAGE ASSOCIATED WITH MEDIASTINITIS

Objective To elucidate the causes of cardiovascular hemorrhage associa ted with mediastinitis and to review recommendations for prevention an d treatment. Summary Background Data Mediastinal debridement with imme diate or early coverage using healthy, vascularized tissue has lead to greatly reduced morbidity and mortality for patients with mediastinit is. Myocardial hemorrhage has been anecdotally reported. Patients and Methods Over a 36-month period, 7 patients developed massive cardiovas cular bleeding after undergoing debridement for poststernotomy mediast initis. Causes included puncture or erosion by a sternal edge in three and tearing al the myocardial-sternal interface in four. Results Five patients survived and remain infection-free at an average of 24 month s of follow-up. In these patients, ventricular defects were closed wit h pledgeted sutures and muscle transposition was used concomitantly to reinforce the repair. This involved a slide of the left Pectoralis ma jor muscle and turnover of the right pectoralis in three patients, bil ateral sliding in one patient, and bilateral pectoralis and an omental flap in one patient who required additional coverage of the lower med iastinum. Conclusions When a patient who has undergone mediastinal deb ridement shows evidence of significant bleeding, we recommend applicat ion of pressure for control of hemorrhage, expeditious return to an op erating room with available cardiopulmonary bypass, and immediate musc le coverage with healthy, weil-vascularized tissue. Finally, early ste rnectomy might largely prevent this life-threatening complication.