Spontaneous right ventricular disruption following treatment of sternal infection

Spontaneous right ventricular disruption is a rare and frequently catastrophic event that occurs during the treatment of mediastinitis complicating median sternotomy wound.

The purpose of this study is to understand the pathogenesis of the spontaneous right ventricular disruption and to suggest strategies for the prevention and treatment of this rare but potentially fatal complication of cardiac surgery.

We report three cases as an introduction to the review of 39 cases found in the English-language literature.

The majority of patients (71%) underwent coronary artery bypass grafting as the primary procedure prior to the development of a sternal infection. Staphylococcus Aureus and Staphylococcus Epidermidis were cultured most frequently from the sternal wound (31% and 24%, respectively). The mean interval between sternal debridement and the right ventricular disruption was 2.9 days. Most patients (24 of 42) required cardiopulmonary bypass for the repair of the right ventricular disruption. Biologic patches and adjuncts were used in 15 patients (36%). Eight patients (19%) died either preoperatively or on the operating-room table.

Spontaneous right ventricular disruption is a potentially preventable complication. To prevent this complication we recommend: (1) avoidance of delay between diagnosis and operative treatment of mediastinitis; (2) complete lysis of adhesions between the posterior sternal edge and anterior surface of the right ventricle under general anesthesia with heart-lung machine stand-by; (3) repair of the right ventricular tear using biologic patches with heart-lung machine stand-by; (4) early (if possible immediate) closure of the chest with a myocutaneous flap.