VENTRICULAR PERFORATION BY STERNOTOMY WIRE IN A DEHISCED STERNAL WOUND OF POST-CABG PATIENT

SESSION TITLE: Cardiothroacic Surgery Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Ventricular perforation and sternal wound dehiscence both are serious complications in a post-CABG patient. We are presenting a case, where a post-CABG patient developed sternal wound dehiscence due to excessive coughing. The patient then suddenly decompensated during a routine position change and was found to have ventricular perforation from a displaced sternal wire. CASE PRESENTATION: A seventy-eight-year-old male with history of hypertension, prediabetes, coronary artery disease, and severe aortic stenosis presented to the emergency department complaining of chest pain. His first cardiac catheterization showed significant stenosis of the right coronary artery (RCA) with stent placement. Second cardiac catheterization one month prior to the current visit showed 20% stenosis of the left main coronary artery, 70% stenosis in the ostial diagonal branch 1 of LAD, 100% occlusion of left circumflex artery, 100% occlusion of the obtuse marginal artery, and 70% restenosis of RCA. CABG was performed. The patient was extubated on POD 9 to NC 6 lit. Post-extubation, he developed a severe cough and wheezing requiring a pulmonology consult. He was started on antibiotics again along with steroids and diuresis. On POD 18, chest x-ray showed lower sternal wound dehiscence (Fig. 1). CT chest was ordered, which showed sternal disunion likely requiring repair. Patient was reintubated, underwent elective exploration of chest wound and insertion of bilateral chest tube with wound vac application to the sternum. Lower sternal wires were broken hence were removed. After bilateral chest tubes placement, a significant reduction in bilateral pleural effusion was noticed. On POD 21, he was turned as a part of routine cleaning. Though precautions were taken to avoid turning the upper body, unfortunately the upper body turned as well. Thus, when the patient was laid back supine, suddenly his BP dropped to systolic 40 mmHg with massive gush of bleeding from sternal wound and wound vac. Patient underwent chest re-exploration, a displaced sternal wire was found to be in the anterior right ventricular wall, which was removed and the ventricle was repaired. All wires were emergently removed (Fig 2). On POD 28, he was transferred to an outside facility. He underwent right rectus flap placement and bilateral pectoralis major Myo-cutaneous flap closure of the dehisced wound. The patient recovered successfully, and was extubated on POD 34. DISCUSSION: Our patient suffered 2 rare and devastating post-CABG complications: Sternal wound dehiscence as a result of excessive coughing from premature extubation, and right ventricular perforation from displaced sternotomy wire. This case also outlines physical manipulation to clean the patient, and every 2 hour turning of intubated patients is a routine nursing practice in an acute care setting, but care should be taken in patients with sternal dehiscence and wires in place. CONCLUSIONS: Simple turning maneuver in a patient with a dehisced sternal wound, resulted in sternal wire dislocation leading to right ventricular perforation. Such cardiac injury due to physical manipulation is not a frequently encountered etiology of right ventricular perforation. Protocols should be initiated emphasizing special training in post-op care in cardiac rehabilitation units related to moving and turning patients. REFERENCE #1: Silverborn M, Heitmann LA, Sveinsdottir N, Rögnvaldsson S, Kristjansson TT, Gudbjartsson T. Non-infectious sternal dehiscence after coronary artery bypass surgery. J Cardiothorac Surg. 2022;17. doi:10.1186/s13019-022-02015-1 REFERENCE #2: O'Brien DJ, Baghaffar A, EL-Andari R, DiQuinzio C, Ali IM. Right ventricular laceration caused by sternal wire fracture following cardiac surgery: a case report. Indian Journal of Thoracic and Cardiovascular Surgery. 2022;38. doi:10.1007/s12055-022-01333-2 REFERENCE #3: Santarpino G, Pfeiffer S, Concistré G, Fischlein T. Sternal wound dehiscence from intense coughing in a cardiac surgery patient: could it be prevented? clinical practice Fig. 1-Chest computed tomography scan with color-coded three-dimensional reconstruction (anterior view) after the episode of intense coughing. 2013 pp. 112–113. DISCLOSURES: No relevant relationships by Nayaab Bakshi No relevant relationships by Mit Chauhan No relevant relationships by Asma Jamil No relevant relationships by Richard Miller