Is vacuum-assisted closure therapy the main culprit in right ventricular rupture after deep sternal wound infection?

Right ventricular rupture after deep sternal wound infection (DSWI) is a rare but fatal complication, and can occur with or without vacuum assisted closure (VAC) therapy. There is currently no strong evidence to suggest whether or not VAC therapy is a contributing factor to this complication. In total, 30 articles were retrieved and assessed through a systematic review strategy from 1953 to 2022. The keywords: 'vacuum assisted closure'; 'VAC'; 'negative pressure wound therapy'; 'deep sternal wound infection'; 'DSWI'; 'right ventricular rupture'; and 'cardiac rupture' were used in the search. Overall, 15 of the included articles satisfied the predefined eligibility criteria. Fatal right ventricular ruptures were reported in 18 (36%) out of 50 cases. In this article, the risk factors, mechanisms and management of right ventricular rupture are discussed. A novel view of the mechanism of VAC-associated right ventricular rupture is highlighted, with a focus on both pre- and intraoperative management.

C-reactive protein and leucocyte counts drop faster using the HeartShield® device in patients with DSWI.

Right ventricular heart rupture is a devastating complication associated with negative pressure wound therapy (NPWT) in cardiac surgery. The use of a rigid barrier disc (HeartShield™) has been suggested to offer protection against this lethal complication by preventing the heart from being drawn up by the negative pressure and damaged by the sharp sternum bone edges. Seven patients treated with conventional NPWT and seven patients treated with NPWT with a protective barrier disc (HeartShield) were compared with regard to bacterial clearance and infection parameters including C-reactive protein levels and leucocyte counts. C-reactive protein levels and leucocyte counts dropped faster and bacterial clearance occurred earlier in the HeartShield® group compared with the conventional NPWT group. Negative biopsy cultures were shown after 3·1 ± 0·4 NPWT dressing changes in the HeartShield group, and after 5·4 ± 0·6 NPWT dressing changes in the conventional NPWT group (P < 0·001). All patients were followed up with clinical check-up after 3 months. None of the patients in the HeartShield group had any signs of reinfection such as deep sternal wound infection (DSWI) or sternal fistulas, whereas in the conventional NPWT group, two patients had signs of sternal fistulas that demanded hospitalisation. HeartShield hinders the right ventricle to come into contact with the sharp sternal edges during NPWT and thereby protects from heart damage. This study shows that using HeartShield is beneficial in treating patients with DSWI. Improved wound healing by HeartShield may be a result of the efficient drainage of wound effluents from the thoracic cavity.

Patient With Missed Right Ventricular Rupture From Blunt Trauma Remains Hemodynamically Stable for 3 Days.

Cardiac chamber rupture from blunt trauma is rare but can be fatal. Surprisingly, in some subsets of patients, it can be subtle and rather easily missed. Rapid recognition and management are essential. Percutaneous closure can be successful in iatrogenic chamber perforation (during pericardiocentesis) but possibly not in traumatic chamber rupture. (Level of Difficulty: Intermediate.).

Oozing-type rupture caused by right ventricular intramural hematoma after right ventricular infarction.

An 81-year-old man was admitted to the hospital because of decreased level of consciousness. He had bradycardia (27 beats/min). Electrocardiography showed ST-segment elevation in leads II, III, and aVF and ST-segment depression in leads aVL, V1. Transthoracic echocardiography (TTE) visualized reduced motion of the left ventricular (LV) inferior wall and right ventricular (RV) free wall. Coronary angiography revealed occlusion of the right coronary artery. A primary percutaneous coronary intervention was successfully performed with temporary pacemaker backup. On the third day, the sinus rhythm recovered, and the temporary pacemaker was removed. On the fifth day, a sudden cardiac arrest occurred. Extracorporeal cardiopulmonary resuscitation was performed. TTE showed a high-echoic effusion around the right ventricle, indicating a hematoma. The drainage was ineffective. He died on the eighth day. An autopsy showed the infarcted lesion and an intramural hematoma in the RV. However, no definite perforation of the myocardium was detected. The hematoma extended to the epicardium surface, indicative of oozing-type RV rupture induced by RV infarction. The oozing-type rupture induced by RV infarction might develop asymptomatically without influence on the vital signs of the patient. Frequent echocardiographic evaluation is essential in cases of RV infarction taking care of silent oozing-type rupture. Learning objective: Inferior left ventricular infarction sometimes complicates right ventricular (RV) infarction. The typical manifestations of RV infarction include low blood pressure, low cardiac output, and elevated right atrium pressure. Although the frequency is low, fatal complications of oozing-type RV rupture might progress asymptomatically. Frequent echocardiographic screening is necessary to detect them.

Traumatic right ventricular rupture: Case report and brief review of the literature.

Rupture of the right ventricular (RV) myocardium is associated with serious morbidity and mortality. Under very rare conditions, a tear in the ventricular wall can lead to the formation of a pseudoaneurysm: an external outpouching of the ventricle that is stabilized by the pericardium, thrombus formation, and/or adhesions. Here, we present a 75-year-old man with RV free wall rupture with pseudoaneurysm following a motor vehicle collision. With concerns for blunt cardiac trauma, initial CTA chest revealed focal outpouching and extension of contrast outside of the confines of the RV chamber, compatible with pseudoaneurysm formation. In this case, conservative management of the pseudoaneurysm was preferred over surgical management, due to the thin RV free wall and present comorbid conditions. We highlight how CTA chest offers a reliable tool for tracking the stability of pseudoaneurysms in the RV and can guide clinical management through directing treatment strategies and appropriate follow-up intervals.

Ventricular pulling sign on computed tomography in mediastinitis-a predictor for right ventricular rupture at surgery.

Mediastinitis is an unusual but potentially life-threatening complication of cardiac surgery. Open drainage is one of the standard therapies, but there could sometimes be potential complications. We had a patient who underwent open drainage surgery for postoperative mediastinitis, and right ventricular rupture occurred subsequently to extubation in an operation room. Retrospectively reviewed, computed tomography showed strong adhesions between the right ventricle and the posterior margin of sternum, pulling his right ventricle to the right side of his sternum. We should have noticed the risk of leaving the sternum open and performed adhesiolysis of the right ventricle and the posterior margin of sternum to prevent the devastating complication. This case illustrates the importance of recognizing the rare computed tomography sign of ventricular pulling-a predictor for right ventricular rupture after open drainage for mediastinitis.

A rare case of post-infarction right ventricular rupture.

A 62-year-old male patient was pronounced dead on admission to the tertiary care hospital. The victim had right ventricular STEMI three years ago. The autopsy showed pericardial tamponade due to the rupture of an acute myocardial infarction of the right ventricle.

Surgical Treatment of Right Ventricular Rupture Caused by Total Occlusion of the Right Coronary Artery.

The rupture of the right ventricular anterior wall after myocardial infarction is a rare and life-threatening complication associated with high mortality. Early diagnosis by echocardiographic examination and successful treatment is discussed in this case report.

Post-trauma "abrasive" right ventricular rupture without mediastinitis early post-CABG. Is the Robicsek closure technique necessary for all elderly patients?

INTRODUCTION: Right ventricular (RV) rupture with mediastinitis, is a very rare but extremely dangerous (even fatal) complication, following CABG surgery. PRESENTATION OF CASE: In this paper, we present the case of a post-trauma (after fall) RV rupture (without mediastinitis) in a patient who had undergone cardiac surgery several days ago. The cause of the rupture proved to be a broken bone piece from the lower sternal edge. DISCUSSION: RV rupture post-operatively caused by broken bone pieces or bone dislocation may occur through two mechanisms: either penetration of the RV, or through the "sandpaper effect". In order to prevent the rupture, we should be able to recognize patients with aggravating factors (age, weight) and choose intra-operatively a suitable closure technique. CONCLUSION: We propose that the technique that could prevent such ruptures is the Robicsek technique.

Right ventricular rupture induced by cardiopulmonary resuscitation.

Right ventricular rupture is a rare complication of cardiopulmonary resuscitation and could be fatal. We report a survival case of right ventricular rupture induced by cardiopulmonary resuscitation in a patient with acute myocardial infarction. A 57-year-old man was admitted to our hospital with ventricular fibrillation. Although chest compression and defibrillation were performed, ventricular fibrillation continued. We inserted a percutaneous cardiopulmonary system and performed coronary angiography, which revealed occlusion of the left anterior descending artery. After coronary stenting and intra-aortic balloon pumping, we succeeded in defibrillation and vital signs became stable. Twenty hours after the intervention, systolic blood pressure dropped to 60 mmHg. Ultrasonic cardiogram at that time revealed massive pericardial effusion. We diagnosed cardiac tamponade, and 8Fr drainage tube was placed in the pericardial space. We determined that emergent operation was necessary because we suspected left ventricular rupture due to acute myocardial infarction or coronary rupture induced by percutaneous coronary intervention. However, operative findings revealed right ventricular free wall rupture, which could have been induced by chest compression. In these cases, we should consider the possibility of not only the rupture of left ventricle and coronary artery but also the rupture of right ventricle induced by cardiopulmonary resuscitation.