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Heart Views. 2016 Oct-Dec; 17(4): 140–141.
PMCID: PMC5363089

Graft Compression by Drain Tube

Abstract

Hemodynamic compromise immediately after chest closure can be potentially fatal event. Such condition warrants urgent reopening of sternum. In the present case, we discover An uncommon cause of unstable hemodynamics.

Key words: Chest drain tube, coronary bypass surgery, venous grafts

INTRODUCTION

Midline sternotomy for coronary artery bypass grafting surgery is the standard approach. Mediastinal chest drain tubes are generally placed through the subcostal incision for postoperative drainage of collection. Sudden fall in systemic arterial pressure after chest closure can be due to increased intrathoracic pressure with positive pressure ventilation or sudden collection of blood causing tamponade effect.

CASE REPORT

A 57-year-old gentleman presented with shortness of breath since 1 month on mild to moderate exertion. He was evaluated thoroughly and coronary angiography revealed triple vessel coronary artery disease. He was scheduled for coronary artery bypass grafting surgery. After midline sternotomy, off-pump three coronary vessels bypass grafting was performed – left internal mammary artery to left anterior descending coronary artery, two saphenous vein grafts to obtuse marginal artery and posterior descending artery.

Intraoperatively, hemodynamics were stable during grafting. Two mediastinal drain tubes were placed. After ensuring adequate hemostasis, sternum was closed by approximating sternal wires. As the skin was being closed, blood pressure started dropping. Trendelenburg position and fluid bolus were given. Escalating doses of inotropic infusions were started. Central venous pressure started rising and inferior leads ST elevation was observed. Hemodynamics were deteriorating so, immediately sternum was reopened. There was no obvious collection observed, however, saphenous venous graft to posterior descending artery appeared bluish in discoloration. One mediastinal drain was seen compressing the graft. Drain tube was removed from that position. Other grafts seemed to be normally functioning. After few moments, hemodynamics became stabilized and inotropic infusions were weaned. The patient was stable after chest closure.

DISCUSSION

Sternal closure can result in a significant restriction in diastolic filling and reduction cardiac output despite good cardiac function.[1] These effects are amplified by poor ventricular compliance due to myocardial edema and ischemia-reperfusion injury.[2] Furnary et al. have shown that opening sternum raises systemic blood pressure by 18% and cardiac index by 59% and thereby beneficial in improving low cardiac output.[3]

Graft compression by chest drain tube is a very unusual complication. It was effectively managed by the immediate reopening of the sternum. To the best of our knowledge, such rare complication has not been reported in the literature. Optimal positioning of drain tube in relation with bypass coronary graft should always be considered.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

1. Johnson JA, Gundersen AE, Stickney ID, Cogbill TH. Selective approach to sternal closure after exploration for hemorrhage following coronary artery bypass. Ann Thorac Surg. 1990;49:771–4. [PubMed]
2. Mubeen M, Dan S, Agarwal SK, Srivastava AK, Kanhere VM. Delayed sternal closure after cardiac operations. Asian Cardiovasc Thorac Ann. 2001;9:82–5.
3. Furnary AP, Magovern JA, Simpson KA, Magovern GJ. Prolonged open sternotomy and delayed sternal closure after cardiac operations. Ann Thorac Surg. 1992;54:233–9. [PubMed]

Articles from Heart Views : The Official Journal of the Gulf Heart Association are provided here courtesy of Wolters Kluwer -- Medknow Publications