Interact CardioVasc Thorac Surg 2009;9:847-848. doi:10.1510/icvts.2008.195768
© 2009 European Association of Cardio-Thoracic Surgery
Negative results - Cardiac general |
Pectoral hematoma mimicking a hemothorax in an octogenarian following aortic valve replacement – a near miss
Prakash Nanjaiah*,
Dharmendra Agrawal and
Sai U. Prasad
Department of Cardiothoracic Surgery, New Royal Infirmary of Edinburgh, #51, Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
Received 13 October 2008;
received in revised form 9 February 2009;
accepted 12 February 2009
*Corresponding author. Tel.: +44 77 23099656; fax: +44 131 242 3239.
E-mail address: ctsace1{at}yahoo.co.uk (P. Nanjaiah).
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Abstract
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Open-heart surgery is associated with higher risk of complications in the octogenarians, specifically because of frailty of tissues and delayed healing secondary to various factors. Here, we present a near miss, where an 86-year-old lady underwent tissue aortic valve surgery complicated with formation of a large retro-pectoral hematoma, which on the initial chest X-ray mimicked a left hemothorax. This was successfully explored surgically and drained promptly within 8 h of the primary surgery. This is illustrated with chest radiographs. The case highlights one of the rare complications that we encountered in cardiac surgery of the elderly.
Key Words: Octogenarian; Aortic valve replacement; Retro-pectoral hematoma
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1. Introduction
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Cardiac surgery in the elderly (octogenarians, nonagerians) runs a higher mortality and morbidity risk [1, 2]. It is in this context, that we present this unusual case of retro-pectoral hematoma following a standard bioprosthetic aortic valve replacement, which mimicked a hemothorax on the chest radiographs. Due to paucity of published literature about such a complication, we would like to share this useful knowledge with the practicing fraternity.
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2. Case report
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An 86-year-old lady was referred for surgery of her symptomatic mixed aortic valve disease. She initially presented with congestive cardiac failure secondary to decompensated severe aortic stenosis. She underwent a transthoracic echocardiogram and left heart catheterization, which revealed severe aortic stenosis with a peak trans-valvular gradient of 80 mmHg, moderate aortic regurgitation and a moderately impaired left ventricular function (LVEF – 30–49%) along with inferior wall hypokinesia. Her coronary angiogram revealed non-significant coronary artery disease.
After an initial period of optimization of her anti-failure treatment, she underwent a standard aortic valve replacement through a median sternotomy, using a 19-mm pericardial bioprosthesis, anchored to the aortic annulus with interrupted 2-0 Ethibond plegetted sutures. This was performed uneventfully on cardiopulmonary bypass with intermittent cold blood cardioplegia for myocardial protection. Here, it would be worth mentioning that the patient's tissues were extremely friable and fragile which led to difficulty in suturing the wound. The patient was transferred to the intensive therapy unit (ITU) with two chest drains (mediastinal and pericardial) in hemodynamically stable condition.
On the ITU, the first few hours were uneventful with minimal initial drainage into the chest drains. However, 4 h post surgery, she became hypotensive and required significant volume resuscitation (colloids and blood products). During this period she just drained ~120 ml of blood into the drains. Her postoperative hemoglobin dropped abruptly from 10.3 g% to 7.1 g%. The coagulation profile was grossly normal. An immediate chest radiograph taken, showed opacification of most of the left hemi-thorax (Fig. 1a). This closely mimicked a left hemothorax and prompted us to start preparation for intercostal drain insertion and would have ideally led to opening of the previous sternotomy and re-exploration of the chest cavity to look for bleeding source. But when we began to prepare the patient for drain insertion, we noticed the left pectoral region and the left breast contour had enlarged considerably. A closer scrutiny of the chest radiograph showed the preserved lung markings on the left side, with unusual enlargement of left breast shadow in comparison to the right. Hence, a diagnosis of an expanding large retro-pectoral hematoma was made and the patient was appropriately re-explored, clots evacuated and the hematoma was drained. A vacuum suction drain was left in situ for 72 h after this re-exploration (Fig. 1b).
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Fig. 1. (a) Left chest opacification on X-ray, black arrow (1) – left pleural cavity border, white arrow (2) – enlarged breast contour. (b) Resolving left pectoral hematoma, black arrow (1) – retro-pectoral vaccum drain in situ, white arrow (2) – near normal left breast contour.
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After three days, the drains were removed and subsequent chest radiograph (Fig. 2) shows the complete resolution of the hematoma and return of the left breast size and contour to normal. She made a slow recovery on the wards and was subsequently discharged home. A routine postoperative follow-up six weeks later showed that her sternal wound had healed well and her chest radiograph was satisfactory.
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3. Discussion
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The higher risk of mortality and morbidity associated with cardiac surgery in the elderly is declining with advances in surgical technique, better myocardial preservation and overall improved better clinical and critical care delivery systems [1, 2].
We know from previous studies, that aging significantly decreases muscle strength, primarily due to decline in skeletal muscle mass (quantity) and protein quality [3]. This adverse effect on muscle structure, composition and function has been termed as ‘sarcopenia’. This in turn leads to physical frailty [4]. Women experience earlier strength losses than men with greater declines in muscle quality with advancing age [3].
The above case summary depicts a very rare complication of cardiac surgery in the elderly. The development of this left pectoral/retro mammary hematoma can be attributed to the frailty of the tissues and inadvertent injury to one of the chest wall arteries during the closure of the sternum, leading to a significant hemorrhage into the potential retro mammary space. This led to hemodynamic instability necessitating massive blood transfusion along with various other blood products. The chest radiograph taken at that time frame could easily be mistaken for that of a left-sided hemothorax and would have led to futile intercostal drain insertion and/re-exploration. However, on closer scrutiny, the left breast contour was asymmetrically enlarged, confirmed on physical examination of the patient. There was a large extra-thoracic, pectoral/retro mammary hematoma with ongoing expanding hemorrhage. This prompted the subsequent surgical exercise.
The above case report underlines the need for appropriate diagnostic skills, when analyzing an investigation and prompt action to avoid mishaps. This is particularly more important in the care of the elderly, where the margin for error is extremely low. It also stresses the need for more dexterous tissue handling in these patients.
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References
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- Akins CW, Daggett WM, Vlahakes GJ, Hilgenberg AD, Torchiana DF, Madsen JC, Buckley MJ. Cardiac operations in patients 80 years old and older. Ann Thorac Surg 1997;64:606–615.[Abstract/Free Full Text]
- Barnett SD, Halpin LS, Speir AM, Albus RA, Akl BF, Burton NA, Massimiano PS, Collazo LR, Lefrak EA. Post-operative complications among octogenarians after cardiovascular surgery. Ann Thorac Surg 2003;76:726–731.[Abstract/Free Full Text]
- Yarasheski KE. Exercise, aging and muscle protein metabolism. J Gerontology A Biol Sci Med Sci 2003;58:M918–M922.
- Doherty TJ. The influence of aging and sex on skeletal muscle mass and strength. Curr Opin Clin Nutr Metabolic Care 2001 Nov;4:503–508.[CrossRef][Medline]
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Abstract
1. Introduction