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Eur J Cardiothorac Surg 2002;21:566-567
© 2002 Elsevier Science NL

Case report

Intra myocardial dissecting hematoma with epicardial rupture — an unusual complication of the octopus 3 stabilizer

N.V. Mandke*, Z.M. Nalladaru, A. Chougule, A.N. Mandke

Lilavati Hospital and Research Center, A-791, Bandra Reclamation, Bandra (W), Mumbai 400 050, India

Received 1 August 2001; received in revised form 29 October 2001; accepted 15 November 2001.

* Corresponding author. Tel.: +91-22-6455891, ext. 2243; fax: +91-22-6552929
e-mail: nvmandke{at}vsnl.com


   Abstract
Top
 Abstract
1. Introduction
 2. Discussion
 References
 
Stabilizer devices have revolutionized off-pump coronary artery bypass surgery. They stabilize the myocardial wall locally and allow the surgeon to accurately place anastomotic sutures without the need of establishing CPB and without much compromise in patient hemodynamics. We report here an unusual complication of an intramyocardial dissecting hematoma with epicardial rupture caused after using the Octopus 3 stabilizer.

Key Words: Off-pump • CABG • Stabilizer • Injury


   1. Introduction
Top
 Abstract
 1. Introduction
2. Discussion
 References
 
Since January 2000 we have been performing all our coronary artery surgery without the use of cardiopulmonary bypass (CPB). In a few we were forced to establish CPB for unstable hemodynamics not responding to conventional management. In most of our cases we used the Octopus stabilizer (Medtronic, Inc. Minneapolis, MN, USA) with a suction pressure of -200 mmHg (Medtronic Inc. has recommended a suction pressure of less than -400 mmHg). Till the time of writing this report we have performed 1059 coronary artery bypass surgeries using this stabilizer and have been impressed with its versatility. This is the only case in which we came across a stabilizer related cardiac injury.

A 66-year-old, hypertensive, female patient with chronic stable angina, triple vessel disease with LVEF of 45% underwent elective off-pump CABG using Octopus 3 stabilizer.

LIMA was used to revascularize the left anterior descending (LAD) artery and separate vein grafts were used for revascularizing the posterior descending artery (PDA) and obtuse marginal (OM) branch of circumflex artery. The anastomosis to the OM was the last to be performed. On removing the Octopus a subepicardial hematoma was noticed on the lateral myocardial wall where the suction pads were applied during the LIMA-LAD anastomosis. The hematoma was evacuated by making a small nick on the epicardium. Local pressure was applied for 15 min to stop the oozing from the nicked surface. After hemostasis was ensured the chest was closed and the patient was shifted to ICU in a hemodynamically stable condition, after extubation in the operating room.

Two hours later she developed signs and symptoms of cardiac tamponade as well as excessive drainage from the chest tubes [800 ml in the first 3 h following surgery]. This together with a mediastinal widening on chest X-ray met our criteria for re-entry.

She was brought back to the OR and reopened. Soon after opening the chest she had a cardiac arrest and had to be given cardiac massage and was put on CPB urgently. Large amounts of clots were evacuated from the pericardial cavity. The hematoma was found to have extended over the anterolateral wall of the LV. The epicardial surface had dissected and had a macerated, raw appearance [Fig. 1 ]. The raw epicardial surface was actively oozing. The anastomosis to the OM was intact.



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  		Fig. 1. Photograph showing the macerated left ventricular epicardial surface.

 
The aorta was cross-clamped and antegrade blood cardioplegia was given to arrest the heart. The raw surface of the decompressed myocardium was dried with a sponge and the biologic glue (Gluetiss-Berlin Heart AG, Germany) was applied over it and the adjacent in-situ pericardium. The hardening solution was then mixed and the pericardium and the myocardium were pressed for 2 min as recommended (Fig. 2 ). The pericardial patch was held in place by few tacking sutures. Surgicel (microfibrillar collagen) was placed on the posterior surface below the macerated area for local hemostasis. The bondage was quite good, but the bleeding continued to a lesser degree. The patient was weaned off CPB with inotropic support and shifted to the ICU.



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  		Fig. 2. Autologous pericardium stuck to the epicardium with biologic glue.

 
In the ICU she continued to bleed and had multiple attacks of ventricular tachycardia and fibrillation and finally succumbed 3 h later.


   2. Discussion
Top
 Abstract
 1. Introduction
 2. Discussion
References
 
Complication of left ventricular free wall rupture (LVFWR) in acute ischemic setting is well known and can manifest either as acute tamponade or a slow leak with formation of a pseudoaneurysm.

In our case we believe that it was not a true rupture of left ventricular free wall but a large hematoma burying in the myocardium producing bleeding and tamponade. Usually in suction device like Octopus, there are small hematoma formations over the epicardial surface of the heart. These usually do not bleed and vanish at the end of the procedure. In this particular case, the suction pads injured deeper portion of the epicardium producing significant hematoma and the damage underneath. Cardiac rupture has also been reported following exercise stress testing, thrombolytic therapy and catheter interventions.

Numerous surgical techniques have been described for treating this condition, which understandably has a high mortality rate. Epicardial patching with pericardium-human or bovine, direct suture, infarct exclusion and debridement and ventriculotomy with patch closure are the methods described in literature, with varying degrees of success [1]. Use of a sutureless technique with a bovine pericardial hood and biologic glue was reported recently by Imagawa et al. [2].

In our case, we attempted to seal the macerated epicardial surface with an in situ autologous pericardial patch held in position with biologic glue as well as anchoring sutures. Unfortunately the area of injury was very large and she continued to bleed from around the patch and finally succumbed in the ICU.

On retrospection we feel that using an in situ pericardial patch instead of a free patch may have been the cause of failure of repair due to shear stress forces between a beating heart and the rigid pericardial patch. A free patch would have eliminated these shear stress forces.

Autopsy was unfortunately not performed in this case. It would have helped to distinguish between a true rupture and an intramural hematoma. However, on visual inspection during surgery we did not feel it was a true rupture.

Hypertrophied myocardium with difficulty in positioning the stabilizer, debilitated or malnourished patients and those on immunosuppressive drugs may be more prone to this type of injury. However, our patient did not have any of the abovementioned characteristics and hence occurrence of this injury in her remains a mystery.

On searching the world literature in English language we found no similar case report and hence have reason to believe that this is the first reported case of myocardial injury caused by a suction device for stabilizing the heart during off-pump CABG.


   Acknowledgments
 
We are grateful to Ms Alodia D'Cruz for the secretarial assistance rendered to us while submitting this manuscript.


   References
Top
 Abstract
 1. Introduction
 2. Discussion
 References
 

  1. Pretre R., Benedict P., Turina M.I. Experience with postinfarction left ventricular free wall rupture. Ann Thorac Surg 2000;69:1342-1345.[Abstract/Free Full Text]
  2. Imagawa H., Susumu N., Akagi H., Yagura A., Fujita T. Pericardial hood repair of cardiac rupture secondary to extended myocardial infarction. Ann Thorac Surg 2000;69:1959-1960.[Abstract/Free Full Text]



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