Case Presentation
A 68-year-old male presented with six months of progressive exertional chest pain radiating to the neck. His past medical history includes diabetes type II, a myocardial infarction 20 years prior, COPD, gastroesophageal reflux disease, gout, dyslipidemia, and a retinal detachment repair. He was found to have three-vessel coronary artery disease on cardiac catheterization and subsequently underwent triple CABG using left internal mammary artery and saphenous vein grafts via median sternotomy. The sternum was closed using six No.6 steel wires in a figure 8 fashion. The chest tubes drained 410 mL in total and were removed. The patient was stable and was transferred from the cardiovascular intensive case unit (CVICU) to the ward.
On post-operative day four, the patient was transferred back to the CVICU due to increasing respiratory requirements, in what appeared to be a COPD exacerbation. The patient improved with medical therapy. On postoperative day six, the patient’s sternum was noted to be unstable on physical exam with no evidence of sternal wound infection. Chest x-ray revealed a fractured sternal wire (figure 1). The patient was scheduled for repair of his sternal dehiscence the following day. While awaiting reoperation, the patient was ambulating with minimal assist and developed shortness of breath, became pale with cool extremities, and had bleeding from his sternal incision. Repeat chest x-ray showed new left pleural effusion (figure 2) and bedside echocardiogram showed a significant pericardial effusion. The patient was resuscitated with fluids, received two units of packed red blood cells (pRBC), and was started on norepinephrine. He was taken emergently to the operating room for re-exploration. On re-exploration, there were large mediastinal clots and all sternal wires were fractured with an injury to the free wall of the RV. The laceration was successfully repaired using a pledgeted 4-0 prolene suture. The patient was transfused a single unit of pRBC intra-operatively and was transferred to the CVICU with stable hemodynamics. He was successfully extubated the next day and discharged home 15 days after his initial procedure.