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.