184 LETTER TO THE EDITOR Pericardial Suspension to Prevent Encroachment of Emphysematous Lungs in Cardiac Surgery Oon C. Ooi, A.F.R.C.S., Robert Grignani, I.B., and Eugene K.W. Sim, F.R.C.S. Department of Cardiac, Thoracic and Vascular Surgery, The Heart Institute, National Healthcare Group, Singapore Dear Editor, buttresses, the pericardial edge on the right side was Air trapping in emphysematous lungs may result in approximated to the posterior surface and lateral edge the lungs compressing the heart as an unusual compli- to the lateral border of the right hemisternum to re- cation following cardiac surgery. This may cause hemo- strain the emphysematous right lung from encroach- dynamic compromise following approximation of the ing into the mediastinal space (Fig. 1B). Thereafter, the two hemisternii and not allow the chest to be closed. sternum was closed uneventfully. This is our second We describe a method of suspending the pericardial successful attempt at using pericardial suspension in a edge to the posterior surface of the ipsilateral hemis- coronary artery bypass grafting case with emphysema- ternum in preventing an emphysematous lung from tous lungs. exerting a compression effect on the heart in cardiac surgery. A 62-year-old gentleman was brought to the Acci- dent and Emergency Department with a massive acute myocardial infarction. Transthoracic echocardiography showed a left ventricular ejection fraction of 25%. Emergency coronary catheterization revealed triple- vessel disease. An intraaortic balloon pump was in- serted. Emergency on-pump beating-heart coronary artery bypass grafting was performed using saphenous vein grafts to the left anterior descending artery, ra- mus intermedius, and right coronary artery. Intraoper- ative ﬁndings are a dilated heart with poor contractility and emphysematous lungs. Cardiopulmonary bypass was terminated uneventfully. While approximating the sternal edges with sternal wires for chest closure, the ST-segment in leads II and aVF on the electrocardio- graph rose signiﬁcantly accompanied by hypotension of 80 mmHg systolic pressure. The sternal wires were divided and the chest reopened. All the saphenous vein grafts were patent. The anterior borders of the em- physematous lungs were noted to have crossed the midline respectively (Fig. 1A) and suspected to be the cause of the cardiac compromise. Similar electrocardio- graphic and hemodynamic deterioration recurred when closure of the sternum was reattempted. The chest was reopened and the saphenous vein grafts checked once more. Again, the mediastinal edges of the em- physematous lungs were found to have crossed the midline. Using interrupted 2-0 polypropylene sutures in interrupted horizontal mattress fashion with pledget Figure 1. A. Anterior borders of right and left lung crossing the Address for correspondence: Eugene KW Sim, Department of Cardiac, midline. B. The edge of the incised pericardium on the right Thoracic & Vascular Surgery, National University Hospital, The Heart side is sutured to the posterior surface of the right hemister- Institute, National Healthcare Group, 5 Lower Kent Ridge Road, Singa- num, thus preventing the anterior edge of the right lung from pore 119074. Fax: +65-6776 6475; e-mail: email@example.com encroaching into the mediastinum. J CARD SURG OOI, ET AL. 185 2004;19:184-185 PERICARDIAL SUSPENSION FOR EMPHYSEMATOUS LUNGS Acute hypotension on sternal reapproximation fol- ologists, appears to dramatically decrease air trapping lowing cardiopulmonary bypass may be caused by and allow closure of the sternotomy without cardiovas- compromise in coronary perfusion from kinking of cular instability. coronary artery bypass grafts, valvular malfunction, or In this patient with a dilated and poorly contract- rarely high intrathoracic pressure transmitted by hy- ing heart, the tamponading effect of air trapping did perinﬂated lungs that compromise cardiac function.1-3 not allow closure of the chest. We describe a tech- The latter, termed “air trapping,” is seen in patients nique of suspension of the pericardial edge to the with pulmonary diseases, e.g., chronic obstructive pul- posterior surface of the ipsilateral hemisternum to monary disease, with loss of elastic recoil or increased prevent the lung from infringing on the pericardial airway resistance and could be attributed to bron- cavity. chospasm, bronchiolar mucosal edema, thick inspis- sated mucus plugging of small airways, and collapsed REFERENCES small airways caused by lack of elastic support in the lung. 1. Dries DJ, Mathru M, Salem R, et al: Hemodynamic compro- Once air trapping is recognized, therapeutic mea- mise associated with air trapping following coronary artery sures should be instituted to minimize the phe- bypass surgery. Chest 1990;97:1002-1003. nomenon. These include bronchodilator therapy to re- 2. Bergman NE: Intrapulmonary gas trapping during me- lieve airway obstruction, reduction in minute venti- chanical ventilation at rapid frequencies. Anesthesiology 1972;37:626-633. lation, and maximizing time available for exhalation. 3. Wallis TW, Robotham JL, Compean R, et al: Mechani- Minute ventilation should be reduced to the minimum cal heart-lung interaction with positive end-expiratory pres- that will maintain adequate pH. Weng and associates1,4 sure. J Appl Physiol 1983;54:1039-1047. described a method of expiratory ﬂow retard to pro- 4. Weng JT, Smith DE, Graybar GB, et al: Hypotension sec- mote emptying of peripheral air space units during ex- ondary to air trapping treated with expiratory ﬂow retard. halation. This technique, instituted by the anaesthesi- Anesthesiology 1984;60:350-353.
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