title: Management and prevention of cardiovascular hemorrhage associated with mediastinitis.
abstract: OBJECTIVE
  To elucidate the causes of cardiovascular hemorrhage associated with mediastinitis and to review recommendations for prevention and treatment.
  
  
  BACKGROUND
  Mediastinal debridement with immediate or early coverage using healthy, vascularized tissue has lead to greatly reduced morbidity and mortality for patients with mediastinitis. Myocardial hemorrhage has been anecdotally reported.
  
  
  METHODS
  Over a 36-month period, 7 patients developed massive cardiovascular bleeding after undergoing debridement for poststernotomy mediastinitis. Causes included puncture or erosion by a sternal edge in three and tearing at the myocardial-sternal interface in four.
  
  
  RESULTS
  Five patients survived and remain infection-free at an average of 24 months of follow-up. In these patients, ventricular defects were closed with pledgeted sutures and muscle transposition was used concomitantly to reinforce the repair. This involved a slide of the left pectoralis major muscle and turnover of the right pectoralis in three patients, bilateral sliding in one patient, and bilateral pectoralis and an omental flap in one patient who required additional coverage of the lower mediastinum.
  
  
  CONCLUSIONS
  When a patient who has undergone mediastinal debridement shows evidence of significant bleeding, we recommend application of pressure for control of hemorrhage, expeditious return to an operating room with available cardiopulmonary bypass, and immediate muscle coverage with healthy, well-vascularized tissue. Finally, early sternectomy might largely prevent this life-threatening complication.
authors.affiliation: Division of Plastic Surgery, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: G
authors.initials: G
authors.lastname: Georgiade
authors.forename: T A
authors.initials: TA
authors.lastname: Levan
authors.forename: J
authors.initials: J
authors.lastname: Anthony
authors.forename: N
authors.initials: N
authors.lastname: Oldham
authors.forename: H
authors.initials: H
authors.lastname: Julio
authors.forename: C
authors.initials: C
authors.lastname: Milano
authors.forename: E
authors.initials: E
authors.lastname: Ritter
mesh_terms: D000368:Aged; D001458:Bandages; D009202:Cardiomyopathies / Q000209:etiology* / Q000601:surgery*; D002315:Cardiopulmonary Bypass; D003646:Debridement / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D006352:Heart Ventricles / Q000293:injuries*; D006801:Humans; D008297:Male; D008480:Mediastinitis / Q000601:surgery*; D008875:Middle Aged; D011182:Postoperative Care; D019106:Postoperative Hemorrhage / Q000209:etiology* / Q000601:surgery*; D012189:Retrospective Studies; D013524:Surgical Flaps