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J Thorac Cardiovasc Surg 1995;110:274-275
© 1995 Mosby, Inc.

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Massive bleeding at resternotomy despite a polytetrafluoroethylene surgical membrane*

Rotterdam, The Netherlands

From the Department of Thoracic Surgery, Thoraxcentre, Bd 156, University Hospital Sophia/Dijkzigt, Rotterdam, The Netherlands.

To reduce the risk of injury to the heart and great vessels at resternotomy, the use of synthetic pericardial substitutes is being advocated. ^{1, 2} The advantages being claimed are the lack of host reaction and the provision of a plane of dissection at reoperation. ^1-3 In a recent survey, polytetrafluoroethylene (PTFE) was regarded as significantly more satisfactory than other substitutes. ³ The increasing popularity of the PTFE pericardial substitute, however, seems to be based only on the ease of implantation ^1-4 and assumed results because adequate and well-analyzed long-term data are still lacking. In fact, only small numbers of actual reoperations with previously implanted PTFE pericardial substitute are being reported. ^{1, 2, 4} Fourteen percent of surveyed surgeons were not satisfied by this material, and caution was suggested before recommendation of its widespread use. ³

This caution is supported by the following case. The patient was 11 years of age at operation. Originally, she had pulmonary atresia with ventricular septal defect (VSD) and multiple systemic-to-pulmonary collateral arteries. After successful bilateral unifocalization procedures, the patient underwent corrective cardiac surgery at 9 years of age. The VSD was closed, the unifocal left and right pulmonary arteries were connected with a 10 mm diameter PTFE tube, and the right ventricle was connected to this tube with a cryopreserved pulmonary allograft. Because possible deteriorization of the allograft was anticipated, a PTFE surgical membrane* was implanted between the pericardial edges. Because of progressive dilatation and regurgitation of the allograft in the presence of bilateral pulmonary arterial stenoses in combination with residual VSD, reoperation was scheduled. With ventral traction of the sternum, the anterior tabula of the sternum was opened. On opening of the posterior tabula, massive loss of venous blood occurred. This could be managed by transfusion and femoral access for cardiopulmonary bypass. On perfusion, the sternum was completely opened. The surgical membrane was adequately in position, and although only slightly attached ventrally to the sternum and dorsally to the heart, it showed a central tear of about 1 cm and an identical hole in the allograft beneath it (Fig. 1). The operation could be finished as planned. The VSD was closed with an additional patch, patch enlargement of the prosthetic confluent pulmonary artery was done, and the allograft was replaced with a new cryopreserved pulmonary allograft. The patient was weaned from bypass without problems. No new pericardial substitute was implanted. The patient recovered uneventfully.

View larger version (137K): [in this window] [in a new window]   Fig. 1. Central sawing tear in the adequately positioned surgical membrane and the pulmonary allograft beneath it. Pump suction is positioned in the tear.

Footnotes

Gore-Tex surgical membrane, registered trademark of W.L. Gore & Associates, Inc, Newark, Del.

J THORAC CARDIOVASC SURG 1995;110:274-5

*Gore-Tex surgical membrane, registered trademark of W.L. Gore & Associates, Inc, Newark, Del.

References

1. Amato JJ, Contreo JV, Galdieri RJ, Alboliras E, Antillon J, Vogel RL. Experience with the polytetrafluoroethylene surgical membrane for pericardial closure in operations for congenital cardiac defects. J THORAC CARDIOVASC SURG 1989;97:929-34.[Abstract]
   
2. Harada Y, Imai Y, Kurosawa H, Hoshino S, Nakano K. Long-term results of the clinical use of an expanded polytetrafluoroethylene surgical membrane as a pericardial substitute. J THORAC CARDIOVASC SURG 1988:96:811-5.
   
3. Heydorn WH, Ferraris VA, Berry WR. Pericardial substitutes: a survey. Ann Thor Surg 1988;46:567-9.[Abstract]
   
4. Minale C, Nikol S, Hollwg G, Mittermayer C, Messmer BJ. Clinical experience with expanded polytetrafluoroethylene Gore-Tex surgical membrane for pericardial closure: a study of 110 cases. J Card Surg 1988;3:193-201.[Medline]
   

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