Combined application of Robicsek procedure and thermoreactive nitinol clips for treating a patient with sternal dehiscence

doi:10.4236/wjcd.2013.36064

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World Journal of Cardiovascular Diseases, 2013, 3, 412-413 WJCD

http://dx.doi.org/10.4236/wjcd.2013.36064 Published Online September 2013 (http://www.scirp.org/journal/wjcd/)

Combined application of Robicsek procedure and

thermoreactive nitinol clips for treating a patient with

sternal dehiscence

Habib Cakir*, Yüksel Besir, Ismail Yurekli, Koksal Donmez, Ersin Celik, Mert Kestelli,

Ufuk Yetkin, Ali Gurbuz

Department of Cardiovascular Surgery, Katip Celebi University Izmir Ataturk Training and Research Hospital, Izmir, Turkey

Email: *[email protected]

Received 24 July 2013; revised 11 August 2013; accepted 19 August 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Postopereative sternal dehiscence is one of the most

important complications of median sternotomy which

may cause pulmonary dysfunction and mediastinitis.

We are reporting a patient with sternal dehiscence

after coronary artery bypass surgery that underwent

application of thermoreactive nitinol clips in addition

to Robicsek procedure. Using thermoreactive nitinol

clips method together with Robicsek procedure may

be a valuable technique for preventing recurrent ster-

nal dehiscence for patients who are candidates of no n-

infective recurrent sternal dehiscence.

Keywords: Sternal Dehiscence; Robicsek Procedure;

Thermoreactive Nitinol Clips

1. INTRODUCTION

Median sternotomy is the most commonly performed

procedure in cardiac surgery. Postopereative sternal de-

hiscence is one of the most important complications of

median sternotomy which may cause pulmonary dys-

function and mediastinitis. Robicsek procedure or ther-

moreactive nitinol treatment may be preferred for treat-

ing non-infective sternal dehiscence [1]. There is not

enough data about combined usage of these two tech-

niques in the literature.

In this case report, we present a patient with non-in-

fective sternal dehiscence after coronary artery bypass

surgery that underwent application of thermoreactive

nitinol clips in addition Robicsek procedure.

2. CASE PRESENTATION

A 72-year-old male patient was referred to cardiology

clinic with complaints of exertional angina. Coronary

angiography revealed three vessel disease and coronary

artery bypass surgery was planned. Mild mitral valve

regurgitation was present at transthoracic echocardi-

ography. His left ventricular ejection fraction was 65%.

He underwent coronary artery bypass surgery and three

vessels were revascularized with saphenous vein graft

(Left anterior descending artery, obtuse margin 1 and

obtuse margin 2 arteries). Ventricular fibrillation oc-

curred after closure of the sternum. After reopening

sternum, cardiopulmonary bypass was reestablished un-

der emergency circumstances. All vein grafts were patent

and there was not any electrolyte imbalance. Inotropic

support was administered and intraaortic balloon pump

was inserted. Weaning from cardiopulmonary bypass was

successful with support of intraaortic balloon pump.

Sternum was not reapproximated due to myocardial

edema. Patient was transported to intensive care unit. On

first postoperative day, revision surgery and approxima-

tion of sternum were performed. Inotropic agents and

intraaortic balloon pump support were terminated on

fifth postoperative day. Patient was transported to car-

diovascular surgery ward on postoperativ e sixth day. Due

to fever, serous discharge from sternal incision and ster-

nal dehiscence patient underwent revision operation on

14th postoperative day. Sternum’s left side was broken

into three pieces caused by sternal wires whipsaw effect.

There were not any sign of deep or superficial mediasti-

nal infection. Debris at anterior mediastinum were re-

moved and cultures were taken. Robicsek sternoplasty

was decided for left half of sternum. Right half was in-

tact and no additional procedures were required. After

sternoplasty, sternum was approximated conventionally

with steel wires (Figure 1). After approximation minor

defects on coaptation surfaces of sternum were noticed

(Figure 1). Application of thermoreactive nitinol clips

*Corresponding a uthor.

OPEN ACCESS

H. Cakir et al. / World Journal of Cardiovascular Diseases 3 (2013) 412-413 413

was decided. Three thermoreactive nitinol clips were

applied to defected areas. Complete coaptation of ster-

num was achieved after procedure (Figure 2). Wound

cultures and debris cultures were negative. He is still

under follow-up of our outpatient clinic with no sternal

dehiscence.

3. DISCUSSION

Sternal dehiscence is one of the most important compli-

cations of median sternotomy and it is incidence is

0.39%. New York Heart Association Class IV, obesity

and chronic obstructive pulmonary disease are consid-

ered to be the most important preoperative risk factors

for sternal dehiscence [2]. None of these risk factors

Figure 1. After approximation minor defects on coaptation

surfaces of sternum.

Figure 2. Complete coaptation of sternum after thermoreactive

nitinol clips application.

were present in our patient. Sternal dehiscence may

cause complications like mediastinitis and pulmonary

dysfunction. This causes necessity of early treatment as

we have treat ed our patient.

Thermoreactive nitinol treatment is being widely used

for treating non-infective sternal dehiscence instead of

Robicsek procedure and succesful results are reported [1].

In one study, applying nitinol clips for approximation of

median sternotomy had better clinical results than con-

ventional methods [3]. There is not enough data about

combined usage of these two techn iques in the literature.

We have stabilized left part of sternum with Robiscek

procedure and sternum was wired conventionally. Al-

though sternum was stable, there were defects at coapta-

tion surfaces caused by fracture. For reducing the risk of

recurrent sternal dehiscence, application of thermoreac-

tive nitinol clips was decided intraoperatively. Three nit-

inol thermoreactive clips were applied to defected areas.

After application, defects on coaptation surfaces of ster-

num were lost and greater stability of sternum was achi-

eved.

In this case, we observed that thermoreactive nitinol

clips application increased sternal stability by by Robis-

cek procedure. In conclusion, for patients with non-in-

fective sternal dehiscence who are candidates of recur-

rence, combined treatment of Robiscek procedure and

thermoreactive nitinol clips application may be the me-

thod of choice to reduce recurrent sternal dehiscence.

However, to obtain more reliable evidence, prospective

randomized controlled trials are needed.

REFERENCES

[1] Gucu, A., Toktas, F., Eris, C., Ata, Y. and Turk, T. (2012)

Nitinol thermoreactive clips for secondary sternal closure

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Institute Journal, 39, 513-516.

[2] Olbrecht, V.A., Barreiro, C.J., Bonde, P.N., Williams,

J.A., Baumgartner, W.A., Gott, V.L., et al. (2006) Clini-

cal outcomes of noninfectious sternal dehiscence after

median sternotomy. The Annals of Thoracic Surgery, 82,

902-907. doi:10.1016/j.athoracsur.2006.04.058

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closure system and chest wound infections: Insight from

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Annals of Thoracic Surgery, 94, 1848-1853.

doi:10.1016/j.athoracsur.2012.08.032