Introduction

Coronary Sinus Injury is a rare complication of the retrograde delivery of cardioplegia [₁, ₂]. This report describes coronary sinus injury secondary to internal cardiac massage and the technique used for repair.

Case Report

A 68-year-old lady underwent coronary artery bypass graft surgery for triple vessel disease. The procedure was uneventful and during insertion of sternal wires, there was an unexplained drop in blood pressure followed by asystolic cardiac arrest. The wires were removed and internal cardiac massage was commenced. This was not particularly helpful and the patient was placed on cardiopulmonary bypass.

The internal cardiac massage had caused injuries to the anterior surface of the heart (a small epicardial tear on the surface of the right ventricle) and the coronary sinus.

There was a large amount of bleeding from the back of the heart and a large hematoma was present in the region of the coronary sinus. There was considerable venous bleeding from the sinus. The hematoma had obscured the tissue planes and it was not possible to discern clearly the edges of the defect in the coronary sinus all round (Figure 1).

Figure 1

Figure 1: Coronary Sinus injury resulted in a large hematoma with obliteration of tissue planes. The edges of the coronary sinus injury were not discernible all round.

The cross clamp was applied and the heart arrested with antegrade cardioplegia. The edges of the coronary sinus injury were not clearly defined. A large patch of pericardium (Tissuemed, Leeds, UK) was laid over the defect and sutured to the epicardial fat with Teflon (Bard Inc, Tempe, AZ) reinforced 40 prolene (Ethicon, Somerville, NJ) sutures. Bio glue (Cryolife, Kennesaw, GA) was then liberally applied at the edges of the pericardial patch (Figure 2).

Figure 2

Figure 2: Repair of the coronary sinus injury by a pericardial patch sutured to the epicardial fat and secured by glue.

The anterior epicardial tear was repaired with 40 prolene sutures.

The cross clamp was removed and the patient was weaned off bypass uneventfully. The repair was intact and there was no further bleeding. The cause of the initial aystolic arrest was unexplained and the patient made an uneventful recovery.

Discussion

Injuries secondary to internal and external cardiac massage have been reported [₃]. Coronary sinus injury can occur secondary to cannulation for delivering retrograde cardioplegia [1,2]. To our knowledge, coronary sinus injury secondary to internal cardiac massage has not been reported.

A ruptured coronary sinus is very difficult to repair primarily as the edges are not clearly seen and the hematoma causes obliteration of normal tissue planes. A large pericardial patch can be laid over the defect and sewn to the epicardial fat. This causes re-establishment of venous drainage. The application of glue to the edges of the pericardial patch helped secure a watertight repair and there was no further bleeding from the low-pressure venous system.

We believe this technique of repair using a large pericardial patch sewn to the epicardial fat and secured by glue, makes it easy to manage a very difficult complication.

Correspondence to

Mr V Zamvar
Tel : +44-(29)-20747747
Fax: +44-(29)-20745439
Email: zamvarv@hotmail.com
Address: University Hospital of Wales,
Cardiff CF14 4XW, UK