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CASE REPORT Open Access
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Khouzam et al. Journal of Cardiothoracic Surgery (2023) 18:358
https://doi.org/10.1186/s13019-023-02452-6
case of a 62-year-old male who underwent triple coro-
nary bypass surgery and presented five months later with
hemopericardium as a result of a broken sternal wire
penetrating into the pericardial space causing a cardiac
laceration.
Case presentation
e patient is a 62-year-old Caucasian male with a his-
tory of surgical myocardial revascularization performed
five months ago at a different institution who presented
to our emergency department with a sudden onset of
anterior chest wall discomfort radiating to his neck and
both shoulders. e pain was associated with dizziness,
nausea and diaphoresis. ere were no precipitating fac-
tors. e patient took three aspirins without relief of his
Introduction
Hemopericardium is a potential life-threatening compli-
cation that can occur after a sternotomy [1]. Most cases
of post-operative hemopericardium are caused by infec-
tion or bleeding within the pericardial space, leading to
the accumulation of blood [2]. Penetrating and blunt
trauma are also a widely recognized cause of hemoperi-
cardium, though are not often thought of in the context
of post-cardiac surgery complications. We present a
Journal of Cardiothoracic
Surgery
*Correspondence:
Matthew S. Khouzam
mkhouzam9@gmail.com
1Loyola University Medical Center, Stritch School of Medicine, Maywood,
IL, USA
2Division of Cardiothoracic Surgery, AdventHealth, Orlando, Florida, USA
Abstract
Background Hemopericardium is a serious complication that can occur after cardiac surgery. While most post-
operative causes are due to inflammation and bleeding, patients with broken sternal wires and an unstable sternum
may develop hemopericardium from penetrating trauma.
Case presentation We present the case of a 62-year-old male who underwent triple coronary bypass surgery
and presented five months later with sudden anterior chest wall pain. Chest computed tomography revealed
hemopericardium with an associated broken sternal wire that had penetrated into the pericardial space. The patient
underwent a redo-sternotomy which revealed a 3.5 cm bleeding, jagged right ventricular laceration that correlated to
the imaging findings of a fractured sternal wire projecting in the pericardial space. The laceration was repaired using
interrupted 4 − 0 polypropylene sutures in horizontal mattress fashion between strips of bovine pericardium. The
patient’s recovery was uneventful and he was discharged on post-operative day four without complications.
Conclusion Patients with broken sternal wires and an unstable sternum require careful evaluation and management
as these may have potentially life-threatening complications if left untreated.
Keywords Hemopericardium, Broken sternal wire, Unstable sternum, Cardiac laceration, Case-report
Fractured sternal wire causing a cardiac
laceration
Matthew S. Khouzam1*, Kristina Jacobsen2, Joseph H. Boyer2, Ahmad Zeeshan2, David Spurlock2, Tomer Z. Karas2,
Jorge E. Suarez-Cavelier2, Daniel Rinewalt2, Linda Bogar2, Scott Silvestry2, George J. Palmer2, Kevin D. Accola2 and
Nayer Khouzam2
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Page 2 of 5
Khouzam et al. Journal of Cardiothoracic Surgery (2023) 18:358
symptoms. His past medical history was significant for
essential hypertension, dyslipidemia, non-insulin-depen-
dent diabetes mellitus, chronic kidney disease, and gout.
He had a previous left sided thoracentesis performed six
weeks ago for a symptomatic left pleural effusion.
On examination, the patient appeared acutely ill. He
had a body mass index of 36.6kg/m². He was diaphoretic.
He was tachycardic with a pulse rate of 102bpm, regu-
lar sinus rhythm on telemetry. His systolic blood pres-
sure was 132 mmHg without pulsus paradoxus. He had
no jugulovenous distention. ere was visible paradoxical
movement of his sternum that, according to the patient,
has been present several weeks after his original surgery.
An electrocardiogram showed no evidence of ischemia
or acute injury. Chest roentgenograms revealed a large
left sided pleural effusion and two fractured lower ster-
nal wires (Fig.1). It is also noteworthy that a chest X-ray
from five months prior only revealed one broken sternal
wire (Fig.2). Echocardiography revealed a small to mod-
erate sized hemopericardium, without evidence of tam-
ponade physiology.
Computed tomography angiography (CTA) of the chest
confirmed the large left sided pleural effusion with asso-
ciated left lung atelectasis. ere were also findings sug-
gestive of sternal dehiscence with diastasis of the sternal
bone. Two lower sternal wires demonstrated wire frag-
ments which projected posteriorly and appeared to pen-
etrate the anterior pericardial space. ere was a small
to moderate sized hemopericardium present. No active
extravasation of contrast was present.
e patient was emergently taken to the operative suite.
Intraoperative, transesophageal echocardiogram (TEE)
confirmed a moderate-sized hemopericardium with
blood and blood clots in the pericardial space. e clot
was visualized overlying the right ventricle. ere was
no evidence of early, diastolic collapse of either the right
atrium or right ventricle. Both right and left ventricular
function were preserved. Shortly thereafter, his hemo-
dynamics began to deteriorate, necessitating volume
administration, and pressor support with epinephrine.
Systemic heparinization, 4mg/kg of heparin, was admin-
istered, and the patient was placed on femoral artery –
femoral vein cardiopulmonary bypass.
A redo-sternotomy incision was made. All sternal wires
and wire fragments were removed. Findings revealed
complete dehiscence of the sternal bone from the
manubrium to the xiphoid with a tremendous amount
of granulation tissue present. Dark blood was welling
up between the sternal bone halves. Dense mediasti-
nal adhesions were present and lysed as encountered.
Mediastinal exploration revealed a large clot overly-
ing the free wall of the right ventricle. Beneath the clot,
we identified a 3.5cm bleeding, jagged right ventricular
laceration that correlated with the CTA findings of the
lower fractured sternal wire projecting in the pericardial
space. Digital control of the laceration was performed.
Limited dissection of the right heart was performed to
Fig. 1 A) Computed tomography angiography at the level of the left atrium demonstrating sternal bone diastasis (blue arrow), fractured sternal wire
angulating into the pericardial space (yellow circled arrow), hemopericardium (red arrow), and left pleural effusion (green arrow)
B) Computed tomography angiography at the level of the diaphragm demonstrating sternal bone diastasis (blue arrow), fractured sternal wire angulating
into the pericardial space (yellow circled arrow), hemopericardium (red arrow), and left pleural effusion (green arrow)
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Page 3 of 5
Khouzam et al. Journal of Cardiothoracic Surgery (2023) 18:358
allow a tension-free repair of the cardiac laceration. e
jagged, right ventricular laceration was repaired using
interrupted 4 − 0 polypropylene sutures in horizontal
mattress fashion between strips of bovine pericardium
(Fig.3). Further inspection revealed no other pathology.
After volume loading the heart and confirming that the
repair was solid, the patient was easily weaned from car-
diopulmonary bypass without difficulty. TEE revealed
good biventricular function. e sternum bone was
debrided and closed using sternal plates. e patient’s
hospital course was uneventful and he was discharged on
post-operative day four.
Discussion
is case demonstrates a patient who presented with
chest discomfort post-bypass surgery and was found to
have a small to moderate-sized hemopericardium as a
result of a fractured sternotomy wire projecting poste-
riorly into the pericardial space resulting in a cardiac
wound. In our patient, the fractured and posteriorly
angulated sternal wire is thought to have been a result
Fig. 2 Lateral chest X-ray from five months prior demonstrating a fractured sternal wire located at the posterior sternal table (arrow)
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Khouzam et al. Journal of Cardiothoracic Surgery (2023) 18:358
of his sternal instability. is case highlights the impor-
tance of evaluating patients with an unstable sternum
who have recently undergone a sternotomy as this can
lead to a sternal wire fracture and potential angulation.
Although sternal wire fractures occasionally appear on
post-operative follow-up chest roentgenograms, they are
often thought of as nonspecific findings or even omitted
from the final radiology report [3–5]. Findings of central
sternal lucency and loss of sternal wire alignment raises
the suspicion for sternal nonunion/dehiscence. More-
over, this radiologic findings, particularly in the context
of an unstable sternum, may result in the fractured wire
angulating and penetrating the pericardium causing seri-
ous cardiovascular injury.
Post-sternotomy hardware complications include ster-
nal wire rotation, migration, displacement, rupture, and
fracture [6]. e incidence of each of these complications
has not been elucidated. e mechanism for wire-frac-
ture is hypothesized to be multifactorial, with mechani-
cal distortion during sternal closure and chemical
erosion from contact with bodily fluids being the main
contributing factors [3]. e breaking of sternal wires
has the potential to cause serious complications, with the
literature reporting cases of fractured fragmented wire
embolizing to the lung [7] and migration and puncture
of the wire fragments into the ascending aorta [8]. We
present however, to the best of our knowledge, the first
reported case of a direct sternal wire puncture into the
pericardial space.
Other, more common sequelae of post-sternotomy
hardware complications include sternal instability and
sternal dehiscence, which when combined, have an
estimated prevalence of 1–3% [9]. ere are several
patient-specific risk factors that can contribute to sternal
dehiscence, including chronic obstructive pulmonary dis-
ease, obesity, trauma, and diabetes mellitus. In addition,
certain operative and post-operative factors may also
increase the risk of sternal dehiscence, such as prolonged
time on pump, procedures involving the internal thoracic
artery, repeat surgery, and prolonged post-procedure
ventilation. [10]. Sternal dehiscence is usually evident
clinically, but may be clinically occult in a small subset
Fig. 3 Surgical image demonstrating repaired jagged right ventricular laceration
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Page 5 of 5
Khouzam et al. Journal of Cardiothoracic Surgery (2023) 18:358
of patients [4]. In the modern day, surgeons often close
sternotomies by placing wires in figure-of-8 fashion,
as it increases the area of contact between the wire and
the sternum and is associated with lower rates of wire
loosening or fracturing [11]. In high risk patients, some
surgeons augment their sternal closures with additional
hardware such as plates or clips, though recent studies
have shown that these often have little to no impact on
post-operative morbidity [12, 13].
Treatment of sternal wire fractures, particularly in
patients with an unstable sternum, is often left up to the
individual surgeon, as the literature is limited to case
reports only [7, 8]. Central sternal lucency and loss of
sternal wire alignment on post-operative chest X-rays
should alert the clinician of sternal malunion/dehiscence.
We recommend that sternal wire fractures in this set-
ting should be removed given the potential of angulation
and penetration into the mediastinum. In our patient,
after repairing the cardiac wound, the sternal bone was
repaired using sternal plates.
Conclusion
In conclusion, recognizing and managing an unstable
sternum in patients who have undergone a recent ster-
notomy is important. A combination of a broken ster-
nal wire with sternal instability may lead to serious and
potentially life-threatening complications such as cardiac
perforation from an angulated sternal wire. Prompt diag-
nosis and surgical intervention are essential in treatment
in such patients.
Abbreviations
CTA Computed tomography angiography
TEE Transesophageal echocardiogram
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s13019-023-02452-6.
Supplementary Material 1
Authors’ contributions
MK composed the initial draft of the manuscript. KJ, JB, AZ, DS, TK, JS-C, DR, LB,
SS, GP, KA, and NK edited and revised the information. All authors have read
and approved the final manuscript.
Funding
Not applicable.
Data Availability
Not applicable.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Patient consented for participation in research.
Competing interests
The authors declare no competing interests.
Received: 28 May 2023 / Accepted: 4 November 2023
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