Massive Bleeding After Median Sternotomy: Case Report of an Infrequent Complication of Infective Endocarditis

We report an unusual complication of acute infective endocarditis, found in a 70 year-old man with a previous history of two cardiac surgery procedures. The first one was a full root replacement (Bentall- De Bono procedure), associated with three bypasses (one mammary and two vein grafts). The second procedure was a mitral valve replacement through a right thoracotomy ought to native mitral valve endocarditis. In the current admission, echocardiography showed a periaortic abscess (Figure 1) and severe prosthetic mitral valve insufficiency. CT scan showed a big collection in the anterior mediastinal space adjacent to the composite graft (Figure 2), which was suspected to be purulent material. A third surgical intervention was programmed despite the extreme surgical risk. During the median sternotomy, a massive bleeding occurred. It was originated in the mediastinal collection, which truly was a collection of contained bleeding, originated in the 10 yearsold anastomosis of the saphenous vein to the composite graft, which was completely detached due to endocarditic involvement of the aortic graft. The institution of cardiopulmonary bypass before sternal opening enabled the surgical team to maintain a stable hemodynamic situation and to continue the procedure satisfactorily. Keywords: Infectious endocarditis; Composite graft; Combined surger