Unusual Cause of Dyspnea and Chest Pain in Cardiac Patient

Dr. Ayman Helal, MD^*.

*Corresponding Author: Dr. Ayman Helal, MD, FACC, FSCAI, Faculty of Medicine, Fayoum University, Fayoum, Egypt.

Received Date:  December 11, 2020

Publication Date: January 01, 2021

Abstract
Background: Postoperative dyspnea is common after cardiac surgery that may differ in causes. In common, it may be due to the incision, operation site, cardiopulmonary bypass, and internal thoracic artery harvesting, or lung diseases.

Case summary: Fifty-three years old female presents with dyspnea associated with limiting stitching chest pain 1 year after cardiac surgery. She was diagnosed to have bronchial asthma at this time and she was commenced on inhaled bronchodilators and inhaled steroids without any improvement. Echocardiography showed a good cardiac function, well-functioning prosthetic mitral valve, and a 0.3cm sub-aortic ventricular septal defect with left to right shunt which was insignificant. A respiratory function test demonstrated a restrictive lung disease. According to these results, a chest x-ray was requested that revealed the presence of fractured sutures with some parts within the upper part of the left side of the chest. A CT chest confirmed these findings and some of the fractured sutures even infiltrating the lung tissue. Fractured migrated sutures are the cause of the stitching chest pain that limit this patient’s inspiration.

Discussion: The integration of history taking, echocardiographic findings including shunt quantification, and the result of respiratory function test guide the diagnosis towards a restrictive lung disease which is demonstrated by the chest X-Ray and CT chest to be due to fractured migrated sutures that cause stitching chest pain that limits patient’s inspiration.

Keywords: Fractured suture; Dyspnea; Stitching chest pain; post-operative.

Learning Points

- The importance of integrating history taking, examination, laboratory and radiological investigation to reach a final diagnosis. 

- Fractured sutures are not un-common after cardiac surgeries and should be suspected especially if there is dyspnea with stitching chest pain.

Introduction

Postoperative dyspnea is common after cardiac surgery, even in low-risk patients. Cardiac surgeons and anesthesiologists are familiar with patients suffering from dyspnea in the early postoperative period, but in some cases, conventional treatment strategies may be ineffective, and a consultation with a pulmonologist may be required. Causes of dyspnea may differ because of the incision, operation site, cardiopulmonary bypass, and internal thoracic artery harvesting, which are unique to cardiac surgery. (1)

Timeline

Case Presentation

Fifty-three years old female presents with gradual onset progressive course of shortness of breath for the last 5 years (since 2014). The dyspnea was associated with limiting stitching chest pain over the upper part of the left side of the chest wall that increases with deep inspiration. The patient is known to be hypertensive for the last 5 years that was controlled on Bisoprolol 5mg/d and Candesartan 4mg/d. She has a past medical history of mitral valve replacement in 1996 at which she was commenced on an oral anticoagulant (Warfarin 5mg/d with a stable mean INR of 2.5). She underwent another operation in 2013 for removal of a missed sub-aortic membrane and thyroidectomy at the same time!!!. She sake medical advice many times during this period and she was told that she has bronchial asthma and she was commenced on inhaled bronchodilators and inhaled steroids without any improvement. 

On examination, her vital signs were (Pulse= 90/min, Blood pressure=130/85mmHg, Respiratory rate=30/min, Temperature= 37oC). General examination revealed normal JVP, normal chest examination (vesicular breathing without any additional sounds) apart from sternotomy and thyroidectomy scars, and normal abdominal examination and normal upper and lower limbs without any edema. The local cardiac examination demonstrated normal prosthetic metallic mitral valve sound with a pan-systolic murmur over the A2 area associated with thrill.

Routine investigations were unremarkable (Table 1/Figure 6). ECG was normal (Figure 1). Echocardiography was performed that showed a good cardiac function, well-functioning prosthetic mitral valve (PPG=22mmHg, MPG=9, MVA=1.7cm2), and a 0.3cm sub-aortic ventricular septal defect with left to right shunt (Figure 2, video link: https://www.youtube.com/watch?v=73JbbJrSKdI). The shunt is shown to be in-significant as the calculated Qp/Qs was 1.44 (Figure 3).

A respiratory function test (Table 2/ Figure 7) was requested that demonstrated a restrictive rather than obstructive lung disease. According to these results, a chest x-ray was requested that revealed the presence of fractured sutures with some parts within the upper part of the left side of the chest (Figure 4). A CT chest was performed and confirmed the site of fractured wires with some of them inside and outside the chest wall and some of them even infiltrating the lung parenchyma. Fractured migrated sutures are the cause of the stitching chest pain that limit this patient’s inspiration.

Table 1(Figure 6): Laboratory investigations of the patient

Figure 1: Electrocardiogram of the patient

Figure 2: Echocardiography of the patient. (A) Normal LV function (B) Normal RV function (C) A short axis view showing the VSD (D) VSD measuring 0.3cm (E) A VSD flow with left to right shunt (F) Prosthetic valve area and gradients

Figure 3: Shunt quantification showing insignificant shunt (Qp/Qs=1.44)

Figure 4: Chest X-Ray of the patient

Figure 5: CT scan of the chest showing fractured sutures outside (Red arrow) and inside (Yellow arrow) the chest wall and some infiltrating the lung tissue (Green arrow).

Discussion

This case presents the importance of integrating history taking, examination, laboratory and radiological investigation to reach a final diagnosis. One can say that the residual ASD after sub-aortic membrane removal is the cause of dyspnea and sent the patient to surgery for the 3rd time but the history, shunt quantification, and the result of respiratory function test guide the diagnosis towards a restrictive lung disease which is demonstrated by the chest X-Ray and CT chest. Fractured migrated sutures are the cause of the stitching chest pain that limits a patient’s inspiration.

Moreover, another one may suspect coronary artery disease as it is a disease with high prevalence worldwide especially in Egypt (2). Mainly, two reasons responsible for the sternal wire fracture: the overloading due to the patient’s activity and the wire mechanical fatigue, such as the growth of sternum, activities, and the sharp increase of wires’ yield strength. Usually, wire fracture occurs a week or more after surgery. (3)

Conclusion

Fractured migrated sutures are the cause of the stitching chest pain that limits a patient’s inspiration.

Consent: The author confirms that written consent for submission and publication of this case report including the image(s) and associated text has been obtained from the patient in line with COPE guidance. 

Conflict of interest: The author has no conflict of interest to declare.

References

1)Bolukçu A, ?lhan S, Topçu AC, Günay R, Kayac?o?lu ?. “Causes of Dyspnea after Cardiac Surgery”. Turk Thorac J. 2018;19(4):165–169.

2)Helal AM, Shaheen SM, Elhammady WA, Ahmed MI, Abdel-Hakim AS, Allam LE. “Primary PCI versus pharmacoinvasive strategy for ST elevation myocardial infarction”. Int J Cardiol Heart Vasc. 2018;21:87–93.

3)Gong W, Ye X, Wang Z, Li S, Zhao Q. “Fatal bleeding due to sternal steel wire fracture following open-heart surgery”. J Thorac Dis. 2015;7(10):E517–E519.

Volume 2 Issue 1 January 2021

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