Year : 2012  |  Volume : 15  |  Issue : 2  |  Page : 171--172

Tracheal injury causing massive air leak during mitral valve replacement surgery

Arindam Choudhury, Neeti Makhija, Usha Kiran 
 Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Arindam Choudhury
Flat No. 260, DDA Flats, Pocket 1, 2; Sector 3, Dawarka, New Delhi 110 075

How to cite this article:
Choudhury A, Makhija N, Kiran U. Tracheal injury causing massive air leak during mitral valve replacement surgery.Ann Card Anaesth 2012;15:171-172

How to cite this URL:
Choudhury A, Makhija N, Kiran U. Tracheal injury causing massive air leak during mitral valve replacement surgery. Ann Card Anaesth [serial online] 2012 [cited 2022 Aug 14 ];15:171-172
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Full Text

The Editor,

Median sternotomy is a routinely performed procedure during cardiac surgery for gaining access to the mediastinal structures. [1] Engaging the sternal saw in the suprasternal notch requires dissection and division of interclavicular ligaments. We describe a case where the trachea was injured during sternotomy leading to massive air leak.

A 40-year-old, male patient with severe calcific mitral stenosis was scheduled for mitral valve replacement. Airway examination was unremarkable. Anesthesia workstation (Datex-Ohmeda Aestiva S5, Helsinki, Finland), breathing circuit and endotracheal tube (ETT) cuff leak test were satisfactory. Electrocardiogram, pulse oximetry (SpO 2 ), end tidal carbondioxide (EtCO 2 ) and invasive radial artery pressure monitoring were initiated prior to induction.

General anesthesia was induced and trachea was intubated with a 9.0-mm cuffed polyvinyl chloride (PVC) ETT (Smiths Portex, Kent, UK), which was fixed at 22 cm at the right angle of the mouth. Anesthesia and neuromuscular blockade was maintained with repeated doses of fentanyl, midazolam, vecuronium bromide intravenously and sevoflurane-air-oxygen mixture through the inhalational route.

The sternal notch was made prominent by placing a sand bag underneath the shoulder. The lungs were deflated by disconnecting the ETT from the ventilator prior to sternotomy as per institutional protocol and ETCO 2 read zero with a flat capnograph. The sternotomy saw could not be engaged in the suprasternal notch in the first attempt. The 'inter-clavicular ligament' was excised with scissors; the saw was reinserted, and the sternum was divided. A Sarns TM sternotomy saw (Ann Arbor, MI, USA) was used to perform the midline sternotomy. On resuming mechanical ventilation, the capnograph reappeared, but a low airway pressure alarm prompted us to check ETT connection and the pilot balloon assembly. The pilot balloon could not be inflated despite repeated attempts to do so. Clamp was applied at the insertion point of the inflation tube to the ETT to demonstrate that the pilot balloon and the tubing were intact. Hissing sounds and air bubbles emerging from the cranial end of the sternotomy wound were also noted. The surgeon was informed immediately and manual ventilation was started with increased fresh gas flow (FGF) from 2 to 12 L/min with 100% O 2 . The surgical trainee detected a rent in the trachea and tried to occlude it with the tip of his index finger, but then air started leaking from the oropharynx. It was apparent that the ETT needed replacement as it's PVC cuff was damaged.

The ETT was pushed further inside by about 2 inches to facilitate ventilation during tracheal repair. Once the trachea was repaired, the damaged ETT [Figure 1] was replaced with a 9.0-mm cuffed PVC tube using direct laryngoscopy with slight repositioning of the patient's head. Emergency airway equipments including an airway exchange catheter were kept ready, although intubation was achieved with direct laryngoscopy alone. Oxygen saturation was closely monitored and at no point of time did the SpO 2 drop below 97%.{Figure 1}

The patient underwent mitral valve replacement uneventfully under cardiopulmonary bypass (CPB) and, while weaning the patient off CPB, the lungs were successfully inflated with manual positive-pressure ventilation with no evidence of any air leak from the tracheal wound. Postoperative bedside chest X-ray was normal and there was no evidence of any surgical emphysema. A fiberoptic bronchoscopy was performed during extubation to rule out any tracheal stenosis or bleeding inside the trachea at the repair site. The patient was extubated in the intensive care unit 8 h after the surgery and was discharged from the hospital in 6 days. During follow-up at 1 and 6 months, the patient did not have either airway obstruction or stridor; therefore, a lung function test was not performed.

Actual sequences of events were analyzed and it was found that a small piece of the tracheal ring had been excised mistakenly by the surgical trainee, as it came in between the sternotomy blade and the superior border of the manubrium sterni. It is common practice to divide the interclavicular ligament just before the actual sternotomy. [2] However, in this case, the tracheal ring was confused with the interclavicular ligament. This mishap could be partly due to incorrect surgical positioning of the patient as well as carelessness on the part of the trainee.

Hyperextension of the neck produced by sand bags may shift the trachea anteriorly at the thoracic inlet thus leaving less space for engaging the sternotomy saw. Therefore, the authors suggest that hyperextension of neck may be avoided, especially in thin-built patients. Although iatrogenic tracheal injuries due to other procedures such as endotracheal intubation, tracheal stenting, thyroid surgeries or transhiatal esophagectomy are not uncommon, [3] sternotomy, being a major procedure; it should be supervised by an experienced surgeon or else avoidable complications like this may recur, as trainees are more likely to commit such mistakes. [4]


1Takanami I. Tracheal laceration: A rare complication of median sternotomy. J Thorac Cardiovasc Surg 2001;122:184.
2Reed MF. Thoracic incisions. In: Little AG, Merrill WH, editors. Complications in cardiothoracic surgery: Avoidance and treatment. 2 nd ed. Oxford, UK: Blackwell Publishers; 2010. p. 22-53.
3Berry M, Van Schil P, Van Meerbeeck J, Vanmaele R, Eyskens E. Surgical treatment of iatrogenic tracheal lacerations. Acta Chir Belg 1997;97:308-10.
4Bakaeen FG, Huh J, Lemaire SA, Coselli JS, Sansgiry S, Atluri PV, et al. The July effect: Impact of the beginning of the academic cycle on cardiac surgical outcomes in a cohort of 70,616 patients. Ann Thorac Surg 2009;88:70-5.