Left thoracotomy approach for left ventricular pseudoaneurysm due to myocardial infarction after mitral valve replacement for papillary muscle rupture

A 59-year-old man with acute mitral regurgitation due to papillary muscle rupture after myocardial infarction was admitted to our hospital. He underwent emergent mitral valve replacement with a mechanical valve by median sternotomy. Although postoperative echocardiography showed no sign of a ventricular aneurysm, echocardiography performed 5 weeks after the surgery showed enlarging left ventricular pseudoaneurysm of the inferior to the posterior cardiac wall. He underwent dacron patch closure of the orifice by fifth intercostal left thoracotomy. The postoperative course was uneventful and he was discharged on postoperative day 10. The patient was successfully treated for two life-threatening complications occurring subsequently after myocardial infarction.     

Acute myocardial infarction with left ventricular free wall rupture and papillary muscle rupture caused by infectious endocarditis

Infectious endocarditis sometimes causes coronary embolism which induces acute myocardial infarction. A 59-year-old man was admitted to our hospital with a diagnosis of acute myocardial infarction accompanied by left ventricular free wall rupture and papillary muscle rupture. We perfomed mitral valve replacement combined with repair of left ventricular free wall rupture. The anterior mitral leaflet had perforation and vegetation, which suggested that acute myocardial infarction was caused by septic embolus originated from infectious endocarditis in this case.     

A case of emergency surgery for acute mitral regurgitation due to complete papillary muscle rupture as a severe form of reperfusion injury: report of a case

Complete rupture of a papillary muscle following acute myocardial infarction is a severe complication associate with acute left ventricular failure and pulmonary edema. Since the introduction of acute percutaneous transluminal coronary angioplasty (PTCA) in the management of acute myocardial infarction, the frequency of this complication has further decreased. We described a patient who had acute mitral regurgitation due to complete rupture of papillary muscle rupture after successful coronary intervention. Transesophageal echocardiography demonstrated severe mitral regurgitation and the ruptured papillary muscle. At operation, posteriol papillary muscle was found to be totally ruptured. Mitral valve replacement was performed. Postoperative course was uneventful, with 2 days of IABP and 5 days of ventilator support.     

Mitral valve surgery with surgical embolectomy for mitral valve endocarditis complicated by septic coronary embolism.

Acute myocardial infarction (AMI) complicated by septic coronary embolism due to active infective endocarditis is rare but usually fatal. We report a case of successful mitral valve surgery with surgical embolectomy in a 27-year-old man with an AMI complicated by septic coronary embolism due to mitral valve endocarditis. A chest radiograph revealed cardiomegaly and marked pulmonary edema. A transthoracic echocardiogram disclosed severe mitral regurgitation with highly mobile vegetations and hypokinesia of the left ventricular apex. The electrocardiographic findings of ST segment elevation in leads V2-4 and elevated cardiac enzyme levels were strongly suggestive of an acute anterolateral AMI. Nevertheless, emergent cardiac surgery was needed without selective coronary angiography because of intractable heart failure and life-threatening ventricular tachyarrhythmia requiring cardiopulmonary resuscitation. A total occlusion of the distal left anterior descending artery caused by embolic vegetation and thrombus, which was incidentally detected intraoperatively, was successfully recanalized by surgical embolectomy and thrombectomy using a direct coronary incision. The mitral valve endocarditis was managed with wide debridement and mechanical valve replacement. Three years after the surgery a follow-up echocardiogram showed no abnormalities of the regional wall, motion in the left ventricle and the patient is living an active life without any complications.     

Posterior ventricular aneurysm, severe mitral regurgitation, and rupture of the left ventricle after acute myocardial infarction: six-year survival after surgical correction.

Posterior ventricular aneurysm and severe mitral regurgitation due to acute myocardial infarction are rarely recognized during life. This report describes the successful surgical treatment of a patient with this combination of lesions who at operation was found to have rupture of the left ventricle as well. Aneurysmectomy, mitral valve replacement, and coronary artery bypass were performed with a gratifying late result. Aggressive investigation of patients with hemodynamic deterioration after posterior myocardial infarction may identify surgically correctable mechanical complications.     

Delayed left ventricular free wall rupture complicating coronary artery bypass surgery. A case report

Rupture of the left ventricular free wall is a not uncommon life-threatening complication of acute myocardial infarction and after prosthetic mitral valve replacement. To our knowledge, no case of left ventricular rupture after coronary artery bypass surgery has been reported. A case is now described in which coronary artery bypass grafting was complicated by delayed rupture, which was successfully repaired. Different etiologic factors are discussed, but the cause considered most likely was trauma from elevation of and traction on the heart in exposure of its posterior aspect.     

Left ventricular pseudoaneurysm arising between two papillary muscles: repair without mitral regurgitation

Left ventricular pseudoaneurysm is a rare lesion that occurs when a contained free-wall rupture occurs after a transmural myocardial infarction. Such a pseudoaneurysm may be lethal if subsequent rupture or progressive heart failure occurs. We describe a 67-year-old man who, one year after undergoing coronary artery bypass grafting, developed an infero-apical left ventricular pseudoaneurysm between the bases of two papillary muscles without incurring significant mitral regurgitation. This was a highly unusual presentation. We were able to repair the aneurysm and restore normal mitral geometry without causing regurgitation.     

Spontaneous closure of a large left ventricular pseudoaneurysm after mitral valve replacement

Left ventricular pseudoaneurysm is a rare, but potentially fatal, condition that generally occurs as a complication of myocardial infarction, infective endocarditis, or cardiac surgery. Surgical repair is the treatment of first choice because of the marked risk of rupture, but deteriorated hemodynamics and complicated procedures to treat the pseudoaneurysm may lead to a high mortality rate. We report a 62-year-old woman with a large left ventricular pseudoaneurysm after mitral valve replacement for rheumatic mitral valve stenosis. Surgical repair was not performed due to the patient’s refusal, but her pseudoaneurysm resolved spontaneously by 2 years after mitral valve replacement. Spontaneous obliteration of a large left ventricular pseudoaneurysm is very rare in a patient on warfarin therapy. This case suggests that a left ventricular pseudoaneurysm with a narrow neck may resolve spontaneously in rare settings.     

Surgical treatment of left ventricular aneurysm associated with mitral regurgitation

The purpose of this study is to analyze the early and late results of left ventricular aneurysmectomy in patients with mitral regurgitation secondary to myocardial infarction. Twenty patients who had left ventricular aneurysm combined with mitral regurgitation underwent the isolated or combined aneurysmectomy during the last 10 years. There were 18 male cases and 2 female cases, and their age ranged from 31 to 64 (mean age 52.6 years). In 19 cases, the left ventricular aneurysm were caused secondary to antero-septal infarction due to the occlusion of the left anterior descending coronary artery. In one case, the coronary spasm of circumflex artery provoked the posterolateral myocardial infarction and the tendon rupture of posterior papillary muscle. The isolated left ventricular aneurysmectomy were performed in 6 cases and the combined operations were coronary artery bypass grafting in 11 cases, mitral annuloplasty in 1 case, mitral annuloplasty and bypass grafting in 1 case, and mitral replacement in 1 case. There were no operative death cases. The preoperative mean functional class (NYHA classification) was 2.9 and the postoperative class was 1.4. The preoperative mitral regurgitation of grade 1 in Sellers' classification was observed in 11 cases. Grade 2 regurgitation was observed in 6 cases, grade 3 in 2 and grade 4 in 1. After surgery, mitral regurgitation more than grade 2 was recognized in 3 cases (group A) and regurgitation less than grade 1 was seen in 17 cases (group B).(ABSTRACT TRUNCATED AT 250 WORDS)     

Long time use of percutaneous cardiopulmonary support after cardiovascular operation; clinical problems from our experience

Result and problems were studied in 12 patients who received percutaneous cardiopulmonary support (PCPS) after cardiac or aortic surgery. Causative diseases included acute myocardial infarction in 7 cases, rupture of the left ventricular septum after infarction, acute mitral valve regurgitation after infarction, rupture of the left ventricular free wall, a stuck valve, and an aortic aneurysm in the thoracicoabdominal region in each 1 case. The time of postoperative PCPS ranged from 2 to 361 hours, and the mean supply flow volume was 1.78 +/- 0.45 l/min/m2. Seven patients could be taken off the treatment or discharged from the hospital (58.3%). The comparison between surviving and non-surviving cases showed a significantly longer assisted circulation time in the latter. An increase of bleeding after surgery was found in all 8 patients who received PCPS for a long period postoperatively. This was assumed to be due to the thrombocytic activation by heparin.     

Left ventricular free wall rupture possibly induced by coronary spasm

A 68-year-old woman complained of chest discomfort after a traffic accident in which she driving hit a child. At about twenty-five minutes later, she went into sudden cardiogenic shock due to acute myocardial infarction caused by non-occlusive intracoronary thrombosis without significant organic coronary stenosis and without any sign of extraluminal contrast pooling on coronary angiography. She was transported to our emergency room by ambulance because of cardiac tamponade caused by a left ventricular free wall rupture following the acute myocardial infarction. On arrival, she was near cardio-pulmonary arrest on intraaortic balloon pumping. We performed emergency open cardiac massage and pericardiotomy. The hairline perforation responsible for the blowout-type left ventricular free wall rupture was successfully closed with Teflon-reinforced sutures. In conclusion, it was strongly suspected that the present case of left ventricular free wall rupture was caused by acute myocardial infarction due to intracoronary thrombosis following coronary spasm without significant organic coronary stenosis or rupture of atheromatous plaque.     

Papillary muscle rupture following myocardial infarction: Successful treatment by resection of akinetic left ventricular area, mitral valve replacement, and aorta to coronary artery bypass graft

A patient is reported in whom rupture of the posterior papillary muscle of the left ventricle occurred following myocardial infarction. The intractable pulmonary oedema that followed responded to the combined surgical approach of mitral valve replacement, resection of the akinetic area of the left ventricular wall, and saphenous vein aortocoronary bypass. This combination of surgical procedures has not been reported to date, and was considered to have preserved adequate left ventricular performance.     

Role of echocardiography/Doppler in cardiogenic shock: silent mitral regurgitation

Two cases of cardiogenic shock and pulmonary edema due to acute, severe, silent mitral regurgitation are discussed. The mechanism for the mitral regurgitation was papillary muscle rupture in the setting of acute myocardial infarction. Echocardiography established the presence, severity, and cause of the mitral regurgitation and the associated hyperdynamic left ventricular function in the setting of cardiogenic shock. Transesophageal echocardiography is excellent for assessing the mitral valve in critically ill patients in whom transthoracic echocardiography may be inadequate or misleading. This allowed for emergency mitral valve replacement without prolonged attempts at medical stabilization.     

Survival after sequential mechanical complications of acute myocardial infarction, complicated with heparin-induced thrombocytopenia and multiple organ failure: report of a case

BACKGROUND: Ventricular wall rupture and acute mitral regurgitation due to papillary muscle rupture post-acute myocardial infarction are rare and dramatic mechanical complications. The operative mortality of both complications remains extremely high but this is the only treatment which has greatly improved the prognosis. CASE PRESENTATION: We describe the course of a patient, who survived after left ventricular free wall rupture two days post-acute myocardial infarction. He underwent left ventricular rupture repair plus two coronary artery bypass grafting. On the fifth postoperative day he developed papillary muscle rupture and acute mitral valve regurgitation. He was reoperated as an emergency case for mitral valve replacement. The patient sustained numerous complications, such as renal failure, heparin-induced thrombocytopenia, sepsis, acute respiratory distress syndrome, and multiple organ failure. He was on continuous venous-venous hemofiltration for one week and underwent a tracheostomy on the ninth postoperative day. He remained on a ventilator for three weeks. The patient survived, was discharged home after six weeks, and remains in very good condition on follow-up so far. CONCLUSION: The operative mortality of both complications remains high but this is the only treatment which improves the prognosis. Surviving both events is rare and few cases have been reported in the literature. This case highlights the necessity of careful echocardiographic examination in any patient presented with post-myocardial infarction new onset of hemodynamic instability. Identification of a single site of rupture does not eliminate the possibility of additional ruptures in the papillary muscle and intraventricular septum, and transesophageal echocardiography should be used to search for these entities. Although repair of each of these complications carries a high mortality, failure to address them will almost certainly result in death. Using standard surgical techniques, including preoperative intraaortic balloon pump insertion and careful postoperative management, successful outcome is possible.     

Successful repair of a large pseudoaneurysm of the left ventricle late after mitral valve replacement due to rupture of the papillary muscle following acute myocardial infarction.

We present a rare case demonstrating a large pseudoaneurysm of the left ventricle late after mitral valve replacement due to rupture of the papillary muscle following acute myocardial infarction. A 52-year-old man, who had undergone mitral valve replacement 7 months previously, presented with severe congestive heart failure. Echocardiography and computed tomography of the chest demonstrated a large pseudoaneurysm of the left ventricle. The patch repair of the orifice of the pseudoaneurysm was successfully performed.     

Surgery for acute myocardial infarction

We discuss the current status and outcome of surgery for acute myocardial infarction (AMI). The optimal timing of surgical revascularization following AMI is a matter of controversy. Early surgery after an AMI involves high risk If elective surgery is possible under mechanical cardiac support cardiac artery bypass grafting (CABG) can be performed with acceptable mortality rates early after AMI. On-pump beating heart revascularization is efficacious in patients in cardiogenic shock or with unstable hemodynamics early after AMI. For postinfarct ventricular septal perforation, an infarct exclusion technique is a standard surgical procedure. For an oozing-type postinfarction left ventricular free wall rupture, a sutureless technique is effective. For papillary muscle rupture, emergent mitral valve replacement concomitant with CABG is recommended.     

Repair of Ventricular Septal Rupture Through the Right Atrium

A bstract The right atrial approach for repair of ventricular septal rupture associated with myocardial infarction is an alternative technique to the conventional approach of exposing the septum through the left ventricle. This technique may be combined with mitral valve replacement, infarct excision, or aneurysm resection, by avoiding a direct incision in the ventricle reduce postrepair bleeding and impairment of ventricular contractile function. We present a case of ventricular septal rupture repaired through the right atrium and review our surgical technique. This technique may be applied to most cases of ventricular septal rupture, and is particularly useful when the ventricular wall is not infarcted or aneurysmal, and the defect involves the central portion of the muscular septum, the inlet septum, and the subaortic and membranous area.     

Left ventricular fibroma masquerading as postinfarction myocardial rupture.

A large left ventricular fibroma was encountered perioperatively for what was presumed to be a sealed ventricular rupture after thrombolytic therapy for an acute myocardial infarction. We review the pertinent literature concerning the diagnosis of ventricular rupture and this rare benign tumor of the heart.     

Acute mitral regurgitation requiring urgent surgery because of chordae ruptures after extreme physical exercise: case report

Chordae rupture is the most common cause of severe acute mitral insufficiency. Many different mechanisms can cause an acute chordal rupture: degenerative mitral valve disease, infective endocarditis, myocardial infarction, or a posttraumatic event. We present 2 cases of acute mitral regurgitation requiring urgent surgery due to a posterior leaflet chorda rupture after extreme physical exercise.     

Atrial septal dissection late after congenital heart surgery

Atrial septal dissection is a rare entity usually seen after surgical mitral valve repair, myocardial infarction, or endocarditis. This is a report of an atrial dissection in a young girl found on routine follow-up echocardiography after repair of atrial and ventricular septal defects. No identifiable predisposing risk was found prior to or at the time of surgical repair. Considerable risk of significant morbidity and even mortality attends atrial dissection due to the risk of rupture.