Surgery for left ventricular free wall rupture: patch glue repair without extracorporeal circulation.

Left ventricular free wall rupture is a dramatic complication after myocardial infarction. We present our experience with the simple, expedient technique of patch glue repair without extracorporeal circulation. Access is obtained via median sternotomy. Evacuation of blood and haematoma is undertaken and a Goretex patch exceeding the size of infarct is fashioned. The patch is applied to the epicardium using enbrucrilate surgical glue instilled with gentle pressure against the beating heart. We performed this technique on 17 patients from 1993 to 2001, with a operative (30-day) mortality of 23.5% with a post-discharge survival of 85% at 2.2 years.     

Subacute left ventricular free wall rupture

In a 59-year-old man, Left ventricular free wall rupture following acute myocardial infarction was diagnosed by transthoracic echocardiography, left ventriculography and a combination of saline injection into the left ventricle and concomitant transthoracic echocardiography. The Operation was successfully performed with an extracorporeal bypass on the beating heart. Some technical aspects of the treatment are discussed.     

A surgical case of ventricular septal perforation after repairing left ventricular free wall rupture.

A 78-year-old woman with diagnosis of acute myocardial infarction (AMI) in the anteroseptal area fell into cardiogenic shock suddenly just before starting percutaneous coronary intervention (PCI). Echocardiography showed left ventricular free wall rupture, then an emergent operation was performed by sutureless patch repair using collagen fleece with fibrinogen-based impregnation. Eight days later from the initial operation, the onset of ventricular septal perforation (VSP) was recognized. Fifteen days after, the infarct exclusion technique with endocardial patch was performed. She has been doing well 4 months after the operation without residual shunt. To our best knowledge, this is the first surgical case report that free wall rupture of left ventricle and VSP which are serious complications after myocardial infarction happened in succession.     

Sutureless technique for oozing type postinfarction left ventricular free wall rupture

We report our experience using a sutureless technique for oozing type postinfarction left ventricular free wall rupture. Several materials such as fibrin seat, autologous or heterologous pericardial patch, fibrin glue, and geratin-resorcin-formaldehyde (GRF) glue have been used. Nine patients, who developed postinfarction left ventricular free wall rupture, underwent surgical repair using a sutureless technique between 1999 and 2004. All patients survived and discharged our hospital without any postoperative complications. And all are alive an exellent condition in 5 to 44 months. A sutureless technique for the treatment of oozing type postinfarction left ventricular free wall rupture is simple, effective, and associated with a favorable outcome.     

Case report of surgical repair of left ventricular free wall rupture using GRF® glue and pericardial patch

A 73-year-old woman with acute myocardial infarction (Seg. 6:100%) was admitted to our hospital. She underwent percutaneous transluminal angioplasty (PTCA) and stent insertion to Seg. 6 on that day and anticoagulant therapy with urokinase and heparin was started in CCU. On the 4th day, chest pain developed suddently and echocardiography revealed cardiac tamponade, so we suspected left ventricular free wall rupture. When blood pressure increased to 100 mmHg in the operating room, the left ventricular free wall rupture became “blow out” type. After establishing extracorporeal circulation, we glued Xenomedica and autologous pericardium using gelatin-resorcin-formaldehyde glue (GRF® glue) to the linear tear without damaging the myocardium and coronary arteries and reducing left ventricular volume. Bleeding was completely controlled. This experience suggests that this procedure might be effective for left ventricular free wall rupture.     

Sutureless patch technique for postinfarction left ventricular rupture

BACKGROUND: Left ventricular free wall rupture is an uncommon but catastrophic event after myocardial infarction and is associated with a high mortality. After prompt diagnosis some patients may be salvaged with immediate surgical intervention. Surgical techniques used to seal the rupture vary, as few surgeons have experience with this pathologic process. We report our experience using a sutureless patch technique to treat this entity. METHODS: A review of 6 consecutive patients during an 8-year period who were referred to one cardiac unit with postinfarction left ventricular rupture was conducted. RESULTS: There were 3 men and 3 women with an average age of 71.8 years. All were hemodynamically unstable, and 4 were in electromechanical dissociation. Echocardiography confirmed the diagnosis in 5 patients, and cardiac catheterization had been performed in 4 before rupture. All patients were treated promptly with fluid, inotropic agents, and, if needed, cardiopulmonary resuscitation and pericardiocentesis. Resuscitation was continued in the operating room, and the myocardial tear was sealed with a generous patch of unsupported felt secured to the heart with cyanoacrylate glue. Coronary artery bypass grafting was performed in 3 patients if the anatomy was known. All patients survived to the intensive care unit. One death occurred as a result of severe neurologic injury. Five patients were discharged from the hospital, and all were alive 2 months to 7.5 years after operation. CONCLUSIONS: A sutureless patch technique for the treatment of postinfarction rupture is simple, effective, and associated with a favorable outcome.     

Surgical experience with left ventricular free wall rupture

Background. Autopsy studies reveal that left ventricular free wall rupture (LVFWR) accounts for 7% to 24% of deaths after myocardial infarction. The condition occurs up to 10 times more often than papillary muscle or interventricular septal rupture. A high index of suspicion must be maintained to differentiate LVFWR from infarct extension, cardiogenic shock, pulmonary embolus, and even Dressler’s syndrome.

Methods. Since 1980, we have operated on 18 patients with LVFWR. Fourteen patients had experienced “blow-out” rupture associated with cardiogenic shock. Four patients had “stuttering” ruptures, a less spectacular occurrence. Echocardiography was the most important diagnostic tool. Repair was performed, usually using infarctectomy and direct suture closure.

Results. Eleven patients (61%) died after operation, 4 patients as a result of rerupture 1 to 12 hours after operation. Recently, we have used a “patch/glue” technique to repair ruptures in 2 patients. We believe this technique is superior to direct suture closure in preventing rerupture. There have been 7 long-term survivors (39%) from 6 months to 15 years.

Conclusions. Left ventricular free wall rupture is not always sudden and dramatic. Yet, the operating staff must be willing to race to the operating room even with the patient in full resuscitation. Echocardiography is the most sensitive and efficient diagnostic tool. All rupture sites should be aggressively repaired, possibly combining direct suture and patch/glue techniques.     

Experience with postinfarction left ventricular free wall rupture

BACKGROUND: Postinfarction rupture of the left ventricle is a rare event in which approach is not clearly standardised and outcome after repair is unknown. Our experience with this pathology was reviewed to analyze methods of repair and assess outcome beyond the patient's hospitalisation. METHODS: Five patients underwent surgical repair of a postinfarction ventricular rupture between 1990 and 1998. Electromechanical dissociation (3 patients) and sudden hypotension and bradycardia (2 patients) were clinical indicators of rupture. Four patients underwent repair with cardiopulmonary bypass and 1 patient without. Repair consisted of epicardial patching (2 patients), direct suture (1 patient), infarct-exclusion (1 patient), and debridement and patch closure (1 patient) of the rupture. Myocardial revascularization was performed in 3 patients and mitral valve repair in 1 patient. RESULTS: A satisfactory hemodynamic state was restored and bleeding was controlled in all patients. Two patients died postoperatively and another patient died 4 months after hospital discharge as a result of cardiac failure and/or sepsis. The other 2 patients are alive and in excellent condition 6 and 30 months respectively after repair. CONCLUSIONS: Postinfarction rupture of the left ventricle bears a high mortality, but survival with an excellent quality of life is possible after surgical repair.     

Post myocardial infarction left ventricular free wall rupture

Occurrence of left ventricular free wall rupture following myocardial infarction is an unpredictable event associated with very high mortality rate. The most appropriate surgical approach remains controversial. With recent advances in portable echocardiography machines there has been a progressive rise in the number of cases of left ventricular free wall rupture diagnosed and reported. Early diagnosis and expeditious relief of tamponade followed by emergency surgery could save many lives. We present a review of six patients treated at our institute for ventricular free wall rupture over the last ten years. A literature review of the optimal management strategy follows. All patients were operated using cardiopulmonary bypass. Two patients died following surgery. Intra-aortic balloon pump was used in all patients. One patient had coronary artery bypass grafting empirically based on palpable disease in the epicardial coronary arteries. None of the surviving patients showed any evidence of neurological deficit. We advocate tailoring the type of repair to the status of the tear at the time of operation.     

Successful weaning from a left ventricular assist device after surgical repair of a left ventricular free wall rupture

We present a case of an insertion of a left ventricular assist device for severe cardiac failure after the repair of a left ventricular free wall rupture. A 72-year-old man was admitted with chest pain and unconsciousness, and required emergency surgical repair of a left ventricular free wall rupture under percutaneous cardiopulmonary support. Severe cardiac failure occurred postoperatively, and weaning from percutaneous cardiopulmonary support was impossible. We implanted a left ventricular assist device, and this could be removed at one week after implantation. The left ventricular assist device was very useful as a "bridge to recovery".     

Technique for repair of left ventricular free wall rupture

A case of postinfarction left ventricular free wall rupture is reported. The technique used to repair the rupture is described, along with a modification of the technique.     

Therapeutic strategies for postinfarction left ventricular free wall rupture

We treated 93 patients who developed left ventricular free wall rupture after acute myocardial infarction. Medical management including pericardial drainage was performed in 78 patients (84%), but 67 of them died. All 11 surviving patients showed an oozing type rupture. Surgical repair was performed in 15 patients (16%). As a result, 9 patients died and 6 survived. All but 1 of the patients who died presented with a blow-out rupture. Blow-out type rupture occurred in 3 and oozing type rupture in 3 of the surviving patients. One patient with blow-out type rupture underwent implantation of a left ventricular assist device following percutaneous cardiopulmonary support (PCPS), because of low output syndrome after the operation. The device was successfully removed 7 days after implantation. In all of the 3 patients with oozing type rupture, sutureless technique was successfully performed using fibrin-glue or fibrin-glue sheet fixation. After a mean follow-up period of 7 years after operation, 5 of 6 are still alive. To improve the clinical outcome of left ventricular free wall rupture, it is important for surgeons to closely liaise with physicians, to perform surgical repair as soon as possible, and to utilize a circulatory support system after operation. Therefore, we developed a new PCPS system compatible with emergency cardiac surgery and a new left ventricular assist system draining via the left ventricle.     

Double-patch sandwich repair for left ventricular free wall rupture

We present a case of a patient with left ventricular free wall rupture who successfully underwent emergency surgical repair using the double-patch sandwich technique. This technique has already been used for the treatment of left ventricular aneurysm and retains the proper shape and size of the left ventricle. Multislice computed tomography was fast and non-invasive in the detection of a ventricular rupture.     

Ischemic left ventricular free wall rupture followed by ventricular septal perforation

A 78-year-old woman underwent coronary angiography because of acute onset of anterior chest pain, disclosing total occlusion of the left anterior descending artery. After this she fell into circulatory collapse. As a subsequent chest computed tomography (CT) revealed pericardial effusion, she was transferred to our hospital. At operation, an oozing lesion was found on the left ventricular anterior wall near the apex. Under extracorporeal membrane oxygenation, the bleeding was completely controlled by applying fibrin glue sheets. On the thirteenth day after operation, a new systolic murmur appeared with hemodynamic deterioration. Echocardiographic examination revealed ventricular septal perforation, and she underwent reoperation. The ventricular septal perforation was recognized on the apical anterior wall. It was repaired by an infarction exclusion method. The postoperative course was uneventful. Although ischemic ventricular double rupture is a very rare complication, patients who have risk factors for cardiac rupture need to be intensively followed up.     

Sutureless technique for subacute left ventricular free wall rupture: A case report of an 85-year-old.

This case was an 85-year-old female who developed left ventricular free wall rupture (LVFWR) of the anterior wall 13 days after an acute myocardial infarction. She was further complicated with an ascending aortic aneurysm and severe aortic regurgitation. The wall was repaired using a sutureless technique with an autologous pericardial patch and GRF glue without cardiopulmonary bypass. Although the complication of a left ventricular aneurysm was seen, the postoperative course was uneventful. Nevertheless, she is doing well 9 months after surgery.     

Myocardial infarction complicating left ventricular free wall blowout rupture: a survival case after surgical repair

A 58-year-old man who suffered from acute myocardial infarction complicated with left ventricular rupture and subacute pericardial tamponade was reported. On admission, echocardiography strongly suspected presence of intrapericardial fluid. And immediate pericardiocentesis proved left ventricular free wall rupture (LVFWR). Coronary angiography with the support of IABP revealed occlusion of LAD (# 8). Percutaneous transluminal coronary angioplasty was performed with partial success. After pericardiotomy, the hemodynamic state was improved, however, 2 hours later, his blood pressure fell down to 40 mmHg suddenly. Emergent operation (re-mediastinumotomy+ ) was performed under the suspicion of left ventricular blowout rupture with the direct closure of the perforated site with 4 woven Dacron pledgets at bedside in ICU. The patient ran an uneventful postoperative course and is now doing well. Clinical and therapeutic features of LVFWR were discussed.     

Successful surgical management of left ventricular free wall rupture in the course of myocardial infarction

The case of a 49-year-old patient is described who presented with cardiogenic shock and electrocardiographic signs of an inferolateral Q-wave infarction, and who received systemic lysis with anisoylated plasminogen streptokinase activator complex (Eminase). After coronary angiography had revealed only peripheral occlusion of a posterolateral branch of the left circumflex coronary artery, a pericardial effusion surrounding both right and left ventricular cavity was identified by echocardiography and was successfully drained via an inferior pericardiotomy with an immediate rise of blood pressure. Upon thoracotomy myocardial rupture was detected in the infarct area and was closed with mattress sutures. A total of 39 cases of successful surgical repair of myocardial free wall rupture reported in the literature is discussed. The mean age of patients was 59.6 +/- 1.3 years. Posterior and anterolateral infarctions were the preferred locations of myocardial rupture. Rupture occurred with a mean delay of 5.0 +/- 1.0 days after the onset of clinical infarct signs. Among patients saved by surgical means were 33 males and 6 females.     

A successful repair of post-infarction left ventricular free wall rupture

Left ventricular free wall rupture secondary to acute myocardial infarction is almost invariably fatal. This report is the case presentation of a successful repair of left ventricular free wall rupture. A 55-year-old man, with a diagnosis of acute infero-lateral myocardial infarction, was transferred from another hospital to our CCU having recurrent chest pain on the fourth day after infarction. Shortly after admission, he lost his consciousness and fell into cardiogenic shock. Echocardiography showed a large pericardial fluid. He was immediately transferred to the operating room with the diagnosis of the heart rupture. After opening the pericardium containing 200 cc of blood, cardiac tamponade was relieved. The posterolateral portion of the left ventricle was found to be bluishly discolored, with a 8 mm-long tear of epicardium. Using cardiopulmonary bypass, the tear was closed with Teflon-reinforced sutures. The post-operative course was uneventful.