A successful surgical repair of ventricular septal perforation following acute myocardial infarction in a 83-year-old man

A 83-year-old man, who experienced a sudden severe malacia 13 days before, was admitted, complaining of dyspnea since 8 hours before. A loud systolic murmur of Levine IV/VI was audible on the left sternal border of the 4th intercostal space. The chest X-ray film demonstrated severe pulmonary congestion. The ECG showed abnormal Q waves in II, III, a VF and V1-5. The right heart catheterization revealed an intraventricular shunt from left to right and thus ventricular septal perforation (VSP) 13 days after acute anteroseptal-inferior myocardial infarction was diagnosed. Continuing an aggressive medical treatment with the intraaortic balloon pumping, an emergency operation for VSP was performed 2 days after the onset. A single Teflon patch was sutured on the left side of the septum around VSP (2.5 x 2.5 cm) and the ventricular free wall was closed including the patch with two felt strips. The patient survived through the operation and is doing well at the 11 months of follow-up. Twenty patients above 70 years old have been surgically treated with success for VSP after acute myocardial infarction in Japan. Our patient was the oldest.     

Left ventricular pseudoaneurysm after sutureless repair of subacute left ventricular free wall rupture: a case report.

A 65-year-old woman presenting with a left ventricular pseudoaneurysm 27 months after sutureless repair of a subacute left ventricular free wall rupture complicating acute myocardial infarction is described. An autologous pericardial patch and gelatin resorcin formaldehyde (GRF) glue were used in the repair. A small pseudoaneurysm bulged out over the true aneurysm of the left ventricle. We performed a Dor operation and concomitant bypass grafting to the right coronary artery. Although sutureless repair is an effective procedure for subacute left ventricular free wall rupture, left ventricular pseudoaneurysm in the late postoperative period may be a rare problem after this repair.     

Embolic myocardial infarction and left ventricular rupture due to mitral valve endocarditis.

A left ventricular rupture due to embolic myocardial infarction is extremely rare. A 72-year-old woman developed an acute embolic myocardial infarction and mitral regurgitation due to infective endocarditis. Two days after the infarction, a left ventricular free wall rupture occurred after transesophageal echo examination. She received an epicardial patch and mitral valve replacement. Perioperatively, an intra-aortic balloon pump and long-term antibiotics were used. The postoperative course was uneventful, and she is doing well 10 months after surgery.     

Surgical strategy for left ventricular free wall rupture after acute myocardial infarction

BACKGROUND: Left ventricular free wall rupture is usually fatal without surgical intervention. However, the most appropriate surgical procedure remains controversial. METHODS: Seventeen patients (14 men, 3 women) who developed left ventricular free wall rupture after acute myocardial infarction were treated surgically. Their mean age was 65.4 years (range, 55 to 79 years). The following surgical procedures were performed: infarctectomy and patch reconstruction in 1 patient, direct closure with or without patch covering in 4 patients, simple patch covering anchored by running suture in 4 patients, and a sutureless technique in 7 patients. Endventricular patch closure was performed in 1 patient with ventricular septal perforation. RESULTS: One of 3 patients with a blow-out type rupture and 1 of 13 patients with an oozing type rupture died shortly after operation. The overall surgical mortality rate was 11.8%. CONCLUSIONS: Selection of the optimal procedure for each cardiac condition is important for obtaining good results. For patients with ongoing squirting bleeding, patch covering is the technique of choice. For oozing, the sutureless technique is preferable.     

Posterior ventricular septal perforation successfully repaired through right ventricular approach

A 65-year-old man underwent a successful repair of a posterior ventricular septal perforation (VSP) 9 days after suffering an acute inferior myocardial infarction. After hospitalization, his hemodynamic condition gradually worsened, in spite of administering intensive medical therapy. Emergent operation was performed on the 4th day after onset. An equine pericardial patch was sutured around the VSP through the right ventricular side of the septum using the double-patch repair method and the right ventricular wall was closed as using the standard extracorporeal perfusion technique. The dimensions of the VSP measured 5 mm in diameter. Transesophageal echocardiography was performed on the 14th postoperative day. Cardiac catheter examination was done on the 18th postoperative day. No residual shunt was recognized and cardiac function was good. He was discharged on the 20th postoperative day. The occurrence of a posterior VSP is comparatively rare, and repair of VSP is difficult to perform during an acute period. Therefore, the operative results of VSP cases remain poor.     

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.     

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.     

Early pseudoaneurysm formation after the sutureless technique for left ventricular rupture due to acute myocardial infarction

Left ventricular free wall rupture is a fatal and catastrophic complication after acute myocardial infarction. The sutureless technique with a fibrin tissue-adhesive collagen fleece is reportedly safe and effective in the oozing type of left ventricular free wall rupture. However, late pseudoaneurysm formation after this technique has been reported. We herein report a 65-year-old male patient who presented with pseudoaneurysm formation 8 days after the sutureless technique for the oozing type of left ventricular free wall rupture. Successful repair of the pseudoaneurysm was subsequently performed. Pseudoaneurysm formation should be recognized even early after the sutureless technique.     

Sutureless patch repair for small blowout rupture of the left ventricle after myocardial infarction

Rupture of the left ventricular free wall is one of the most serious complications of myocardial infarction. A 73-year-old man with severe chest pain visited our hospital. Coronary angiography revealed acute myocardial infarction in the territory of the diagonal branch. About six hours after successful percutaneous coronary intervention, the patient fell into cardiogenic shock with chest pain. Echocardiography showed moderate pericardial effusion with a subepicardial hematoma, and percardioentesis led to the diagnosis of free wall rupture. Emergency surgery was performed with the use of intra-aortic balloon pumping. The rupture was a blowout type in a small tear at the anterolateral wall of the left ventricle. We repaired the tear with an off-pump sutureless patch using collagen fleece with fibrinogen-based impregnation (TachoComb™) and equinous pericardium with fibrin spray. The patient was free of both re-rupture and pseudoaneurysm postoperatively, and was discharged 20 days after the operation. Considering previously reported various procedures for surgical repair, this technique may be useful if the tear is small.     

Chinese-hat patch glue repair of incomplete apical ventricular rupture

Left ventricular free wall rupture is a dramatic complication of myocardial infarction. Sub-acute rupture may be compatible with life for several days or even longer. We present a simple and effective technique of construction of a conical apical patch, Chinese-hat, which was applied successfully to the infracted left ventricular (LV) apex with surgical glue, without using cardiopulmonary bypass. The application of this technique permitted the consequent off-pump double coronary artery bypass of a patient, who was at high risk of complications due to extracorporeal circulation.     

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.     

Self-limiting left ventricular wall rupture following myocardial infarction

Abstract   A left ventricular posterior–inferior free wall rupture without pseudo aneurysm following inferior myocardial infarction was identified in a 40-year-old male patient. Coronary angiography of the patient demonstrated a total occlusion of the circumflex artery. Repair of the rupture was performed during an elective surgery carried out 15 days after the infarction. We approved to discuss this rarely encountered clinical case with the cases in the literature.     

Early operation for postinfarction ventricular septal perforation; report of three cases

Three patients underwent surgery for postmyocardial infarction ventricular septal perforation (VSP) within 3 to 21 days after onset of infarction. The hemodynamic stabilization was not obtained despite aggressive medical treatment including Intra-aortic Balloon Pumping (IABP) in one patient. The others had sudden hemodynamic deterioration during IABP support. In two of the three cases, the VSP were closed via transinfarct ventriculotomy with double Dacron patch, and ventricular wall reconstruction was performed to sandwich the double septal patch between ventricular free walls with Dacron felt strips. Two of the three patients survived. Our experience suggests that early surgical intervention is essential unless medical therapy results in clinical improvement and the double patch method may provide a successful operative repair and comeout.     

Right phrenic nerve palsy in a patient with ventricular septal perforation after acute myocardial infarction

A 77-year-old female had acute myocardial infarction and ventricular septal perforation (VSP). An operation was performed 14 days after VSP. During cardiopulmonary bypass, a patch was sutured in place on the left side of the defect under a mild hypothermia with topical cardiac cooling procedure. In the postoperative period, mechanical ventilation was continued with use of pulmonary monitor (CP-100, BICORE). When the patient was weaned of mechanical ventilation, work of breathing increased (WOBp: 1.67 J.l-1) without the change of SaO2, PaO2, PaCO2 and the respiratory state. After extubation, the chest X-ray showed elevated right diaphragmatic level and a diagnosis of unilateral diaphragmatic paralysis was made. Oral intake was started two days after extubation. SpO2 decreased after oral intake, and it was significantly improved by taking a left lateral position. The symptoms disappeared 47 days after the operation. It should be noticed that the rise of endoceliac pressure in the patient who had a unilateral phrenic nerve palsy, affected the SpO2.     

A successful transatrial repair of post-infarction ventricular septal defect]

A 63-year-male underwent successful operation for the ventricular septal perforation (VSP) caused by the inferior myocardial infarction. As the condition was stable, an operation was performed at the 43rd day after onset of myocardial infarction. Exposure was obtained by the opening the right atrium and retracting the tricuspid valve. The defect was in the posterior portion of the ventricular septum and closed using a Dacron patch. His postoperative course was uneventful. Postoperative examinations show no residual shunt. We believe that this approach may offer reduced mortality and morbidity in a selected group of patients with acquired posterior VSP, by avoiding such complications as further trauma to the ventricle, hemorrhage, and arrhythmias.     

Surgery for postinfarction ventricular septal perforation under hypothermic fibrillatory arrest with pulsatile perfusion

Surgery were performed by 2 different methods of myocardial protection in 17 patients with postinfarction ventricular septal perforation (VSP) from 1982 to 1989. Ten consecutive operations were performed using hypothermic fibrillatory arrest with pulsatile perfusion (VF group). Pulsatile flow was produced by an intra-aortic balloon pumping device. Other 7 consecutive VSP operations were performed using cardioplegic arrest (CP group). In the VF group, the mean age was 67 years (range 54 to 78 years), and VSP was located in the anterior wall in 7, in the inferior wall in 2, and in the anterior and inferior walls in 1 patients. The operation was performed 2.5 days after the onset of VSP. In the CP group, the mean age was 71 years (range 50 to 78 years), and VSP was located in the anterior wall in 6 and in the inferior wall in 1 patient. The operation was performed 4.7 days after the onset of VSP. Cardiogenic shock developed after septal rupture in 50% of the patients in the VF group and 71% in the CP group (N.S.). Prior to the operation, no significant differences were found in hemodynamic status between the 2 groups. Cardiac index in the VF group was higher than that of the CP group (p less than 0.05) shortly after cardiopulmonary bypass. The operative mortality rate was 10% in the VF group and 57% in the CP group. From these clinical results, hypothermic fibrillatory arrest with pulsatile perfusion can be beneficial as a method of myocardial protection during surgery for VSP and presently this has become the method of choice in our department.     

Clinical experience with gelatin-resorcine-formol glue for repair of postinfarction ventricular septal rupture]

We report a surgical technique for treatment of postinfarction ventricular septal rupture (VSR). An 82-year-old woman underwent successful surgical repair of a VSR two days after suffering anterior myocardial infarction. After repair of the VSR with a Dacron patch, the left ventriculotomy was closed with mattress sutures over felt strips using the gelatin-resorcine-formol glue to reinforce the left ventricular wall. The patient was doing well four months after surgery.     

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.     

Surgical treatment for postinfarction ventricular septal perforation

Between November 1985 and April 2003, surgical treatment for ventricular septal perforation (VSP) after acute myocardial infarction was performed in 16 patients. Patients were divided into 2 groups by method of operation. One group is infarct exclusion technique (n = 10). The other group is trans right ventricular (RV) approach (n = 6). No significant differences were observed between 2 groups in preoperative states. Operative death rate was high in both groups. Five patients (50%) were died in infarct exclusion group, 4 patients (67%) in trans RV group. Infarct exclusion technique needed longer extracorporeal circulation time (201 +/- 33 min) than trans RV approach (170 +/- 32 min). Although trans RV approach is attractive for its simplicity, 3 cases died of rupture of remained left ventricle infarction area. On the other hand, there were no mortality cases caused by left ventricle rupture in infarct exclusion technique group. As this result, we select infarct exclusion technique as a surgical correction for VSP.     

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.