Repair of right ventricular free wall defect with a de-epithelized pedicled myocutaneous latissimus dorsi muscle flap

Rupture of the right ventricle may occur because of sternal dehiscence or mediastinitis after cardiac surgery. Direct suture, polytetrafluoroethylene patch, fasciae, and muscle flaps have been used to close a right ventricular rupture. A unique occurrence of repair of a full-thickness right ventricle defect with a de-epithelized myocutaneous flap is presented. Our patient experienced a rupture of the right ventricle complicating sternal wound infection. The rupture was reconstructed with a polytetrafluoroethylene patch, but the patch needed to be removed because of infection. The defect was reconstructed with a de-epithelized myocutaneous latissimus dorsi flap. The patient indicated no signs of complication during follow-up.     

Ventricular tachycardia in hypertrophic cardiomyopathy with apical aneurysm

Midventricular hypertrophic cardiomyopathy is a rare form of cardiomyopathy that may be associated with an apical aneurysm. The mechanism of aneurysm formation is uncertain, but it may be related to subendocardial ischemia. In this report, we describe a 57-year-old man with recurrent ventricular arrhythmias that were refractory to medical treatment because of midventricular hypertrophic cardiomyopathy and apical aneurysm. He was treated successfully with apical aneurysmectomy, myectomy, and subendocardial resection. Six months postoperatively, the patient was free of symptoms and was taken off all anti-arrhythmic medications with one inappropriate discharge from the implantable cardioverter-defibrillator at 4 months.     

Takotsubo syndrome after mitral valve replacement for acute endocarditis

Takotsubo syndrome is characterized by transient and acute left ventricular dysfunction and apical ballooning, with electrocardiographic abnormalities, but without coronary disease. We report a case of Takotsubo syndrome occurring after emergent mitral valve replacement for acute infective endocarditis. The patient is a 66-year-old woman who regained complete recovery of left ventricular function.     

Technique for insertion of HeartMate II left ventricular assist device inflow cannula

During implantation of the HeartMate II left ventricular assist device, the inflow cannula is typically inserted in such a way that the sewing ring is placed within the ventricular cavity in contact with the endocardium. We describe a novel implantation technique in which the sewing ring is secured to the left ventricular epicardium, thus avoiding the complication of bleeding from the exposed cut surface of apical myocardium. In addition, the shortened intraventricular segment of the inflow cannula protects against inflow occlusion by the interventricular septum.     

Rapid pacing for the off-pump insertion of the Jarvik left ventricular assist device

We present our technique for the implantation of the Jarvik 2000 left ventricular assist device (Jarvik Heart, Inc, New York, NY) without cardiopulmonary bypass by the induction of rapid pacing that allows the insertion of the apical device into the left ventricle, minimizing blood loss and surgical complications. Although the off-pump implantation of left ventricular assist devices is not new, our experience of rapid pacing has not been previously reported to our knowledge.     

Open plugging and extra-anatomical bypass for iatrogenic rupture of coarctation of the aorta

We report a successful repair of aortic rupture after balloon angioplasty for re-coarctation using a unique approach and method. A 22-year-old woman underwent emergency surgery for aortic rupture after balloon angioplasty for postoperative aortic re-coarctation. We performed extra-anatomic bypass from the ascending aorta to the descending thoracic aorta through a median sternotomy and incision in the posterior pericardium. The transverse aortic arch was transected, and the distal aortic arch was opened under deep hypothermic circulatory arrest of the lower extremities. The proximal aorta was closed. To seal the aortic rupture site, a tube graft was inserted through the aortotomy and was oversewn with the aorta. Repair of the right ventricular outflow stenosis was concomitantly performed. The patient's postoperative course was uneventful, and she successfully gave birth 2 years postoperatively.     

Off-pump implantation of the HeartWare HVAD left ventricular assist device through minimally invasive incisions

Implantation of left ventricular assist devices through small incisions, avoiding cardiopulmonary bypass, may decrease the activation of the inflammatory and coagulation cascades and decrease bleeding and vasoplegia. One patient with severe, inotrope-dependant cardiomyopathy received the HeartWare left ventricular assist device (HeartWare Inc, Framingham, MA) through an upper ministernotomy and left minithoracotomy. The outflow graft was connected to the ascending aorta, and the inflow of the left ventricular assist device was attached through to the apex of the heart. The apical puncture was performed under rapid ventricular pacing, followed by insertion of the inflow of the pump. The patient was extubated rapidly and discharged home 14 days later.     

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.     

Transventricular mitral valve operations

We report transventricular mitral valve operations in 2 patients with severe mitral regurgitation and postinfarction left ventricular rupture and pseudoaneurysm. The first patient had direct papillary muscle involvement necessitating replacement of the mitral valve. The second patient had indirect mitral involvement allowing for placement of an atrial mitral annuloplasty ring via the left ventricle. Both patients showed no mitral valve regurgitation after replacement or repair and had uneventful postoperative recoveries. These cases demonstrate a feasible, alternative, transventricular approach to mitral valve replacement and repair.     

Apparent rupture of the ventricular septum after myocardial infarction in an infant with congenital heart disease

Clinical and angiocardiographic simulation of rupture of the interventricular septum, in an infant with an endocardial cushion defect and documented myocardial infarction is reported. Close straddling of a proven congenital muscular apical ventricular septal defect by trabeculae carne is believed to have led to the angiocardiographic simulation of a post-infarction apical ventricular septal defect. In the surgical approach to post-infarction ventricular septal defects, the implication of such a simulation could be important.     

Anomalous intrathoracic left vagus and recurrent laryngeal nerve course

An anomalous course of the vagus nerve is an extremely rare congenital anomaly. We report the case of a 59-year-old man who had left lung cancer. We performed a left upper lobectomy and mediastinal lymphadenectomy, paying attention to the pathway of the left vagus nerve, which had an anomalous course passing anteriorly to the left pulmonary trunk between the apical and anterior branches. The left recurrent laryngeal nerve hooked around the lower border of the apical branch of the left pulmonary artery.     

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.     

Traumatic free wall and ventricular septal rupture - 'hybrid' management in a child.

A 8-year-old boy showed a traumatic ventricular septal rupture following a blunt chest trauma, and was scheduled for elective catheter closure. Two weeks later, a follow-up echocardiogram revealed a pseudoaneurysm of the anterior wall of the left ventricle. Because of the apical location of the VSD, it was decided to proceed with transcatheter occlusion. After successful VSD closure, the patient was taken to the operation room for surgical repair of the left ventricular pseudoaneurysm. Symptoms and signs seen in patients with ventricular pseudoaneurysms appear to be discrete and variable, and a high clinical index of suspicion with a very close echocardiographic follow-up is strongly recommended after occurrence of a blunt cardiac trauma. The combined 'hybrid' approach of transcatheter closure of the intraventricular rupture followed by surgical closure of the pseudoaneurysm allows for a less invasive and efficient management of this rare combination of post-traumatic ventricular free wall and septal rupture in a child.     

Obstruction of left ventricular outflow tract after mechanical mitral valve replacement

We successfully operated on a patient with a rare complication of left ventricular outflow tract obstruction after mitral valve replacement. In a 57-year-old woman with previous mitral valve replacement, transthoracic echocardiography showed left ventricular outflow tract obstruction as a result of anterior displacement of the mitral prosthesis and local thickening of the interventricular septum. Cardiac surgery verified this rare lesion. During the operation, the anterior half of the prosthesis ring was cut away from hyperplastic tissue and sutured to the natural mitral annulus. Subaortic hyperplastic tissue was excised to enlarge the left ventricular outflow tract. The patient had an uneventful postoperative recovery, and left ventricular outflow tract obstruction disappeared on postoperative transthoracic echocardiography.     

Endovascular treatment of an acute subdiaphragmatic aortic rupture

We report the case of a 23-year-old man presenting an acute rupture of the subdiaphragmatic aorta in front of a T12 vertebral fracture after a road accident. Because of the location of this lesion, the operative risk and a cardiac instability, we opted for an endovascular treatment with a new and original approach in covering a small part of the aorta using commercial devices. We also describe the probable mechanism of this uncommon aortic rupture. The surgical outcome was uneventful and the 3 month computed tomographic scan confirmed the complete exclusion of the aortic disruption.     

Percutaneous ventricular assist device support during off-pump surgical coronary revascularization

Intraaortic balloon pump counterpulsation has been used for mechanical circulatory support in cardiogenic shock patients, but percutaneous left ventricular assist devices can provide superior circulatory support in the same group of patients. We describe the case of a patient in cardiogenic shock after a myocardial infarction. A percutaneous ventricular assist device was used to provide immediate active hemodynamic support, and, because the patient's condition necessitated surgical revascularization, percutaneous left ventricular assist device support was continued during off-pump coronary artery bypass.     

Risk of Left Ventricular Assist Device as a Bridge to Heart Transplant Following Postinfarction Ventricular Septal Rupture

A bstract Heart transplantation is an effective treatment for end-stage heart failure. However, due to the persistent shortage of donor hearts, many patients die awaiting a transplant. Implantable left ventricular assist devices are now available as a reliable bridge to cardiac transplantation. This report presents a patient with terminal heart failure as a result of a postmyocardial infarction ventricular septal rupture (VSR), who underwent a successful placement of the HeartMate left ventricular assist device (LVAD) and velour patch closure of an apical VSR. Despite this therapy, the patient expired after developing a second VSR, which created a high-flow right-to-left shunt and caused hypoxic irreversible brain injury. We suggest that use of a left ventricular assist device as a bridge to transplantation be approached with extreme caution in a patient with a postinfarction ventricular septal rupture.     

Isolated papillary muscle rupture complicating acute pancreatitis

Papillary muscle rupture in the absence of coronary stenoses is a rare event. An isolated infarction of the papillary muscle is involved in most cases, but the pathogenesis is still debated. We describe an anterolateral papillary muscle rupture complicating acute pancreatitis in a patient without significant coronary stenoses and with evidence of coronary spasm. This suggests that an increased susceptibility to coronary spasm and thrombosis, triggered by an acute systemic inflammatory response, may represent a mechanism of selective papillary muscle infarction.     

Left ventricular apical pseudoaneurysm with aortic prosthetic valve endocarditis

We report an 83-year-old man with a mycotic left ventricular apical pseudoaneurysm and aortic prosthetic valve endocarditis caused by Enterococcus spp. Mycotic left ventricular pseudoaneurysm is very rare and is associated with a high risk of rupture. Here, we report the clinical presentation, diagnosis, prognosis, and treatment of a case of mycotic left ventricular pseudoaneurysm to raise awareness regarding this unusual and potentially fatal complication.     

Asymptomatic giant traumatic right coronary artery pseudoaneurysm caused by sternal fracture

Giant traumatic coronary artery pseudoaneurysm is extremely rare, and very few cases of traumatic coronary artery aneurysm have been previously reported. We present a case of an asymptomatic, giant, traumatic right coronary artery pseudoaneurysm caused by blunt chest trauma and sternal fracture. The risk of rupture or peripheral embolization remains unclear, but we believe that pseudoaneurysm resection and coronary artery bypass grafting are adequate procedures for preventing rupture or ischemia.