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.     

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.     

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.     

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.     

Sutureless off-pump repair of post-infarction left ventricular free wall rupture

Left ventricular free wall rupture after myocardial infarction has a high mortality. Suturing techniques of repair may be technically difficult and require cardiopulmonary bypass. We report a case of left ventricular rupture in a 47 year old man managed off pump employing a sutureless technique with Gelatine-Resorcin-Formalin glue and bovine pericardial patches.     

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.     

New surgical technique of left ventricular free wall rupture: double patch sealing method.

We experienced two cases of left ventricular free wall rupture (LVFWR) following acute myocardial infarction (AMI). Case 1, with the blowout type of LVFWR was initially closed by direct suture, followed by hemostasis using a double patch sealing method (DPS) by which the tear was doubly sealed with large and small bovine pericardium patches to which GRF glue was applied. Case 2 with the oozing type of LVFWR was treated only using DPS. Complete hemostasis was achieved in both cases, and aneurysmal dilatation or constrictive heart failure were not detected by postoperative left ventriculography. Therefore, DPS may be useful for treating LVFWR following AMI.     

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.     

Surgical repair of left ventricular free wall rupture using layered fibrin glue sheet and fibrin glue; report of a case

A 57-year-old man with acute myocardial infarction (#13:90%, #6-#8:75%) was admitted to our hospital after the administration of tissue plasminogen activator. Three hours' after emergent percutaneous transluminal coronary angioplasty, he developed left ventricular free wall rupture in the left circumflex artery area. After bleeding was completely controlled by aortic cross clamping, a three-layered of fibrin glue sheet (TachoComb) with fibrin glue was extensively applied to the ruptured site including the infarcted area. He was discharged on the 25th postoperative day and underwent coronary artery bypass grafting to the left anterior descending artery three weeks later. This experience suggests that the layered TachoComb and fibrin glue are effective for left ventricular free wall rupture.     

Surgical repair of acute left ventricular free wall rupture: report of a case.

We present a case of acute (blowout) left ventricular free wall rupture (LVFWR) that occurred on the third day after inferior myocardial infarction. Because electromechanical dissociation developed abruptly and pericardiocentesis was no effective, there was no time for establishing a cardiopulmonary bypass (CPB). Emergency thoracotomy and direct closure were successfully performed at the bed-side. We believe that acute type of LVFWR in which initial symptom is electromechanical dissociation without any preceding symptoms can be rescued by emergency thoracotomy and direct closure of the rupture with no aid of CPB provided that the rupture is a small tear located on the anterior, lateral, or even the inferior wall of the left ventricle, if hemodynamical stability is obtained.     

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.     

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.     

Pitfalls of sutureless repair of a blow-out type left ventricular free wall rupture

A 55-year-old man was admitted for acute myocardial infarction. Cardiac catheterization revealed total occlusion of the left circumflex artery. During catheterization, he suffered cardiogenic shock. Percutaneous cardiopulmonary support was established, and the patient was transferred to the operating room. A blow-out left ventricular free wall rupture (LVFWR) with an epicardial tear, 1 mm in diameter, was found, and sutureless repair with a collagen hemostat (TachoComb™) was performed. However, on postoperative day 7, echocardiography revealed an echo-free space resembling a pseudoaneurysm. A second operation was performed immediately for impending re-rupture. An epicardial tear, 2×10 mm in diameter, was found at the previous bleeding point where hemostasis had been achieved with only one sheet of TachoComb™. The defect was closed with mattress sutures buttressed with Teflon? felt. We conclude that even if the risk of re-rupture is low, sutureless repair with a collagen hemostat alone should be avoided in treating blow-out LVFWR.     

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.     

Successful repair of subacute left ventricular free wall rupture after acute myocardial infarction

A 67-year-old man sustained free wall rupture of the left ventricle following an acute myocardial infarction 8 hours after percutaneous transluminal coronary recannalization (PTCR). Echocardiography and pericardiocentesis which improved the hemodynamic state confirmed the diagnosis. Under extracorporeal circulation, direct closure was successfully accomplished following resection of ruptured and necrotic anterior left ventricular myocardium. The patient has remained well for 9 months after the operation. Clinical and therapeutic features of subacute cardiac rupture and affecting factors of PTCR were discussed.     

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.     

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.