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.     

Subepicardial aneurysm by venting catheter via the right superior pulmonary vein

Subepicardial aneurysm caused by a left ventricular venting catheter inserted from the right superior pulmonary vein is very rare. Generally, this type of aneurysm is a complication of acute myocardial infarction. We report a 76-year-old woman in whom a left ventricular aneurysm was shown by transthoracic echocardiography 3 years after mitral valve replacement. She underwent left ventricular aneurysmectomy via the 4^th left intercostal space. The left ventricular aneurysm was separated from the pericardium completely; therefore, this aneurysm was not thought to be pseudoaneurysm. The postoperative course was uneventful and the aneurysm was diagnosed as a subepicardial aneurysm from a histological examination.     

A case report of successful mitral valve replacement for congenital mitral stenosis associated with coarctation of the aorta and ventricular septal defect

A 5-month-old infant with coarctation of the aorta, ventricular septal defect and mitral stenosis known as "Shone's anomaly" is presented. He underwent the repair of coarctation of the aorta by means of the extended aortic arch anastomosis and banding of the pulmonary trunk at 1 month of age and the patch closure of ventricular septal defect and debanding of the pulmonary trunk at 3 months of age in our institution. About 2 months after second surgery, he had been admitted to our institution due to developing tachypnea and he needed the support of mechanical ventilation. The chest X-ray showed pulmonary congestion and the echocardiography revealed only one papillary muscle of mitral valve and pressure gradient about 30 mmHg through mitral valve. Mitral stenosis due to parachute mitral valve was suspected and he was subjected to an emergent surgery. Initially we performed mitral valve repair for parachute mitral valve but echocardiography during the surgery revealed moderate grade of mitral regurgitation and a hemodynamics was not satisfactory. Eventually mitral valve replacement was successfully done with Carbo-Medics mechanical valve (19 mm in diameter) in the position of left atrial wall because his mitral annulus was so small as 10 mm in diameter. The postoperative course was uneventful and the patient has been doing well.     

Management of intraoperative systolic anterior motion of the mitral valve after valve plasty: a case report

We report a case of intraoperative systolic anterior motion (SAM) of the mitral valve after mitral valve plasty (MVP). A 53-year-old man underwent MVP for mitral regurgitation (MR). MVP was carried out uneventfully. We weaned the patient from cardiopulmonary bypass (CPB) with continuous administration of catecholamines and a vasodilator. However, after the weaning from CPB, transesophageal echocardiography (TEE) detected moderate MR with left ventricular outflow tract obstruction (LVOTO) due to SAM. LVOTO and SAM gradually disappeared after the reduction of catecholamines and volume loading. He was transferred to the intensive care unit postoperatively and extubated 18 hours after operation. Transthoracic echocardiography after operation revealed disappearance of MR. He was discharged from the hospital on postoperative day 15 without complications. We successfully managed MR with LVOTO due to SAM by reduction of catecholamines and volume loading.     

Acute early failure of a bioprosthesis after mitral valve replacement with completely preserved annuloventricular continuity

We report a case of acute early bioprosthetic failure after mitral valve replacement with completely preserved annuloventricular continuity. A 77-year-old man with left ventricular dysfunction underwent double valve replacement with Carpentier-Edwards pericardial bioprostheses. Routine postoperative echocardiography revealed 1.4 cm² of estimated mitral valve area, and computed tomography revealed a large thrombus in the left atrium. Transesophageal echocardiography showed a restricted opening of the bioprosthetic leaflets. After a month of strict anticoagulation therapy, cusp mobility improved, with a calculated mitral valve area of 3.5 cm²; and the left atrial thrombus had almost disappeared 2 months after initiation of therapeutic anticoagulation. Surgeons should be watchful for bioprosthetic thrombosis in patients with left ventricular dysfunction who undergo mitral valve replacement with a preserved mitral subvalvular apparatus.     

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.     

Coronary artery bypass grafting for unstable angina pectoris with aortitis syndrome; report of a case

A 78-year-old male with aortitis syndrome was referred to our hospital for the treatment of unstable angina pectoris with ischemic mitral regurgitation, which was diagnosed by transthoracic echocardiography and coronary artery angiography. Computed tomography showed segmental wall thickness of thoracic and abdominal aorta He underwent an emergent coronary artery bypass grafting. The postoperative course was uneventful without any neurological complications. Postoperative echocardiogram and coronary artery angiography showed good mitral valve function and all patent bypass grafts. He was discharged 33 days after surgery. At 26 months after surgery, he is well without limitation of daily activities and any evidence of myocardial ischemia.     

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.     

Mitral valve plasty and coronary artery bypass grafting under beating heart cardiopulmonary bypass for severe left ventricular dysfunction; report of a case

A 54-year-old man with ischemic mitral regurgitation and severe heart failure due to broad myocardial infarction successfully underwent mitral valve plasty and coronary artery bypass grafting under beating heart. He had an old anterior myocardial infarction and was admitted to our hospital with acute inferior myocardial infarction. Two weeks later, the cathetelization revealed moderate mitral regurgitation and triple vessel coronary artery disease. We selected antegrade continuous blood perfusion for myocardial protection on operation. He recovered uneventfully and discharged on postoperative day 31. We could perform this procedure safety and satisfactorily, we could this procedure for heart valve operation with other complications.     

A case of ischemic mitral regurgitation treated by mitral annuloplasty (MAP) and coronary artery bypass grafting (CABG)]

A 79-year-old woman with a previous history of myocardial infarction, suffered acute myocardial infarction again. A coronary angiogram revealed triple vessel disease, and a left ventriculogram showed severe mitral regurgitation. The patient fell into cardiogenic shock after cardiac catheterization, and IABP was started. She underwent MAP and saphenous vein bypass grafting to the left anterior descending coronary artery and left circumflex coronary artery. Although the postoperative course was complicated by acute renal failure and respiratory dysfunction, the patient recovered from the operation and was discharged on the 137th postoperative day. Since the operative mortality of conventional valve replacement combined with CABG in ischemic mitral regurgitation has been high, we preferred MAP for this case.     

Successful surgical treatment of mitral regurgitation for complete rupture of the anterior papillary muscle after acute myocardiAl infarction

Papillary muscle rupture complicating acute myocardial infarction leads to mitral regurgitation and is associated with significant mortality. We experienced a case involving massive mitral regurgitation caused by complete anterior papillary muscle rupture following acute lateral myocardial infarction. A 75-year-old woman developed heart failure shortly after her admission, and the diagnosis was confirmed by echocardiography and cardiac catheterization. Under intra-aortic balloon pumping, the patient underwent emergency mitral valve replacement and coronary revascularization. Her postoperative course was uneventful, and she was discharged on the 40th postoperative day. We believe that prompt surgical treatment should be performed even in stable patients with ischemic mitral regurgitation, given that deterioration may be sudden and unpredictable especially in cases involving complete papillary muscle rupture.     

A case report of hypertrophic obstructive cardiomyopathy after the correction of atrioventricular septal defect

A 47-year-old woman who had closure of an atrioventricular septal defect and repair of mitral cleft developed severe dyspnea on effort 6 years after surgery. An echocardiography showed asymmetric left ventricular hypertrophy and a left cardiac catheterization revealed marked intraventricular pressure gradient and moderately severe mitral regurgitation. The patient underwent mitral valve replacement through transseptal approach during empty beating heart. Symptomatic relief was obtained and marked reduction of intraventricular systolic pressure gradient was noted in postoperative cardiac catheterization about 40 days after the operation. Mitral valve replacement should be considered for the treatment of hypertrophic obstructive cardiomyopathy in severe cases with associated morphological abnormality of mitral leaflet or severe mitral regurgitation.     

Valvuloplasty for mitral regurgitation immediately following Kawasaki disease without abnormal coronary arteries lesion; report of a case

It is not uncommon that valve disease is complicated with Kawasaki disease (KD). However, it is rare to show normal coronary arteries simultaneously. We experienced a case of valvuloplasty towards the mitral regurgitation (MR) followed immediately after KD showing normal coronary arteries. A 3 year-old-female, with a diagnosis of KD at 4 months after birth, was referred to our hospital 5 months after birth. The echocardiography detected a moderate MR. The preoperative catheterization at 2.5 years old showed grade III MR, enlargement of left atrium and left ventricle, pulmonary capillary wedge pressure (PCWP) = 12 mmHg, left ventricular ejection fraction (LVEF) = 675, and normal coronary arteries. Pulmonary hypertention was not revealed. The operative findings showed mitral valve prolapse due to the elongation of the chordae of the anterior leaflet. She underwent artificial chordal reconstruction using expanded polytetrafluoroethylene sutures and mitral annuloplasty by Kay-Reed method. The postoperative course was uneventful, and she was discharged on postoperative day 19.     

结合尸解分析二尖瓣置换术后左室破裂原因

目的分析二尖瓣置换术后左心室破裂的原因。方法作者经历2例二尖瓣置换术后左心室破裂,其中1例进行了尸体解剖,另外1例进行了术中探查。结合尸体解剖及术中探查的结果,以及二尖瓣置换术对心脏解剖的改变,分析左心室破裂的原因。结果 2例患者左心室破裂均排除了外科直接损伤,存在因解剖结构改变导致自发性破裂的因素。结论二尖瓣置换术后发生左心室破裂的原因与左心室结构改变有密切关系。     

Mitral tendon prolapsing into the left ventricular outflow tract

Intracardiac masses of the mitral valve are rare. Their differential diagnosis is wide, ranging from tumors (myxomas, lipomas and fibroelastomas), thrombi and abnormal muscular or fibrous bands. We report a case and management. A 68 year-old asymptomatic female who had undergone coronary angioplasty and stent placement in the left anterior descending artery for acute myocardial infarction four years earlier, was shown to have, on routine follow-up, an intracardiac mass originating from the anterior leaflet of the mitral valve and prolapsing into the left ventricular outflow tract (LVOT). The patient underwent surgical excision of the mass under cardiopulmonary bypass, to prevent cerebral or coronary embolization and sudden death due to the highly sensitive location of the mass, in the high-velocity flow LVOT. A transverse aortotomy provided exposure of the ventricular surface of the anterior mitral leaflet and revealed a fusiform mass attached to the medial segment of the anterior leaflet, resembling a secondary cordae, measuring 20 by 3 mm. The implantation was calcified on the ventricular aspect of the anterior mitral leaflet. This mass was completely excised. Postoperative recovery was uneventful. Peroperative and postoperative transesophageal echocardiography were normal. Histological examination showed a partially necrosed and calcified fibrous tissue lined by endothelium. The final diagnosis was that of a mitral tendon. Intracardiac masses of the mitral valve are rare lesions, mostly papillary fibroelastomas and myxomas and more rarely mitral tendons, which require surgical resection for prevention of embolization. The definitive diagnosis is often only obtained on histological analysis.     

Progressive mitral regurgitation which is necessitated the mitral valve replacement after partial left ventriculectomy (Batista procedure): a case report]

The patient is 61-year-old woman who underwent partial left ventriculectomy, (Batista procedure) due to dilated cardiomyopathy and multiple thromboembolism. Although postoperative course was uneventful, she has had clinical symptoms of the left heart failure due to the increased mitral valve regurgitation at the early postoperative period, gradually. Even though mitral valve regurgitation was severe, it was not apt to re-dilatate the left ventricular capacity evaluated by echocardiography. She underwent the mitral valve replacement on the 92nd postoperative day, and was once possible for weaning from cardiopulmonary bypass under the support of IABP. However, she died on the 19th postoperative day caused by sepsis. It is important to evaluate the accurate mitral valve regurgitation preoperatively for Batista procedure. Although there was the mild mitral valve regurgitation, it is essential to repair or replace the mitral valve for Batista procedure.     

Critical hypertrophic obstructive cardiomyopathy patient with improved hemodynamics following mitral valve replacement: report of a case

A 75-year-old man with dyspnea was admitted to our hospital in critical condition. Catheterization showed normal coronary arteries and good left ventricular function. Transesophageal echocardiography showed left ventricular hypertrophy and severe mitral regurgitation. We decided to perform mitral valve replacement because the patient was in critical condition and it was necessary to complete the operation smoothly. During the operation, we could see the dilated mitral valve annulus and hypertrophic mitral valve, which was restricted. The patient's hemodynamics showed improvement after mitral valve replacement with a mechanical prosthesis, and he was discharged on postoperative day 21. In conclusion, mitral valve replacement is a beneficial method for the treatment of patients with critical hypertrophic obstructive cardiomyopathy.     

Epicardial stripping for constrictive pericarditis after mitral valve plasty; report of a case

A 65-year-old man who underwent mitral valve plasty was readmitted the hospital with severe dyspnea and hypotension 7 months after operation. Results of computerized tomographic scanning and transesophageal echocardiography showed pericardial thickening and left ventricle out flow stenosis due to a constrictive epicardial peel. At the time of reoperation, he underwent both pericardial and epicardial stripping. He demonstrated only limited hemodynamic improvement after pericardial stripping. His hemodynamic status improved markedly after epicardial stripping. His postoperative course was uneventful and no complication was recognized. Epicardial stripping is important in patients with epicardial sclerosis.     

Effects of the Dor procedure on left ventricular dimension and shape and geometric correlates of mitral regurgitation one year after surgery

OBJECTIVES: In the present study we retrospectively analyzed ventriculographic data from symptomatic patients after myocardial infarction who underwent the Dor procedure (endoventricular circular patch plasty repair) to evaluate left ventricular shape 1 year after the operation and to analyze the geometric correlates of late mitral regurgitation. METHODS: Forty-four patients with previous transmural anterior myocardial infarction comprised the study group. Left ventricular volumes, global left ventricular systolic and diastolic sphericity, the extent of wall motion abnormalities, and the presence and degree of mitral regurgitation were analyzed before and 1 year after operation. RESULTS: Comparing preoperative diastole to systole within the cardiac cycle, left ventricular shape becomes more elliptical in systole than it was in diastole (eccentricity index closer to 1). The intervention leads to an increased diastolic sphericity, but for each cardiac cycle, the systolic shape is more elliptical relative to its diastolic counterpart in respect to basal conditions. Mitral regurgitation was detected after operations in 17 patients; 14 of them did not have mitral regurgitation before operations. Patients with late mitral regurgitation had greater preoperative volumes and more spherical chamber than did patients without late mitral regurgitation. CONCLUSIONS: Despite a more spherical postoperative left ventricular chamber, systolic pump function improves after the Dor procedure, mainly for the improvement in inferior wall shortening. The presence of late mitral regurgitation is relatively frequent in this series of patients, and this emphasizes the importance of a more accurate quantitative evaluation of preoperative functional mitral regurgitation to repair the valve when appropriate. Geometric correlates of late mitral regurgitation appeared to be greater chamber sphericity and larger ventricular volumes preoperatively.     

A case of emergency surgery for acute mitral regurgitation due to complete papillary muscle rupture as complication of acute inferior myocardial infarction

We experienced a case with acute mitral regurgitation caused by complete posterior papillary muscle rupture as complication of acute inferior myocardial infarction, who underwent successfully emergency operation of mital valve replacement and coronary revascularization in acute stage. A 64-year-old woman developed sudden cardiogenic shock shortly after the onset of acute inferior myocardial infarction. The diagnosis of acute inferior myocardial infarction was based on the electrocardiographic findings. Under IABP support, preoperative coronary angiography visualized total occlusion of segment 3 of the right coronary artery, and preoperative left ventriculography showed akinesis of inferior wall and severe mitral regurgitation. At 6 hours after onset of papillary muscle rupture, emergency operation was performed. At operation, posterior papillary muscle was found to be totally ruptured. Coronary artery revascularization and mitral valve replacement were performed. Postoperative course was uneventful, with 4 days of IABP and 5 days of ventilatory support. She was discharged on the twentieth postoperative day in NYHA class I. Reports of successful emergency operation for total papillary muscle rupture following acute myocardial infarction are rare. Early diagnosis and surgical treatment are mandatory to save this group of patients.