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Interactive Cardiovascular and Thoracic Surgery 2:94-96(2003)
© 2003 European Association of Cardio-Thoracic Surgery

Negative results - Coronary

A huge pseudoaneurysm of the left ventricle after simple gluing of an oozing-type postinfarction rupture

Satsuki Fukushima, Junjiro Kobayashi*, Osamu Tagusari and Yoshikado Sasako

Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan

* Corresponding author. Tel.: +81-6-6833-5012; fax: +81-6-6872-7486
jkobayas{at}hsp.ncvc.go.jp

Received April 5, 2002; received in revised form July 4, 2002; accepted November 7, 2002


   Abstract
Top
 Abstract
1. Introduction
 2. Patient and technique
 3. Discussion
 Appendix A
 References
 
Objective: Left ventricular free wall rupture is a major complication after myocardial infarction. Simple gluing for a rupture site, without a cardiopulmonary bypass, has been reported useful. Methods: We experienced a left ventricular pseudoaneurysm, of 8 cm in size, emerging at a previous rupture site 1 year after gluing with TachoComb for an oozing-type rupture due to an acute anteroseptal myocardial infarction. Results: The pseudoaneurysm was successfully extirpated, under a cardiopulmonary bypass, with induction of ventricular fibrillation. Conclusions: Patients, after simple gluing for a left ventricular free wall rupture, should be carefully followed up regarding the occurrence of a pseudoaneurysm at the repair site.

Key Words: Postinfarction left ventricular free wall rupture; Oozing-type left ventricular rupture; Simple gluing; Left ventricular pseudoaneurysm


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patient and technique
 3. Discussion
 Appendix A
 References
 
Left ventricular (LV) free wall rupture is a serious complication after acute myocardial infarction (MI) [1–3]. Although the appropriate treatment for this lethal condition is still controversial, the sutureless gluing technique with fibrin and collagen hemostats has been reported useful, especially for oozing-type ruptures [1,2]. We experienced a huge LV pseudoaneurysm, of 8 cm in size, emerging at a previous rupture site 1 year after successful use of this technique for an oozing-type LV rupture due to an acute anteroseptal MI.


   2. Patient and technique
Top
 Abstract
 1. Introduction
 2. Patient and technique
3. Discussion
 Appendix A
 References
 
A 66-year-old man was referred to our surgical service for an oozing-type rupture, 12 h after an anteroseptal transmural MI. Emergency drainage through a median sternotomy was carried out, after coronary artery angiography, which revealed severe three-vessel disease unsuitable for bypass grafting because of extensive diffuse atherosclerotic coronary artery disease. An epicardial hematoma, without active bleeding, was observed at the anterior left ventricular infarction site. TachoComb (Collagen patch covered with a fixed layer of the solid human fibrinogen, bovine thrombin and aprotinin) was applied to the rupture site. The postoperative course was uneventful. Percutaneous transcatheter coronary angioplasty (PTCA) was successfully carried out for the left anterior descending artery (LAD) and the left circumflex artery, 1 month after the operation. He was discharged 2 months after the operation.

An aneurysmal projection from the anterior wall of the left ventricle was detected by a routine chest X-ray and an echocardiographic check up, 1 year after that operation. Further examinations, including computed tomography (Fig. 1) and magnetic resonance imaging (Fig. 2), revealed a huge aneurysm, 8 cm in diameter, originating from the left ventricle, with mural thrombi on the internal wall, and surrounded by the anterior thoracic wall. Cardiac catheterization was performed, and the left ventriculogram showed an aneurysm of 120 ml cavity size. Left ventricular end-diastolic and end-systolic volume indices were 174 and 126 ml/min per m2, respectively. The ejection fraction was 28%. There was no mitral regurgitation. Concomitant PTCA for restenosis of the LAD was carried out.



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  		Fig. 1 Computed tomography 1 year after an oozing-type LV free wall rupture showed an LV pseudoaneurysm projecting from the rupture site with mural thrombi.

 


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  		Fig. 2 Sagittal view of magnetic resonance imaging obviously confirmed an LV pseudoaneurysm. LV, left ventricle.

 
Redo operation was performed through a re-median sternotomy on cardiopulmonary bypass with bicaval drainage and cannulation to the ascending aorta. Under induced ventricular fibrillation, the pseudoaneurysm was extirpated with mural thrombi. The internal wall of the pseudoaneurysm was smooth and was clearly differentiated from the normal ventricular muscle wall. The defect of the left ventricle was directly closed with Teflon felt strip reinforcement. Extracorporeal circulation time was 118 min, and ventricular fibrillation time was 25 min. The postoperative course was uneventful with an intensive care unit stay of 3 days. Pathological examination of the resected aneurysmal wall revealed absence of endocardium and myocardium.


   3. Discussion
Top
 Abstract
 1. Introduction
 2. Patient and technique
 3. Discussion
Appendix A
 References
 
Blow-out-type postinfarction rupture of the free wall of the left ventricle has been repaired under a cardiopulmonary bypass [4]. A cardiopulmonary bypass is mandatory in patients with posterior rupture, severe mitral regurgitation, ventricular septal rupture, and graftable coronary artery disease [1,2,5]. Conventional technique closes the defect with horizontal mattress sutures buttressed with two felt strips of Teflon felt [4]. The closure, and surrounding infarcted myocardium, are then covered with a Teflon patch, which is sutured on the healthy epicardium. This method provides good control of active bleeding, though it usually requires using a cardiopulmonary bypass [6]. The surgical technique without using a cardiopulmonary bypass is simple gluing, with a patch of either Teflon or autologous glutaraldehyde-preserved bovine pericardium, to the ventricular tear and infarcted area, using a biocompatible glue of either fibrin or collagen hemostats, for an oozing-type rupture [1–3]. This technique may be the preferred repair with respect to avoiding a cardiopulmonary bypass in an emergency, when active bleeding is not observed [1–3].

A cardiac pseudoaneurysm is defined as a rupture of the myocardium that contains adherent pericardium and scar tissue [7]. The most frequent cause of a cardiac pseudoaneurysm is a transmural inferior MI. An inflammatory reaction of the posterior pericardium may result in pericardial adhesion and the formation of a posterior LV pseudoaneurysm, instead of cardiac tamponade [7]. An anterior pseudoaneurysm after simple gluing technique for an oozing-type LV rupture is considered to develop in the similar way. Infarcted areas remain and fibrin or collagen hemostats provide adhesion between infarcted areas and pericardium. One out of five patients that survived after this technique underwent reoperation for an LV pseudoaneurysm 26 months after operation, in a previous report [1].

Spontaneous rupture of an LV pseudoaneurysm is relatively rare, because of adhesion with pericardium. Surgical intervention has been indicated in asymptomatic patients with a chronic LV pseudoaneurysm larger than 3 cm, or expanding signs [8]. Aortic stenosis and anticoagulant therapy have been reported to be risk factors for spontaneous rupture, even if a pseudoaneurysm is small [9]. Operative mortality for surgical treatment of LV pseudoaneurysm was about 25% in previous reports [7,8,10]. This is probably due to poor LV function, or the need for mitral valve surgery or myocardial revascularization, rather than to technical difficulties in repair of a pseudoaneurysm. In the present case, a pseudoaneurysm could be safely dissected with use of a cardiopulmonary bypass.

As a conclusion, a patient who undergoes simple gluing for an oozing-type LV free wall rupture should be carefully followed up for the occurrence of a pseudoaneurysm at the repair site.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Patient and technique
 3. Discussion
 Appendix A
References
 
ICVTS on-line discussion

Author: Dr. Suresh Bhagia, Cardiothoracic Surgeon, Apollo Hospitals, Cardiothoracic Surgery, 21 Greams Lane, Chennai, India

Date: 20-Dec-2002 08:04

Message: We recently used biological glue to seal off an oozing type of ventricular rupture post myocardial infarction 48 h after thrombolysis. The result was instantaneous and the weeping area of the myocardium was hemostatic within a few minutes. Postoperative echocardiography confirmed that there was no evidence of tamponade and the EF was maintained at 45%.

I am sure that biological glue will have an extended application for a variety of post myocardial infarction and post traumatic left ventricular wall ruptures and aneurysm problems.

doi:10.1016/S1569-9293(02)00112-2


   References
Top
 Abstract
 1. Introduction
 2. Patient and technique
 3. Discussion
 Appendix A
 References
 

  1. Kamohara K, Minato N, Ikeda K, Rikitake K, Takarabe K. Life-saving strategy for left ventricular free wall rupture after acute myocardial infarction. Infarction-covering repair on the ruptured site under the beating heart. Jpn J Thorac Cardiovasc Surg. 2000;48:291–294[Medline]
  2. Iemura J, Oku H, Otaki M, Kitayama H, Inoue T, Kaneda T. Surgical strategy for left ventricular free wall rupture after acute myocardial infarction. Ann Thorac Surg. 2001;71:201–204[Abstract/Free Full Text]
  3. McMullan MH, Maples MD, Kilgore TL Jr, Hindman SH. Surgical experience with left ventricular free wall rupture. Ann Thorac Surg. 2001;71:1894–1899[Abstract/Free Full Text]
  4. Nunez L, de la Llana R, Lopez Sendon J, Coma I, Aguado MG, Larrea JL. Diagnosis and treatment of subacute free wall ventricular rupture after infarction. Ann Thorac Surg. 1982;35:525–529
  5. David TE. Surgery for postinfarction rupture of the free wall of the ventricle. David TE. Mechanical complications of myocardial infarction. Austin, TX: Landes; 1993. p. 142
  6. Coletti G, Torracca L, Zogno M, Canna GL, Lorusso R, Pardini A, Alfieri O. Surgical management of left ventricular free wall rupture after acute myocardial infarction. Cardiovasc Surg. 1995;3:181–186[Medline]
  7. Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol. 1998;32:557–561[Abstract/Free Full Text]
  8. Pretre R, Linka A, Jenni R, Turina MI. Surgical treatment of acquired left ventricular pseudoaneurysms. Ann Thorac Surg. 2000;70:553–557[Abstract/Free Full Text]
  9. Hamamoto M, Ogino H, Hanafusa Y, Numata S, Ando M. Ruptured left ventricular pseudoaneurysm penetrating into the left pleural cavity. Jpn J Thorac Cardiovasc Surg. 2001;49:581–583[Medline]
  10. Komeda M, David TE. Surgical treatment of postinfarction false aneurysm of the left ventricle. J Thorac Cardiovasc Surg. 1993;106:1189–1191[Abstract]



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Surgical repair of left ventricular free wall rupture
MMCTS, January 4, 2005; 2005(0104): 653.
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Yoshikado Sasako
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