Interactive Cardiovascular and Thoracic Surgery 2:193-195(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Case report - Cardiac general |
Post-infarct left ventricular free wall rupture and ventricular septal defect managed by pericardial aspiration during transport to referral hospital
Rolf Svedjeholma,*,
Erik Håkansonb,
Mårten Lindströmc and
Per Hjortd
a Department of Cardiothoracic Surgery, Linköping Heart Center, University Hospital, SE-581 85 Linköping, Sweden
b Department of Cardiothoracic Anesthesia, Linköping Heart Center, University Hospital, SE-581 85 Linköping, Sweden
c Department of Internal Medicine, Ryhov Hospital, Jönköping, Sweden
d Department of Radiology, Ryhov Hospital, Jönköping, Sweden
* Corresponding author. Tel.: +46-13-222-000; fax: +46-13-100-246
rolf.svedjeholm{at}lio.se
Received October 3, 2002;
received in revised form January 31, 2003;
accepted February 3, 2003
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Abstract
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Although left ventricular free wall rupture is a comparatively common cause of death in acute myocardial infarction survival is infrequently reported. However, even in cases where surgical expertise is not immediately available the condition can be temporarily controlled by judicious pericardial aspiration and blood transfusion until definitive repair can be undertaken. Here we report the successful management of a patient sustaining combined left ventricular free wall rupture and ventricular septal rupture in a community hospital 130 km from the referral center.
Key Words: Acute myocardial infarction; Complications; Left ventricular free wall rupture; Fibrinogen
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1. Introduction
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Left ventricular rupture is more common than generally appreciated and after arrhythmias and cardiogenic shock one the most common causes of death in acute myocardial infarction [1]. Left ventricular free wall rupture secondary to myocardial infarct is almost invariably fatal but survival has infrequently been reported [1–3]. It has then either been associated with prompt diagnosis and surgical treatment or rare cases of contained ruptures with subsequent development of pseudoaneurysms [1–3]. Here we report a rare case of acute combined left ventricular free wall rupture and ventricular septal rupture occurring in a community hospital. The patient survived with the aid of immediate drainage of the pericardium and repeated aspiration during transport to the referral center where definitive repair was undertaken.
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2. Case history
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The patient, a 73-year-old previously healthy woman was urgently admitted to her community hospital because of chest pain since 2–3 h. Electrocardiogram showed signs of an anterior myocardial infarction and thrombolytic treatment with streptokinase was instituted. A few hours later she deteriorated and a murmur raising the suspicion of a ventricular septal defect could be heard. During echocardiography the patient developed circulatory collapse and signs of a free wall rupture with pericardial effusion were evident on the echocardiogram. Pericardiocentesis and introduction of drain was undertaken. After aspiration of 150 ml of blood arterial systolic blood pressure increased from 50 to 90–100 mmHg which was followed by recovery of consciousness. After telephone contact, a decision was taken to transfer the patient – a distance of 130 km – with ambulance to the referral center. During transport the patient was hemodynamically unstable and intermittently lost her consciousness. However, intermittent aspiration of up to 150 ml of blood on four occasions was sufficient to achieve recovery of consciousness and to improve the hemodynamic state. During transport two units of erythrocytes and crystalloid solutions were infused. On arrival to the University Hospital the patient was in cardiogenic shock. Repeat echocardiography demonstrated free wall rupture, pericardial effusion and a large anterior ventricular septal rupture (Fig. 1). The patient was immediately transferred to the operating room. During induction of anesthesia pericardial aspiration was repeated and blood transfused to prevent circulatory collapse. Median sternotomy was performed and large amounts of fresh blood removed from the pericardium. Cardiopulmonary bypass was instituted and the anterior infarct partially excised. A large anterior rupture in the septum was closed with a patch and the left ventricle closed with the suture line strengthened by patches and glue. Severe bleeding tendency was encountered presumably due to previous streptokinase treatment. The patient was treated with aprotinin, tranexamic acid, desmopressin, transfusion of fresh frozen plasma and platelets with limited clinical signs of improvement. Analyzes showed complete consumption of fibrinogen in the blood. Subsequent administration of fibrinogen 2 g intravenously was associated with a marked improvement of hemostasis and the operation could be finished. The postoperative course was protracted but the patient gradually recovered and was discharged to her home after 18 days. She required treatment for heart failure but was in comparatively good health until a year later she developed ACE-inhibitor induced liver disease to which she later succumbed [4].
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Fig. 1 Transthoracic echocardiography. The upper part shows large hemopericardium (PER) and a continuity defect at the left ventricular apex (arrow) indicating the site of free wall rupture. Below, apical four-chamber view with color Doppler flow (arrows) across the apical ventricular septum. RV=right ventricle, LV=left ventricle.
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3. Discussion
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The present case is unique in the sense that the patient developed combined free wall and septal rupture after acute myocardial infarction and that she survived a transport of 130 km to the referral center by the aid of repeated aspiration of the pericardium. It is possible that streptokinase treatment may have played a role in the development of ventricular rupture as it occurred very early in the course of acute myocardial infarction and the hemodynamic deterioration developed shortly after streptokinase was given. An aspect that was important for the successful management was that free wall rupture probably occurred during or just before echocardiography and hence a pericardial drain and aspiration could be instituted without delay. By repeated aspiration and blood transfusion the patient could be transported to the referral center for surgical repair. Although our patient is not the first with left ventricular free wall rupture to survive transport from a community hospital to a cardiothoracic center for subsequent surgical repair we believe that this report further emphasizes the importance of early and aggressive diagnostic and therapeutic management of these cases [5]. Even in cases where surgical expertise is not immediately available the condition can be temporarily controlled by judicious pericardial aspiration and blood transfusion until definitive repair can be undertaken. In the present case standard surgical repair for anterior post-infarct ventricular septal defect was undertaken. In cases with isolated anterior free wall rupture, repair may even be achieved without cardiopulmonary bypass by closure of the rupture with the aid of glue and a patch [6].
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Appendix A
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ICVTS on-line discussion
Author: Dr. Suresh Bhagia, Cardiothoracic surgeon, Sri Sathya Sai heart Hospital, Cardiothoracic surgery, Kalavad Road, Rajkot, 380005, India
Date: 21-Mar-2003 08:19
Message: It was interesting to learn how you salvaged the post-MI LV free wall rupture via pericardiocentesis.
It needs sharp clinical acumen and a high index of suspicion to diagnose the "oozing" or slow variety of these kinds of left ventricular free wall ruptures. They still constitute about 3% of post MI complications resulting in a significant morbidity if not managed quickly.
Also, pericardiocentesis should be done using the most sterile technique since this is being done outside the operating room and on an emergency basis where sterility maybe compromised if attention to detail is lacking.
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Acknowledgements
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The authors are grateful to Eva Nylander, MD, Dept of Clinical Physiology, Linköping Heart Center, for providing the figure from available echocardiography recordings and for preparing the figure legend.
doi:10.1016/S1569-9293(03)00038-0
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References
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- Hagley MT, Hulisz DT, Burns CM. Hepatotoxicity associated with angiotensin-converting enzyme inhibitors. Ann Pharmacother. 1993;27:228–231[Abstract]
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Abstract
1. Introduction