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Interact CardioVasc Thorac Surg 2005;4:203-206. doi:10.1510/icvts.2004.100321 © 2005 European Association of Cardio-Thoracic Surgery
Surgical treatment for rupture of left ventricular free wall after acute myocardial infarctionDivision of Cardiovascular, Thoracic, and Pediatric Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan Received 12 October 2004; received in revised form 22 January 2005; accepted 7 February 2005
*Corresponding author. Tel.: +81-78-382-5942; fax: +81-78-382-5959.
Left ventricular (LV) free wall rupture particularly in blow-out type is still one of the fatal complications after myocardial infarction. Seven patients had LV rupture following acute myocardial infarction. LV rupture was divided into two categories: blow-out type (true rupture) in 5 cases, or oozing type (incipient rupture) in 2 cases. All patients were in deep shock condition and underwent surgery on emergency basis. Patch and glue (fibrin glue) technique was applied for oozing type patients, while direct closure using buttress sutures with additional sutured patch and glue (including GRF glue) technique for blow-out type patients. Surgery was performed on heart beating without cardioplegic arrest. Complete homeostasis and circulatory recovery were obtained in all cases. One blow-out type patient (14.3%), who had preoperative cardiopulmonary arrest (CPA), died of multiple organ failure. Four patients (57.1%) who had preoperative CPA or were in prolonged deep shock resulted in vegetative condition regardless of rupture type. Two patients (28.5%) of blow-out type were successfully rescued without any severe brain complications. No recurrence of free wall rupture was demonstrated during follow-up in all cases. Fifty-seven percent of patients had postoperative vegetative condition because of inadequacy of cardiopulmonary resuscitation including delayed circulatory support. Our surgical procedure provided sufficient circulatory recovery and survival without recurrence, even in patients with blow-out type rupture, as long as prompt resuscitation was performed.
Key Words: Rupture; Left ventricular free wall; Acute myocardial infarction; GRF glue; Hypothermia
Acute myocardial infarction is complicated by left ventricular (LV) rupture in approximately 0.8–6.02% of patients [1,2]. Prompt diagnosis and surgical intervention is demanded, even if operative mortality is sometimes exceedingly high (i.e., 24–35%) [3,4]. Several types of surgical repairs have been proposed, including use of sutures with pledgets [5], Dacron patch, and infarctectomy, as well as use of biologically glued sutureless pericardial patches [2,6–8]. This report present our surgical experience of LV rupture for this challenging complication.
Three hundred and thirty-one cases underwent surgery for ischemic heart disease between October 1999 and September 2003. Of 331, 7 patients (2.1%) with LV rupture following myocardial infarction were reviewed. The percentage is rather high, because high-risk cases with emergency such as ischemic complications or acute aortic dissection are intended to refer to out-hospital. Preoperative patients demographics are shown in Table 1. LV rupture was categorized into either blow-out type (true rupture) in 5 cases or oozing type (incipient rupture) in 2 cases. All patients were in either deep shock or in cardiopulmonary arrest (CPA) under resuscitation and underwent surgery on an emergency basis. Three of the 7 patients were referred from outside hospital.
Six patients had prior acute myocardial infarction (AMI) of left anterior descending artery (LAD) in 4 and circumflex artery (Cx) in 2 and one in right coronary artery. The interval between AMI and the onset of left ventricular free wall rupture was 1 h to 10 days. All patients but one (case 7) had circulatory support on IABP (intra-aortic balloon pumping) and/or PCPS (percutaneous cardiopulmonary support). PCPS was applied for 5 cases (case 2, 3, 4, 5 and 6). PCPS priming could be performed within 5 min and applied through the femoral artery and vein cannulation. Average time until on PCPS support was 23.6 min (range: 13–38 min). Two (case 3 and 4) of the LV rupture occurred in angio suite. PCPS was immediately applied for two (case 3 and 4) of them within 15 min. In the other three cases (case 2, 5 and 6), PCPS was applied with some delay (mean 30 min). Six of 7 patients had pre-op pericardial centesis. Afterward, all patients except case 5 were transferred to operating theatre. Case 5 had blow-out type rupture 4 days after PCI (stent implantation) for the left anterior descending (LAD) and stayed in ICU, whose surgery was obliged to undergo in ICU. 2.1. Operative procedure Surgery was performed on heart beating with IABP/PCPS support to avoid further myocardial ischemia. Primary homeostasis was obtained by direct compression and followed by fibrin glue application for oozing type rupture. Additional sutureless covering equine pericardial patch (Xenomedica®) was placed for one of the cases. Direct closure using felt strips and 3-0 polypropylene suture of MH-1 needle was performed for blow-out type rupture. Additional large equine pericardial patch (Xenomedica®) was applied for 4 cases and sutured on normal myocardium with 4-0 polypropylene running suture. Fibrin glue (Tisseel® (Baxter, Vienna, Austria)) was used for 2 cases and Gelatin-Resorcin-Formalin (GRF) for recent 3 cases. Glues were injected beneath the pericardial patch to reinforce the left ventricular wall (Fig. 1).
Table 2 summarizes the surgical procedure and outcome. Complete hemostasis was obtained in all cases. One patient (case 3) in blow-out type had concomitant ventricular septal rupture and died of multiple organ failure. LV rupture occurred during cardiologic manipulation in angio suite. PCPS was applied as early as 13 min, but not resuscitated even on IABP and PCPS because of big tear (approximately 2 cm), which were beyond IABP/PCPS support ability. The other 6 patients tolerated operation and were weaned from circulatory support 1 to 18 days (mean 8.6 days) after surgery. The operative mortality was 14.3%, but severe brain damage, which resulted in vegetative condition, occurred in 4 cases (57.1%) (2 cases of oozing type (case 1 and 2) and 2 of blow-out type (cases 5 and 6)). In case 1, the patient was fortunately resuscitated on IABP. However, there existed prolonged hypoxemia in spite of mechanical ventilation on his way to our hospital. In cases 2 and 5, it took 30 or 38 min, respectively, to get on PCPS because of delayed procedure. In case 6, the patient got on circulatory support by IABP and PCPS relatively as quick as 23 min and transferred to our hospital. However, blood pressure was as low as 50 mmHg on her way to our hospital after CPR. Taken together, inadequacy of CPR, including delayed application of PCPS or improper patient management even on PCPS, is the major cause of post-op vegetative state.
Two (cases 4 and 7) (28.5%) in blow-out type were rescued without permanent brain complications. In case 4, the rupture occurred in angio suite and PCPS was applied 14 min after onset, which resulted in circulatory stabilization and secure operation. In case 7, the patient was referred to our hospital in deep shock condition and underwent emergency operation, which was followed by mild therapeutic hypothermia for 3 days. He regained consciousness after the procedure and was discharged only with mild hemiplegia. Cardiac functional recovery was good (%FS 34.5) and his ADL is almost back to pre-op status. No recurrence of left ventricular free wall rupture was demonstrated during follow-up in all cases.
Surgical experience for left ventricular free wall rupture after myocardial infarction has been reported, which was performed on heart beating using direct closure, large patch and glue technique to secure homeostasis. Although operative mortality is sometimes exceedingly high (i.e., 24%–40%) [3–5], our surgical procedure provided acceptable mortality (14%) even with a high percentage of blow-out type rupture. LV free wall rupture occurs in approximately 0.8–6.02% of patients [1,2] after acute myocardial infarction. Autopsy studies have shown the incidence was more common in 16–21% of the hospitalized patients [9]. Figueras et al. pointed out that delayed hospital admission or undue in-hospital physical activity appears to increase the incidence of ruptures in patients with potential risks, such as a fisrt transmural AMI, absence of overt heart failure and advaced age [10]. Several procedures of surgical repairs have been proposed, including use of sutures with pledgets [5], Dacron patch, and infarctectomy, as well as the use of biologically glued sutureless pericardial patches [2,6–8]. Recent reports are likely to shift toward the sutureless technique using glue because of its simplicity and effectiveness without troubling with myocardial friability. We are concerned that lack of suture may result in the recurrence of rupture after the recovery of circulation especially in blow-out type rupture. Therefore, we always closed the tear first with felt strips sutured (3-0 MH-1 needle) directly to the myocardium. We also applied a large patch, which bordered on the healthy myocardium with glue and sutured with 4-0 polypropylene suture. Meticulous attention should be paid to avoid the coronary artery involvement. Regarding to synthetic glue, Alamanni et al. [7] applied BioGlue (CryoLife International, Inc, Kennesaw, Ga), Lachapelle et al. [2] did biocompatible glue made of cyanoacrylate monomer (Histoacryl; B. Braun Medical AG, Melsungen, Germany), while Amano et al. [8] used GRF glue for double patch sealing. GRF glue has been applied in the recent three cases because of its strength. However, the dose of formaldehyde must be minimized because of its cytotoxity. In this type of operation, IABP or PCPS were used first for circulatory support and biventricular unloading during the repair. PCPS is applied as quickly as 13 min and provided ventricular decompression, which resulted in the reduction of bleeding. All procedure could be performed on heart beating condition without cardioplegic arrest, which could preserve the myocardial viability. Actually all patients were weaned off those circulatory supports within several days. Although prompt surgery with circulatory support was performed on every case, four patients (case 1, 2, 5, and 6) had permanent brain damage. All of them had preoperative CPA (case 1) or were in prolonged deep shock (case 2, 5 and 6) (30, 38 and 23 min until PCPS application, respectively) and resulted in vegetative condition regardless of rupture type. We believe that prompt diagnosis and adequate CPR including immediate application of PCPS with proper cardiopulmonary management are mandatory. In the next step, additional management to protect the brain is demanded. Mild therapeutic hypothermia has been recognized to improve the neurological outcome after cardiac arrest [11–14], although outcomes were influenced by depth and duration of hypothermia as well as rate of rewarming (<or=24 h) after discontinuation of hypothermia. This strategy was applied in one patient (case 7) after the operation and it was successfully done.
The results of our surgical treatment for LV rupture were satisfactory in terms of hemostasis and circulatory recovery. However, fifty-seven percent of patients had postoperative vegetative condition because of inadequacy of cardiopulmonary resuscitation including delayed circulatory support. We believe it is of utmost importance to perform the operation without any delay before irreversible brain damage ensues. Intensive management including hypothermic brain protection should be considered to rescue the patients at the critical condition.
Author: Hitoshi Hirose (Drexel University College of Medicine, USA) eComment: I agree with the authors that the oozing type of free wall rupture has been successfully managed with glue and patch placement (sutureless technique). It can be done without cardiopulmonary bypass; however, it is easier to do it under cardiopulmonary bypass with the ventricle decompressed. The key points of this procedure are wiping off all blood clots from the heart before placing the glue and patch, and gluing the space between the epicardium and patch. Re-rupture or pseudoaneurysm formation after glue and patch technique is known to be rare.
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Abstract
1. Introduction
