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Interact CardioVasc Thorac Surg 2006;5:197-199. doi:10.1510/icvts.2005.123851 © 2006 European Association of Cardio-Thoracic Surgery
Chinese-hat patch glue repair of incomplete apical ventricular rupture
a Department of Cardiac Surgery, Athens Medical Center, Athens, Greece Received 28 October 2005; received in revised form 21 February 2006; accepted 22 February 2006
*Corresponding author. Address: Efstratios Koletsis 31, Chlois Str, 166 73, Voula, Athens, Greece. Tel.: +30 210 8955570; fax: +30 210 6105524.
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.
Key Words: Myocardial infarction; Ventricle; Rupture
Left ventricular rupture is a well recognized catastrophic complication of myocardial infarction. It involves up to 4.7% of myocardial infarctions and accounts for 12–21% of deaths after infarction [1]. Clinical suspicion, resuscitation, stabilization measures and emergency surgical repair provide the only therapeutic option. Incomplete left ventricular (LV) rupture (type IV) is a less catastrophic pattern of the disease that does not extend through all layers of the myocardial wall. Impending LV rupture, ooze rupture and pseudoaneurysm are terms used in the literature for the description of the same pathologic condition [2]. Debridment of the necrotic tissue and patch repair, direct suturing of the ruptured area (with simple mattress sutures buttressed with felts) or endocardial infarct exclusion, are well described techniques requiring cardiopulmonary bypass [3]. Numerous reports about more conservative approaches (as epicardial patch with biological glue without cardiopulmonary bypass) have been published with successful outcome, especially when the ventricle is not actively bleeding [4,5]. However, in cases of apical involvement the application of patches, even if they are somewhat pliable, is technically difficult due to the three-dimensional geometry of the LV apex.
We describe a technique of external reinforcement of an impending LV apical rupture which was an incidental finding during a coronary artery bypass procedure. A 76-year-old male was operated on for 3-vessel coronary artery disease and unstable post-infarction angina. His medical history was positive for hypertension and chronic obstructing pulmonary disease. He had experienced a myocardial infarction three weeks previously without receiving thrombolytic therapy. We performed preoperative echo and ventriculography. Both revealed an anterior-apical asynergy and failed to diagnose the impending rupture (probably due to the fact that there was neither exsanguinations – blow-out rupture – nor significant pericardiac clot collection). At operation a pericardial effusion of blood was found after the pericardium was incised. The apex was found to have a subepicardial bloody infiltration and on palpation there was no apical muscle (Fig. 1a).
The posterior wall of the ascending aorta had severe atherosclerotic plaques, an absolute contraindication for cross clamping the aorta. We reinforced the LV apex with an ad hoc construction of a Chinese-hat, from Teflon (Boston Scientific, Meditec, NJ, USA). This was produced by excluding a small sector from a Teflon circular patch with a diameter of 7 cm) (Fig. 2a) and suturing the edges, thus producing a 3-d structure (Fig. 2b) that fits the apex better.
The ‘hat’ was gently applied to the apex with surgical glue (Bioglue, Cryolife Georgia) on a beating heart. Care was taken not to exceed the ‘no muscle’ area more than 1–2 cm in order to avoid the possibility of a pseudoaneurysm (Fig. 1b). After the successful reinforcement of the ruptured area, subsequent manipulations of the heart and heparinization of the patient could be performed more safely. The operation proceeded with an off-pump double coronary artery bypass with the aid of a cardiac stabilizer. The left internal mammary artery was anastomosed to the mid left anterior descending and a saphenous vein graft to the second portion of the right coronary artery.
The patient had an uneventful postoperative course and was discharged from the hospital on the 10th postoperative day. He has been followed up for 18 months postoperatively with serial echo studies and the apical area is akinetic and no sign of pericardial fluid, pseudoaneurysm or ventricular restriction has been detected.
The success of the traditional LV repair techniques is limited by the durability of the infracted myocardium. Efforts to tie sutures through friable necrotic muscle are often unsuccessful. In our patient, the relative contraindication for cardiopulmonary bypass due to pulmonary disease and the absolute contraindication because of the severe aorta atherosclerosis (partially porcelain aorta) were taken into consideration for choosing a more conservative approach. Patch-glue repair techniques are definitely less extensive operations. They are, however, complicated by the fact of leaving behind necrotic tissue and by the possible toxicity of the glue to the adjacent normal myocardium [4]. A small patch that covers only the infracted area increases the risk of pseudoaneurysm. On the contrary, an unnecessarily large patch exposes more healthy myocardium to the glue and may cause restrictive pathophysiology [6]. We believe that the use of an easily constructed 3-d Teflon patch, the Chinese-hat, for the impending apical left ventricular rupture is a safe and effective technique, especially when cardiopulmonary bypass is contraindicated. To the best of our knowledge, the construction of a 3-d apical patch is not an established practice, so it might be useful for a cardiac surgeon to know as an alternative in desperate cases.
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Abstract
1. Introduction
