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Interact CardioVasc Thorac Surg 2008;7:733-735. doi:10.1510/icvts.2008.174904 © 2008 European Association of Cardio-Thoracic Surgery
Intraoperative coronary angiography in postinfarction ventricular free wall rupture: how technology can change diagnostic and therapeutic timingDivision of Cardiac Surgery, San Bortolo Hospital, Viale Rodolfi 37, 36100, Vicenza, Italy Received 3 January 2008; received in revised form 14 March 2008; accepted 17 March 2008
*Corresponding author. Tel.: +39 339 4534550; fax: +39 0444 920298.
Left ventricular free wall rupture often presents with an abrupt onset and rapidly progresses towards cardiogenic shock or electromechanical dissociation. The diagnostic pathway is still a matter of debate: echocardiography is commonly decisive but the assessment of coronary artery status is essential in order to optimize the surgical procedure. However, a preoperative coronary angiography could generate a dramatic delay of surgery. We report a case of a patient with a post-infarction left ventricular free wall rupture presenting with cardiac tamponade and cardiogenic shock who underwent emergency surgery. After cardiopulmonary bypass institution, an intraoperative coronary angiography was performed. Successful repair of the ventricular free wall rupture associated with a well-targeted surgical myocardial revascularization were carried out. This case illustrates how the development of technologically advanced hybrid operating rooms could lead to a new diagnostic and therapeutic approach to this potentially fatal complication.
Key Words: Angiography; Rupture; Ventricle left; Myocardial infarction
The rupture of the free wall of the left ventricle (LVFR) is a life-threatening complication that occurs 2–6 days after the onset of an acute myocardial infarction (AMI). The diagnosis is usually made by means of both trans-thoracic (TTE) and trans-esophageal echocardiography (TEE). The clinical status is characterized by the progressive development of pericardial effusion leading to cardiac tamponade and eventually to cardiogenic shock. Surgery is the only possible therapy, it should be accomplished as soon as the diagnosis is made. Since the LVFR is a mechanical complication of AMI it is often associated with coronary artery disease that, if diagnosed, should be treated during the same surgical operation. Unfortunately the patient's clinical condition is often so critical that the decision to perform a coronary angiography in the catheterization laboratory could lead to a significant delay of surgery. We report a case that illustrates a diagnostic-therapeutic strategy aimed at overcoming this problem.
A 63-year-old man with a history of diabetes, systemic arterial hypertension, hypercholesterolemia, peripheral artery disease, stroke and chronic kidney failure (creatinine: 2.0 mg/dl) was referred to our division from a peripheral hospital with a diagnosis of cardiac tamponade about 48 h after a recent AMI treated with thrombolysis. Chest roentgenogram showed an enlarged mediastinal silhouette and TTE and TEE showed massive pericardial effusion together with a thinning of the lateral wall of the left ventricle. These findings were suggestive of a LVFR. Left ventricle ejection fraction (LVEF) and left ventricle end-diastolic volume (LVEDV) were 33% and 151 ml, respectively; a moderate mitral regurgitation (MR) due to papillary muscle dysfunction was also present. The hemodynamic condition was critical and progressively worsening, cardiac index (CI) was 1.4 l/min/m2, systemic arterial pressure and central venous pressure were 75/40 mmHg and 30 mmHg, respectively; heart rate was 120 bpm and urine output was below 30 cc/h. Additive EuroSCORE value was 15. The patient was rapidly moved to the operating room. After IABP positioning, a median sternotomy was performed, the pericardium was initially opened for a few centimeters just above the ascending aorta in order to allow for the positioning of the arterial cannula and then fully entered in the usual fashion. This strategy prevents the massive hemorrhage due to a blow-out rupture that may occur at the opening of the pericardium. A total of 1100 cc of blood and clots was removed from the pericardium, the right atrium was cannulated with a double stage cannula and cardiopulmonary bypass (CPB) was then instituted. The exploration of the heart revealed a rupture of the lateral wall of the left ventricle at the level of the obtuse marginal branch of the left circumflex artery. A normothermic beating heart Teflon buttressed suture of the LV was performed. Coronary arteries diffuse calcifications of both left and right systems were palpable and visible; therefore an intraoperative coronary angiography (ICAN) was performed by interventional cardiologists while the patient was still on CPB and with the chest open. Through a femoral arterial access 6 F-diagnostic catheters were inserted and the procedure was carried out. The angiographic projections performed were: left anterior oblique straight and cranial, right anterior oblique straight and cranial and postero-anterior cranial. These views showed a three-vessel disease with a critical stenosis of the proximal left anterior descending artery (LAD) and a total occlusion of both the left circumflex (CX) (Fig. 1) and the right coronary artery (RCA). Consequently, on-pump beating heart myocardial revascularization was accomplished, with two saphenous vein grafts on the correct sites of LAD and RCA; CX was not revascularized as it was the site of LV rupture. The duration of ICAN and CPB were 20 and 107 min, respectively. The left internal mammary artery was not harvested since the patient had a preoperative history of left subclavian artery stenosis.
ICAN and surgery were performed in a fully equipped hybrid operating room with a digital fluoroscopic ‘C-arm’ system (GE OEC 9800 plus, GE Healthcare, UK), radiotransparent surgical beds and all the equipment and monitoring devices necessary to perform heart surgery as well as percutaneous diagnostic procedures, endovascular aortic stent placement and real ‘hybrid’ operations including open aortic arch or thoracoabdominal debranching procedures. Postoperative stay was uneventful, inotropic support with dopamine and dobutamine was gradually reduced and stopped within 72 h, CI was 2.2 l/min/m2 and IABP was removed four days after the operation. Although the patient was under thrombolysis therapy we did not observe postoperative bleeding and a higher usage of blood products, either. Furthermore, liver function remained normal and a small increase in serum creatinine occurred (Peak creatinine: 2.2 mg/dl) without the need for dialysis. The patient was discharged from the hospital 11 days after surgery. An echocardiography performed before hospital discharge showed: LVEF, 40%; LVEDV, 118 ml; and trivial MR. At six months follow-up the patient is in NYHA functional class I, LVEF is 40% and physical examinations do not show significant problems.
The LVFR is a challenging and potentially fatal complication occurring in about 3% of patients after an AMI [1] and causing 5–24% of all hospital deaths subsequent to AMI [2]. Mortality of surgically treated patients with several different surgical techniques varies widely among centers, ranging from 11% to 80% [3–5]. In many cases LVFR is diagnosed only at autopsy since the diagnosis is not always promptly performed. Thus, early diagnosis, correct critical care management and emergency surgery affect patient's outcome. A complete diagnostic approach in patients with LVFR requires: a) TTE and/or TEE to evaluate the severity of cardiac tamponade and the site of rupture; b) coronary angiography to assess presence and distribution of atherosclerotic lesions and to plan surgical myocardial revascularization. Myocardial revascularization in this subset of patients is mainly aimed at improving coronary blood flow in the remaining viable areas of the myocardium in order to improve short- and long-term outcomes. Unfortunately, the extreme critical clinical conditions of these patients, especially those with ‘blow-out’ ruptures, do not often allow sufficient time to perform coronary angiography in the catheterization laboratory thus making it impossible to carry out an appropriate surgical revascularization. The possibility to perform coronary angiography intraoperatively allows a rapid transfer to the operating room with timely CPB institution and consequent optimal stabilization of hemodynamic condition. LVFR often presents as a two-stage event: a first phase of ‘subacute’ rupture may come before a second ‘blow-out’ dramatic rupture [6]. Pericardial decompression often causes an abrupt increase in blood pressure and consequently increases the risk of a blow-out rupture. Thus, an ‘on-pump’ pericardial opening is theoretically more safe and effective. The evidence of a severe diffuse coronary disease guided our decision to carry out two well-targeted CABGs since a percutaneous approach was not technically feasible. The history of left subclavian artery stenosis together with the emergency conditions led us to use two saphenous vein grafts. Although the presence of a well-equipped hybrid operating room represents the ‘gold standard’ for ICAN execution, the minimal equipment required is achieved with a portable ‘C-arm’ digital fluoroscopic system together with radiotransparent surgical beds. ICAN is commonly performed to assess graft patency especially in minimally invasive [7] or robotic CABG procedures [8]. Furthermore, Neri and associates reported a case of ICAN in a patient with acute aortic dissection [9]. At our institution, ICAN is performed in all those conditions in which the ‘conventional’ cardiac catheterization could generate potential complications for anatomic characteristics (for example, emboli from endocarditic vegetations on the aortic valve) or timing reasons (emergency operations). The good cooperation between surgeons, interventional cardiologists and nursing staff that has developed from this experience allows ICAN to be performed in reasonable times. This case shows how modern technical equipment together with a well-coordinated multidisciplinary approach also in the operating room could improve diagnostic and therapeutic strategies avoiding waste of precious time, especially in those patients with extremely unstable clinical conditions.
We thank Paul Marcucci for his assistance in manuscript revision.
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Abstract
1. Case report
