Asian Cardiovasc Thorac Ann 2002;10:256-258
© 2002 Asia Publishing EXchange Pte Ltd
Postinfarction Left Ventricular Free Wall Rupture Repaired Successfully
Emin Tireli, MD,
Yusuf Kalko, MD,
Eylül Kafali, MD,
Murat Basaran, MD
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Department of Cardiovascular Surgery Istanbul Medical Faculty Istanbul University Istanbul, Turkey
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For reprint information contact: Emin Tireli, MD Tel: 90 212 635 2921 Fax: 90 212 534 2232 email: dr_murat_basaran{at}hotmail.com Department of Cardiovascular Surgery, Istanbul Medical Faculty, Istanbul University, Millet Caddesi, 'apa, Istanbul 34390, Turkey.
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ABSTRACT
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Left ventricular free wall rupture is a well-recognized complication of myocardial infarction and a frequent cause of death. A 49-year-old man was successfully treated for a left ventricular free wall rupture that occurred on the third day after an anterior myocardial infarction. Concomitant myocardial revascularization was performed.
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INTRODUCTION
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Left ventricular (LV) free wall rupture is the third most frequent complication and the second most common cause of death after myocardial infarction (MI).1 Although the most appropriate surgical approach is still controversial, operative intervention is usually the only available treatment.
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CASE REPORT
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A 49-year-old hypertensive man was seen at another hospital with acute onset of central chest pain, dyspnea, and electrocardiographic changes suggestive of anterior MI. A chest radiograph was unremarkable. There was a modest enzyme rise, and a diagnosis of anterior MI was made. The patient was stabilized with thrombolytic therapy, and his initial clinical progress was uneventful. However, 3 days later, he developed chest pain refractory to medical therapy and a diastolic murmur. His central venous pressure was elevated. Transthoracic echocardi-ography showed pericardial effusion, diastolic collapse of the right atrium, and moderate LV dysfunction. A tear in the anterolateral aspect of the LV free wall was identified, and the patient was transferred to our institution for surgical intervention. On arrival, he was found to have tachycardia and a blood pressure of 80/45 mm Hg. Inotropic support was started, and urgent cardiac catheterization was performed. Angiography revealed total occlusion of the proximal left anterior descending artery (LAD), 75% stenosis of the diagonal artery, and 70% stenosis of the 2nd obtuse marginal branch of the circumflex artery. There was no significant abnormality in the rest of the coronary arterial system, and the LAD was filling retrogradely from the right coronary artery. The patient was immediately transferred to the operating room.
Through a standard median sternotomy, the pericardium was opened and found to contain 200 mL of defibrinated blood. There was a large area of infarction on the anterolateral aspect of the left ventricle with a tear in the myocardium, including a full-thickness rupture (Figure 1
). The patient was rapidly placed on cardiopulmonary bypass (CPB) with standard aortic and 2-stage venous cannulation. A retrograde cardioplegia cannula was placed in the coronary sinus, and an antegrade cardioplegia needle was placed in the ascending aorta. The ascending aorta was crossclamped, cardioplegic arrest was induced with antegrade cold St. Thomas’ Hospital crystalloid solution, and iced saline was used for topical cooling of the heart. Cardiac arrest was maintained with intermittent antegrade or retrograde cold blood potassium cardioplegia. The ruptured area was inspected and opened longitudinally. The necrotic myocardium was found to be extremely friable and it was excised to the border of healthy myocardial tissue. A Dacron patch was fashioned and the rupture was repaired by placing the patch subendocardially and securing it with continuous 2/0 sutures (Figure 2). The edges of the ventriculotomy were approximated with interrupted sutures supported by Teflon felt strips (Figure 3). Before removing the crossclamp, aortocoronary bypass was performed with reversed autologous saphenous vein grafts to the LAD, the diagonal artery, and the obtuse marginal branch of the circumflex artery. The patient was weaned from CPB with moderate doses of dopamine and dobutamine. His postoperative course was uneventful and he was extubated after 8 hours. Hemodynamic improvement allowed discontinuation of inotropic support on the 3rd postoperative day. The intensive care unit stay was 4 days, and the patient was discharged on the 11th postoperative day. He resumed a normal life and was in New York Heart Association functional class I at follow-up.
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Figure 3. Teflon felt strips were used to close the ventriculotomy in order to support the necrotic myocardial wall.
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DISCUSSION
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Myocardial rupture has been reported to complicate 4% to 24% of cases of MI.2 It is second to pump failure as a cause of death after MI, accounting for 12% to 21% of postinfarction deaths.3,4 Rupture of the ventricular wall usually occurs between 1 and 7 days after MI and most often involves the anterior or lateral aspect of the left ventricle.4,5 The mid-ventricle is the most frequent site of the rupture.5 The risk factors for postinfarction LV free wall rupture include age over 60 years, female gender, preexisting hypertension, absence of LV hypertrophy, first MI, and mid-ventricular or lateral wall transmural infarction.5
Postinfarction rupture of the left ventricle bears a high mortality, and surgical repair is considered the definitive treatment. Although emergency surgical intervention is very important in this fatal complication, the most appropriate surgical technique remains controversial. The traditional approach consists of infarctectomy followed by replacement with a prosthetic patch under CPB. Recent reports suggest that a more conservative approach may be preferable. Simple mattress sutures buttressed with Teflon felt or application of a patch to the epicardial surface are some of the conservative methods that can be performed without the institution of CPB. However, despite successful results with these conservative approaches, more than 80% of patients in postmortem studies had multivessel disease, and all had severe obstruction of at least one major epicardial artery.2,3 These findings strongly indicate that revascularization of the ischemic myocardium should be undertaken. Although the right coronary artery and the LAD can be grafted without CPB, a more extensive revascularization procedure, as in this case, requires the establishment of CPB. Cardiac rupture is a surgical emergency, and the benefit of coronary grafting is obvious, especially in patients with multivessel disease confirmed by cardiac catheterization.
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REFERENCES
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- Reardon MJ, Carr CL, Diamond A, Letsou GV, Safi HJ, Espada R, et al. Ischemic left ventricular free wall rupture: prediction, diagnosis, and treatment. Ann Thorac Surg
1997;64:1509–13.[Abstract/Free Full Text]
- Veinot JP, Walley VM, Wolfsohn AL, Chandra L, Russell D, Stinson WA, et al. Postinfarct cardiac free wall rupture: the relationship of rupture site to papillary muscle insertion. Mod Pathol
1995;8:609–13.[Medline]
- Sutherland FW, Guell FJ, Pathi VL, Naik SK. Postinfarction ventricular free wall rupture: strategies for diagnosis and treatment. Ann Thorac Surg
1996;61:1281–5.[Abstract/Free Full Text]
- Zahger D, Milgalter E. Clinical problem-solving. A broken heart. N Engl J Med
1996;334:319–21.[Free Full Text]
- Batts KP, Ackermann DM, Edwards WD. Postinfarction rupture of the left ventricular free wall: clinicopathologic correlates in 100 consecutive autopsy cases. Hum Pathol
1990;21:530–5.[Medline]
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ABSTRACT
INTRODUCTION
