Asian Cardiovasc Thorac Ann 2008;16:152-153
© 2008 Asia Publishing EXchange Ltd
Fibrin Sealant for Left Ventricular Rupture after Mitral Valve Replacement
Ovidio A Garcia-Villarreal, MD,
Luis E Casillas-Covarrubias, MD
Department of Cardiac Surgery, Hospital of Chest and Cardiovascular Disease, Number 34, Mexican Institute of Social Security, Monterrey, Mexico
For reprint information contact: Ovidio A Garcia-Villarreal, MD, Tel: 52 81 8377 4610, email: ovidio{at}voila.fr, Vista Florida 460, Col. Linda Vista, 67130, Guadalupe, Nuevo León, Mexico.
 |
ABSTRACT
|
|---|
Despite safer surgical procedures, left ventricular rupture remains a rare but potentially lethal complication of mitral valve replacement. The use of fibrin sealant has substantially improved the outcome of many difficult bleeding episodes after cardiac surgery. We describe a case of left ventricular rupture successfully treated with fibrin sealant combined with external Teflon-pledgeted sutures.
|
INTRODUCTION
|
|---|
Left ventricular (LV) rupture after mitral valve replacement is a rare but dreaded and potentially lethal complication of mitral valve surgery, with an incidence up to 1% and an associated mortality of up to 85%.1 Several repair techniques have been described.1,2 Recently, biological sealants have provided a new solution to this problem.3
|
CASE REPORT
|
|---|
A 59-year-old woman with severe mitral stenosis and mild mitral regurgitation underwent elective mitral valve replacement. The left atrium was judged to be very small in size, thus a superior septal approach to the mitral valve was chosen. The mitral leaflets and chordae were excised. Preservation of the secondary chordae was not possible because the entire mitral valve was heavy thickened. A 27-mm On-X mechanical prosthesis (Medical Carbon Research Institute, Austin, TX, USA) was implanted. There were no complications during the procedure. During sternal closure, brisk bleeding was observed from the posterior pericardium. Lifting the heart, a type III LV rupture was detected. Cardiopulmonary bypass was reestablished, the aorta was cross clamped, and cardioplegic solution was administered. Beriplast fibrin sealant (ZLB Behring GMBH, Hamburg, Germany) was applied to the external surface of the affected area, and multiple horizontal mattress stitches, buttressed with 2 strips of Teflon felt, were placed to close the defect.
A second application of Beriplast was made over the involved area, including the external sutures. The aortic cross clamp was removed and cardiopulmonary bypass was terminated without problems. A small amount of persistent bleeding was observed arising from the sutures, which stopped on packing the area with gauze. The patient was treated with temporary chest packing. After 48 hours under careful observation in the intensive care unit, no further serious bleeding was seen, so the packing was removed and the chest was closed in the routine fashion in the operating room. The postoperative course was uneventful, and the patient was discharged from hospital 9 days after the original surgical procedure. Echocardiography before discharge shown normal LV function, no signs of pseudoaneurysm, and normal function of the mitral valve prosthesis (Figure 1
).
View larger version (86K):
[in this window]
[in a new window]
|
Figure 1. Postoperative 2-dimensional echocardiogram (4-chamber view); the black arrow indicates the affected area, no signs of pseudoaneurysm were observed. LA = left atrium, LV = left ventricle, MVP = mitral valve prosthesis, RA = right atrium, RV = right ventricle.
|
|
|
DISCUSSION
|
|---|
Treasure and colleagues4 described type I and type II LV ruptures as located in the posterior atrioventricular sulcus, and the area overlying the papillary muscles, respectively. Type III cited by Miller and colleagues5 is in an intermediate zone between the base of the papillary muscle and the left atrioventricular groove, which is directly related to the "untethered loop" hypothesis proposed by Cobbs and colleagues.6 The supporting structures of the posterior LV wall form a loop. The outer portion is composed of longitudinal muscle fibers in the LV wall, and the inner portion consists of the papillary muscles with the chordae attached to the annulus of the mural leaflet. Thus, division of the mural leaflet chordae can seriously weaken the posterior LV wall.
Traditionally, type I rupture is treated by internal repair: removing the prosthesis and closing the tear with an endocardial patch.1 Type II and III ruptures can be treated by external repair with multiple horizontal mattress stitches buttressed with Teflon felt.2 In cases where a hematoma is spreading widely, combined internal and external repair might be best. We were discouraged by 2 previous experiences of LV rupture after mitral valve replacement under similar circumstances. Both patients died despite simultaneous internal and external repair. This case was a typical type III LV rupture, and there are some reports of the use of biological sealants for such lesions.7 This approach can undoubtedly simplify repair of LV rupture; however, LV pseudoaneurysm may be a problem in the late postoperative period.8 One must also keep in mind the fact that adhesive strength is not the same for all biomaterials. Fibrin glue offers minimal adhesive strength compared to other biodegradable collagen ready-to-use systems. Fibrin glue, such as the one used by us, may be more suitable for sealing small tissue defects rather than large areas.9 We used a first layer of liquid sealant on the infiltrate-damaged hemorrhagic tissue on the external surface of the LV wall to reinforce the affected area. Horizontal multiples sutures were used to avoid further pseudoaneurysm formation and because LV rupture involves a large area that cannot be sealed by liquid adhesive alone. A second layer of fibrin sealant was placed over the Teflon and the sutures to achieve optimal repair.
Theoretically, LV pseudoaneurysm can develop at the site of previous rupture, contained by the surrounding pericardium or extracardiac tissue. Technical failure and suture tearing of friable myocardium are recognized causes of pseudoaneurysm arising on the closure line. A false aneurysm can occur within the first 2 weeks or more than 3 months after surgery.10 Nowadays, the wide use of echocardiography allows detection of acute pseudoaneurysms. Chronic pseudoaneurysms are generally detected during investigation of cardiac failure, and less often, incidentally. Echocardiography demonstrated no LV pseudoaneurysm in our patient at 9 days and 3 months after surgery, and she remains asymptomatic. We concluded that the use of fibrin sealant can facilitate repair of this highly lethal complication. Moreover, this approach might give better results than the classic methods which have a poor prognosis for LV rupture after mitral valve replacement.
|
REFERENCES
|
|---|
- Celemin D, Nunez L, Gil-Aguado M, Larrea JL. Intraventricular patch repair of left ventricular rupture following mitral valve replacement: new technique. Ann Thorac Surg 1982;33:638–40.[Medline]
- Karlson KJ, Ashraf MM, Berger RL. Rupture of left ventricle following mitral valve replacement. Ann Thorac Surg 1988;46:590–7.[Abstract]
- Albala DM. Fibrin sealants in clinical practice [Review]. Cardiovasc Surg 2003;11(Suppl 1):5–11.[Medline]
- Treasure RL, Rainer WG, Strevey TE, Sadler TR. Intraoperative left ventricular rupture associated with mitral valve replacement. Chest 1974;66:511–4.[Medline]
- Miller DW Jr, Johnson DD, Ivey TD. Does preservation of the posterior chordae tendineae enhance survival during mitral valve replacement? Ann Thorac Surg 1979;28:22–7.[Abstract]
- Cobbs BW Jr, Hatcher CR, Craver JM, Jones EL, Sewell CW. Transverse midventricular disruption after mitral valve replacement. Am Heart J 1980;99:33–50.[Medline]
- Schuetz A, Schulze C, Wildhirt SM. Off-pump epicardial tissue sealing-a novel method for atrioventricular disruption complicating mitral valve procedures [Review]. Ann Thorac Surg 2004;78:569–73.[Abstract/Free Full Text]
- Kimura N, Kawahito K, Murata S, Yamaguchi A, Adachi H, Ino T. Pitfalls of sutureless repair of a blow-out type left ventricular free wall rupture. Jpn J Thorac Cardiovasc Surg 2005;53:382–5.[Medline]
- Carbon RT, Baar S, Kriegelstein S, Huemmer HP, Baar K, Simon SI. Evaluating the in vitro adhesive strength of biomaterials. Biosimulator for selective leak closure. Biomaterials 2003;24:1469–75.[Medline]
- Prêtre R, Linka A, Jenni R, Turina MI. Surgical treatment of acquired left ventricular pseudoaneurysms. Ann Thorac Surg 2000;70:553–7.[Abstract/Free Full Text]
TOP
ABSTRACT
INTRODUCTION
