Asian Cardiovasc Thorac Ann 2008;16:407-409
© 2008 Asia Publishing EXchange Ltd
Postinfarction Heart Rupture of Posterior Wall Repaired by Covering Patch
Naoyuki Kimura, MD,
Atsushi Yamaguchi, MD,
Masashi Tanaka, MD,
Homare Okamura, MD,
Hideo Adachi, MD,
Takashi Ino, MD
Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
For reprint information contact: Naoyuki Kimura, MD Tel: 81 48 647 2111 Fax: 81 48 648 5188 Email: kimura-n{at}omiya.jichi.ac.jp, Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya, Saitama 330-0834, Japan.
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ABSTRACT
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A 46-year-old man underwent emergency surgery for heart rupture after acute infarction of the posterior wall. Echocardiography revealed limited myocardial thinning, so rather than sutureless repair, a covering patch was used in view of the risk of recurrent rupture. Postoperative echocardiography showed the myocardial thinning had progressed to a wide defect, and computed tomography demonstrated that the covering patch had prevented a repeat rupture.
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INTRODUCTION
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Heart rupture is recognized as a serious complication following acute myocardial infarction. Although immediate surgical intervention is necessary, the appropriate surgical approach remains controversial. We describe the surgical treatment of a case of post-myocardial infarction posterior left ventricular (LV) wall thinning that progressed dramatically to a blowout rupture.
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CASE REPORT
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A previously healthy 46-year-old man was admitted to our hospital 3 days after the onset of chest pain. On admission, he was in profound shock with systolic arterial blood pressure of 50 mm Hg. Electrocardiography showed sinus tachycardia and inverted T waves in leads V5 and V6. Echocardiography demonstrated massive pericardial effusion and a hypokinetic area in the posterior LV wall. Fluid and inotropic agents were given immediately. Pericardiocentesis did not improve the circulatory collapse, but drainage of 200 mL of blood by substernal pericardiotomy led to immediate recovery of the patient’s vital signs. Echocardiography after drainage revealed a small area of myocardial thinning in the posterior LV wall (Figure 1A
). After hemodynamic stabilization, coronary angiography indicated occlusion of segment 13 of the left circumflex artery. Heart rupture was diagnosed, and the patient was transferred to the operating room. The pericardium was opened through a median sternotomy, and a large amount of dark blood and clot was evacuated. An epicardial hematoma measuring 5 x 3 cm was found in the posterolateral LV wall, but there was no transmural tear. Although there was no active bleeding site, we decided to carry out covering patch repair under cardioplegic arrest because the small localized thinning in the LV wall and profound shock strongly suggested that a blowout-type rupture had occurred. Under cardiopulmonary bypass, the ascending aorta was cross clamped. Direct transmural horizontal mattress sutures buttressed with 2 Teflon felt strips (LR Bard, Tempe, AZ, USA) were placed circumferentially on the healthy myocardium around the infarcted area (Figure 2A). The area surrounded by felt strips was covered with an elliptical Teflon patch (9 x 6 cm) secured to the epicardium with fibrin glue. A continuous running suture was placed between the felt strip and thinned myocardium to fix the patch (Figure 2B). The bleeding stopped completely, and the patient was easily weaned from bypass. Echocardiography on postoperative day 10 showed normal LV function (ejection fraction, 0.6) and a wide myocardial defect in the posterolateral LV wall (Figure 1B). Multislice computed tomography revealed that the myocardial defect (2 x 2 cm) was adequately covered by the patch (Figure 3). Postoperative hospital stay was 30 days. The patient remained well at 5 months after surgery.
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Figure 1. (A) Preoperative echocardiography showing limited myocardial thinning in the posterior left ventricular wall (arrow). (B) Postoperative echocardiography revealing that the limited myocardial thinning had progressed to a wide myocardial defect (arrowhead).
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Figure 2. Repair technique. (A) Direct transmural horizontal mattress sutures buttressed with 2 Teflon felt strips were placed circumferentially in the healthy myocardium around the infarcted area. (B) The infarcted area was covered with a Teflon patch using a continuous running suture. The patch was secured to the epicardium with fibrin glue.
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Figure 3. Multislice computed tomography showed the wide myocardial defect (2 cm in diameter) was adequately covered by the patch.
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DISCUSSION
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Heart rupture can be a fatal complication after infarction. Although several approaches have been reported, the most appropriate technique depends on the nature of the rupture and its surrounding tissues. Sutureless repair with newly developed adhesives has been reported to be effective, especially for controlling bleeding in the oozing-type of heart rupture.1–4 However, recurrent rupture after this procedure has been noted.2 In our case, although there was no active bleeding site, the small area of localized thinning in the posterior LV wall increased postoperatively to a wide myocardial defect. We previously encountered a patient in whom a pseudoaneurysm developed after sutureless repair of a small blowout rupture of the posterior LV wall with a collagen hemostat.5 We think that in both cases the residual rupture tract expanded to a wide defect because of the fragility of the surrounding necrotic myocardium. Sutureless repair in this case might have led to recurrent rupture.
The covering patch technique may be limited to relatively small infarcts. Mantovani and colleagues6 recommended use of a large patch because progression of myocardial dissection can lead to new heart rupture in the area adjacent to the primary endocardial tear. Batts and colleagues7 reported that heart rupture tends to occur along the interface between viable and infarcted myocardium where shear forces are greatest. We used a large patch because it was difficult to identify the area of myocardial thinning during surgery. We believe the echocardiographically determined thinning of the LV wall and profound shock in this case strongly suggested a blowout rupture and associated cardiac tamponade. When there is a risk of recurrent rupture, even if there are no operative findings of active bleeding, a covering patch repair should be considered for this type of heart rupture.
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REFERENCES
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- Padró JM, Mesa JM, Silvestre J, Larrea JL, Caralps JM, Cerrón F, et al. Subacute cardiac rupture: repair with a sutureless technique. Ann Thorac Surg 1993;55:20–4.[Abstract]
- Canovas SJ, Lim E, Dalmau MJ, Bueno M, Buendia J, Hornero F, et al. Midterm clinical and echocardiographic results with patch glue repair of left ventricular free wall rupture. Circulation 2003;108(Suppl II):237–40.
- Lachapelle K, deVarennes B, Ergina PL, Cecere R. Sutureless patch technique for postinfarction left ventricular rupture. Ann Thorac Surg 2002;74:96–101.[Abstract/Free Full Text]
- Iemura J, Oku H, Otaki M, Kitayama H, Inoue T, Kaneda T. Surgical strategy for left ventricular free wall rupture after acute myocardial infarction. Ann Thorac Surg 2001;71:201–4.[Abstract/Free Full Text]
- Kimura N, Kawahito K, Murata S, Yamaguchi A, Adachi H, Ino T. Pitfalls of sutureless repair of blow-out type left ventricular free wall rupture. Jpn J Thorac Cardiovasc Surg 2005;53:382–5.[Medline]
- Mantovani V, Vanoli D, Chelazzi P, Lepore V, Ferrarese S, Sala A. Post-infarction cardiac rupture: surgical treatment. Eur J Cardiothorac Surg 2002;22:777–80.[Abstract/Free Full Text]
- Batts KP, Ackermann DM, Edwards WD. Postinfarction rupture of the left ventricular free wall: clinicopathological correlates in 100 consecutive autopsy cases. Hum Pathol 1990;21:530–5.[Medline]
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ABSTRACT
INTRODUCTION
