Myocardial rupture. Major left ventricular infarct rupture treated by infarctectomy

Intramyocardial Dissection following Postinfarction Ventricular Wall Rupture Contained by Surrounding Postoperative Adhesions

Introduction. Dissection of the myocardium is a rare form of cardiac rupture, caused by a hemorrhagic dissection among the spiral myocardial fibers, its diagnosis is rarely established before the operation or death, and extremely few cases have been reported in the literature and none of these cases seem to have a history of previous cardiac surgery which makes our report unique. Case Presentation. A 61-year-old female patient was admitted into the emergency room with complaints of progressive chest pain for 2 days. She had a history of second time prosthetic aortic valve replacement and was under anticoagulation therapy. She was diagnosed with an acute inferoposterior myocardial infarction and underwent emergency coronary angiography revealing spontaneous recanalization of the right coronary artery. During the follow-up, she developed cardiogenic shock and a new occurring systolic ejection murmur. Transthoracic echocardiography showed a left ventricular free wall rupture; then, she was taken in for emergency surgery. During the operation, a rupture zone and a wide intramyocardial dissecting area were detected. Intraventricular patch repair technic with autologous pericardial patch was used to exclude the ruptured area. Following the warming period, despite adequate hemostasis, hemorrhage around suture lines progressively increased, leading to the patient's death. Conclusion. Pericardial adhesions might contain left ventricular rupture leading to intramyocardial dissection.

Patch-and-glue repair in combination with or without direct suture for cardiac rupture after myocardial infarction

OBJECTIVE

Left ventricular free-wall rupture is a catastrophic event after myocardial infarction. The most appropriate surgical management remains controversial. We have performed a patch-and-glue technique, with or without direct suture and using cardioplegic arrest, to treat postinfarction cardiac rupture. We describe our experiences over a 5-year period, and discuss the optimal surgical repair for each type of rupture.

METHODS

Since 2002, we have managed 5 patients with cardiac rupture. Two patients had a blowout rupture, 2 were of the subacute type, and 1 experienced an oozing rupture. There were 3 men and 2 women, with an average age of 76.2 +/- 12.5 years. Echocardiography confirmed the diagnosis in all patients. Two patients underwent a patch-and-glue repair in combination with direct suture, one had an infarctectomy, and the others had a completely sutureless patch-and-glue treatment performed using cardioplegic arrest.

RESULTS

All patients survived the initial treatment and were moved to the intensive care unit with complete hemostasis. The 2 patients who were treated in combination with direct suture died of brain death or cardiac failure (mortality rate 40%). The 3 patients who were treated with the patch-and-glue sutureless technique were discharged from our hospital, and are alive 15-27 months after the operation. Two are doing well, and the other is breathing on his own but remains nonreactive.

CONCLUSION

We prefer the patch-and-glue sutureless technique even for a blowout rupture. We performed cardioplegic arrest to provide a bloodless surgical field and maximize adhesive function. The whole necrotic area should be covered with a large patch of appropriate size.

Acute heart failure: is there a role for surgery?

Many of the disorders and lesions leading to acute heart failure can be treated surgically. Modern surgical techniques like the off pump coronary surgery, newer techniques for the surgical treatment of the mechanical complications of acute MI and valvular reparative techniques have been added to the surgical armamentarium in recent years. Modern ventricular assist devices have started their career in the clinical arena promising to be less invasive. At the same time the spectrum of indications for mechanical circulatory support continues to witness a rapid expansion. Technical advances have led to an evolution of surgical strategies. Heart failure surgery is now in a position to offer improved outcomes, avoidance of recurrence of acute heart failure or the development of advanced chronic heart failure.

Sutureless Repair With TachoComb Sheets for Oozing Type Postinfarction Cardiac Rupture

Left ventricular free-wall rupture is a well recognized complication of myocardial infarction and a frequent cause of death. The appropriate surgical management varies significantly depending on the condition of the tear and the presence of concomitant lesions. We present a case of oozing type postinfarction cardiac rupture that was treated successfully by a sutureless patch technique using a fibrin tissue-adhesive collagen fleece (TachoComb [Torii Pharmaceutical, Tokyo, Japan]). This represents a quick, effective, and safe option for dealing with oozing type myocardial rupture due to myocardial infarction.

Ventricular aneurysm repair: a new approach

Repair of chronic left ventricular aneurysm or acute rupture of the heart after myocardial infarction is associated with technical difficulties and major morbidity and mortality. We describe a new endoventricular repair for both conditions. The repair consists of externally covering a Duran ring with Dacron and internally lining it with autologous pericardium. The modified ring is then sewn into the neck of the lesion. The technique is rapid, simple, and hemostatic. After repair of the chronic aneurysm, ventricular hemodynamics are improved during both diastole and systole. We have performed this technique in two patients with chronic aneurysm and one with subacute rupture.

Survival after subacute cardiac rupture

A 43-year-old man collapsed suddenly, with pericardial tamponade, seven weeks after an inferior myocardial infarction. Pericardiocentesis disclosed very heavily blood stained fluid. Left ventricular angiography 10 days later showed a left ventricular aneurysm. At operation a left ventricular false aneurysm was resected and the patient recovered uneventfully.