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Ann Thorac Surg 1999;67:1802-1803
© 1999 The Society of Thoracic Surgeons

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Case Reports

Repair of left ventricular rupture after mitral valve replacement: use of a Teflon patch and glue

^a Department of Cardiac Surgery, Hospital de Navarra, Pamplona, Spain

Accepted for publication November 18, 1998.

Address reprint requests to Dr de la Fuente, Department of Cardiac Surgery, Hospital de Navarra, C/Irunlarrea no. 3, 31008 Pamplona, Spain
e-mail: anselmo.delafuente.calixto{at}cfnavarra.es

	Abstract

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Rupture of the left ventricular wall is an infrequent but lethal complication after mitral valve replacement. We present the case of a patient in whom such a rupture was successfully repaired in the intensive care unit with a patch of Teflon felt stuck in place with glue.

	Introduction

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Rupture of the left ventricle, first described by Roberts and Morrow [1] in 1967, is a major complication of mitral valve replacement. In a review by Karlson and colleagues [2], the incidence averaged 1.2% with a mortality rate of approximately 75%. There is controversy regarding the etiology of this complication and various predisposing and intraoperative factors have been suggested [2, 3].

Treasure [4], Miller [4, 5], and their co-workers classified the complication on the basis of the location of the tear: ruptures located in the posterior atrioventricular groove are type I; ruptures in the posterior wall of the left ventricle at the base of the papillary muscles are type II; and ruptures in the area between the atrioventricular groove and the papillary muscles are type III. The complication has also been classified by time pattern of presentation; early, delayed, and late rupture.

We report a case of delayed rupture of the posterior wall of the left ventricle after mitral valve replacement. It was not possible to determine the precise location of the rupture. We used a Teflon felt patch and Histoacryl glue (B. Braun Melsungen AG, Melsungen, Germany) to successfully repair the rupture.

A 67-year-old woman, who had undergone open commissurotomy 23 years previously, underwent elective mitral valve replacement, with a (Carpentier-Edwards) 29-mm porcine mitral bioprosthesis and tricuspid valve repair with a No. 34 Cosgrove ring. There were no complications during the operation, and the patient was taken to the intensive care unit (ICU) in good condition.

Five hours later, the patient sustained massive bleeding (800 mL in 5 minutes) from the chest drainage tubes, hypotension, and shock. We reopened the sternotomy in the ICU and found an epicardial hematoma and massive bleeding from the posterior wall of the left ventricle. Teflon felt–buttressed interrupted sutures were placed, but considerable blood leakage continued. We used Histoacryl glue to stick a Teflon felt patch (approximately 5 cm in diameter) over the involved area. The bleeding stopped, and the condition of the patient improved. This emergency procedure was done in the ICU because the clinical condition of the patient was so poor it was impossible to transfer her to the operating theater. The sternotomy was not immediately closed; instead we sutured a plastic dressing over it. We closed the wound in the ICU 48 hours later, and the patient was moved to the hospital ward in good condition. Seven days later, ventricular function was normal at echocardiography, and the patient was discharged home. At the most recent routine follow-up, 6 months after discharge, echocardiography revealed no signs of pseudoaneurysm, ejection fraction was normal, and the bioprosthesis was functioning well.

	Comment

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Several factors predisposing to left ventricular rupture have been identified: female sex, advanced age, mitral stenosis, small left ventricle, and small body size [2, 3]. In addition, the following intraoperative factors have been considered causes of this complication: retraction of the left ventricle when the left atrium is fixed by adhesions from a previous operation; extensive resection of a papillary muscle; insertion of a prosthesis that is too large; high-profile valves; impingement by a valve strut; presence of deep sutures in the myocardium; mechanical injuries to the left ventricle; forceful retraction; and inadvertent damage to the annulus [2–3, 4, 6, 7]. Our patient was an older woman with a previous operation, a small body size, and a small left ventricle.

This case report concerns delayed rupture as opposed to early or late rupture, and the first manifestation occurred in the ICU 5 hours after the conclusion of mitral valve replacement. Of the patients reviewed by Karlson and associates [2], 34% had delayed rupture, and of these, only 11% survived. In the case of our patient, delayed rupture was successfully repaired in the ICU by placing sutures and then simply sticking a large Teflon felt patch over the bleeding area. In the literature, we found only one reference to the use of such an approach: a case of delayed rupture successfully repaired in the ICU with a hemostatic cellulose patch (Surgicel; Johnson & Johnson) stuck with fibrin glue [8].

In conclusion, a Teflon felt patch glued with Histoacryl can be used with success as a last resort to control the bleeding after left ventricular rupture.

	References

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1. Roberts W.C., Morrow A.G. Causes of early postoperative death following cardiac valve replacement. Clinico-pathologic correlations in 64 patients studied at necropsy. J Thorac Cardiovasc Surg 1967;54:422-437.[Medline]
2. Kalson K.J., Ashraf M.M., Berger R.L. Rupture of left ventricle following mitral valve replacement. Ann Thorac Surg 1988;46:590-597.[Abstract]
3. Katske G., Golding L.R., Tubbs R.R., Loop F.D. Posterior midventricular rupture after mitral valve replacement. Ann Thorac Surg 1979;27:130-132.[Abstract]
4. Treasure R.L., Rainer W.G., Strevey T.E., Sadler T.R. Intraoperative left ventricular rupture associated with mitral valve replacement. Chest 1974;66:511-514.[Abstract/Free Full Text]
5. Miller D.W., Jr, Johnson D.D., Ivey T.D. Does preservation of the posterior chordae tendinease enhance survival during mitral valve replacement?. Ann Thorac Surg 1979;28:22-27.[Abstract]
6. Björk V.O., Henze A., Rodriguez L. Left ventricular rupture as a complication of mitral valve replacement: surgical experience with eight cases and review of the literature. J Thorac Cardiovasc Surg 1977;73:14-22.[Abstract]
7. Azariades M., Lennox S.C. Rupture of the posterior wall of the left ventricle after mitral valve replacement: etiological and technical considerations. Ann Thorac Surg 1988;46:491-494.[Abstract]
8. Otaki M., Kitamura N. Left ventricular rupture following mitral valve replacement. Chest 1993;104:1431-1435.[Abstract/Free Full Text]

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