Ann Thorac Surg 2000;69:1959-1960
© 2000 The Society of Thoracic Surgeons
How to do it
Pericardial hood repair of cardiac rupture secondary to extended myocardial infarction
Hiroshi Imagawa, MDa,
Susumu Nakano, MDa,
Haruhiko Akagi, MDa,
Akihiko Yagura, MDa,
Tsuyoshi Fujita, MDa
a Division of Cardiovascular Surgery, Rinku General Medical Center, Osaka, Japan
Address reprint requests to Dr Imagawa, Division of Cardiovascular Surgery, Rinku General Medical Center, 2-23, Rinku Orai Kita, Izumisano, Osaka, 598-0048, Japan
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Abstract
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A surgical technique for simple and safe repair of oozing-type postinfarction cardiac rupture secondary to extended myocardial infarction is described. A hood-shaped pericardium was glued with gelatin-resorcinol and formaldehyde glue to cover the extended oozing infarcted myocardium. This technique was used on 3 elderly patients with good results.
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Introduction
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There have been some reports of successful repairs of postinfarction cardiac rupture using medical adhesives and a patch [1, 2]. This technique may be effective if no anchoring stitches are required on the fragile infarcted myocardium. However, in a patient with widely extended fragile myocardium, it may be difficult to use this technique. Here we describe a technique to repair a postinfarction cardiac rupture with a hood-shaped pericadium.
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Technique
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The pericardium was opened through a midline sternotomy. The pericardial sac was full of blood, and gradual evacuation of the blood produced hemodynamic improvement. Epicardium of the anterolateral, apical, and inferior walls of the heart was hemorrhagic and showed evidence of an extensive myocardial infarction (Fig 1).
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Fig 1. Cardiac rupture secondary to extended myocardial infarction. Anterior, lateral, and inferior walls of left ventricle (LV) showed hemorrhagic epicardium and demonstrated dyskinetic wall motion. Oozing areas were found in anterolateral, apical, and inferior LV wall. (dotted area = extended infarcted myocardium; hatched area = oozing area).
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Faced with the difficulty of fitting a plain patch on a oozing area of the heart, a glutaraldehyde-fixed bovine pericardium (Tissueguard, 10 x 18 cm, Bio-Vascular, St. Paul, MN) was tailored into a hood-shape (Fig 2). The apex of the heart was raised, and polyepoxy-compound cross-linked collagen hemostat material (Integran, Koken, Tokyo, Japan) was attached to the oozing area with the fibrin sealants (Beriplast, Centeon, Marburg, Germany). Then the hood-shaped pericardium was glued with a small amount of gelatin-resorcinol formaldehyde (GRF) glue (Cardial, Saint-Etienne, France) to cover the extended infarcted myocardium (Fig 3). Surplus parts of the hood-shaped pericardium were transferred to the anterosuperior position of the heart, and the pericardium was fitted on the heart. No deterioration of hemodynamic status was observed during the procedure. Although the femoral vessels were punctured for the instantaneous cardiopulmonary bypass, the aid of the bypass was not necessary. After careful observation, no bleeding was found, and the chest was closed in the usual fashion.
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Fig 2. Bovine pericardial hood. Bovine pericardial patch (10 x 18 cm) was folded in two and cut, making a smooth convex curved line. It was sawed into a hood shape with a 4-0 monofilament suture.
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Fig 3. Application of the hood-shaped pericardium and medical adhesives. The hood-shaped pericardium was glued with gelatin, resorcinol, and formaldehyde (GRF) glue to cover the extended infarcted myocardium. (A) Frontal view. (B) Back view.
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Results
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The technique was applied to three patients (1 man, 2 women; age 71, 75, and 84 years) with oozing-type postinfarction cardiac rupture. The acute myocardial infarction in an anterior lesion was the first cardiac event in all 3 patients. Coronary angiography revealed the culprit was the proximal left anterior descending coronary artery, which was successfully recanalized by percutaneous transluminal coronary angioplasty in all patients. The postinfarction cardiac rupture occurred 24, 28, and 36 hours after percutaneous transluminal coronary angioplasty. The cardiac rupture was diagnosed by clinical features of shock and with a two-dimensional echocardiography.
No surgical reintervention was needed for bleeding. The postoperative course in all patients was uncomplicated. At 13, 21, and 24 months follow-up, all patients are in New York Heart Association class I or II.
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Comment
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Postinfarction cardiac rupture is usually a lethal event without surgical procedure [3]. Lillehei and colleagues [4] described in 1969 the first successful surgical repair of a myocardial rupture after an acute myocardial infarction. However, the literature shows a high mortality for this surgical treatment; infarctectomy that produces the extremely small left ventricular cavity or a patch sutured on an infarcted myocardium, which causes the catastrophic hemorrhage. Sutureless repair of postinfarction cardiac rupture with a patch taking advantage of medical adhesives has been previously reported [1, 2]. This maneuver produces no reduction of the left ventricle, nor does it require anchoring stitches on fragile postinfarction myocardium.
We adopted a hood-shaped bovine glutaraldehyde-stiffened pericardium to cover the infarcted myocardium, because the patient had wide anterolateral infarction extending even to the inferior wall. This shape was indispensable for covering all of the oozing areas. Moreover, bovine glutaraldehyde-stiffened pericardium is essential in this repair, because the pericardium is limp and can be fitted to the shape of the apex of the heart.
The hood-shaped pericardium was glued onto the infarcted pericardium using a small amount of GRF glue. The GRF glue was effective in bonding the pericardium as well as in controlling the oozing blood. Guilmet and associates [5] have reported the usefulness of the GRF glue in the operation for aortic dissections.
Collagen hemostat was also effective when glued on the oozing areas with a small amount of fibrin sealant to absorb the oozing blood, and it kept the field dry while the hood-shaped pericardium was glued on with the GRF glue. This polyepoxy-compound cross-linked cotton-type collagen hemostat is made of highly purified atelocollagen in a fine filament and has excellent blood absorption and hemostat ability. Excessive water on the adhesive field is obstructive for bonding with GRF glue.
Our report shows an available option when the patient has postinfarction cardiac rupture secondary to extended myocardial infarction.
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References
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Padró J.M., Mesa J.M., Silvestre J., et al. Subacute cardiac rupture. Ann Thorac Surg 1993;55:20-24.[Abstract]
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Zongo M., Canna Gla, Ceconi C., et al. Postinfarction left ventricular free wall rupture. J Cardiac Surg 1991;6:396-399.[Medline]
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Feneley M.P., Chang V.P., O’Rourke M.F. Myocardial rupture after acute myocardial infarction. Ten year review. Br Heart J 1983;49:550-556.[Abstract/Free Full Text]
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Lillehei C.W., Lande A.J., Rassman W.A. Surgical management of myocardial infarction. Circulation 1985;39/40(Suppl 4):315-339.
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Guilmet D., Bachet J., Goudot B., et al. Use of biological glue in acute aortic dissection. J Thorac Cardiovasc Surg 1979;77:516-521.[Abstract]
Accepted for publication December 31, 1999.
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Abstract
Introduction
