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Ann Thorac Surg 2001;71:201-204
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Surgical strategy for left ventricular free wall rupture after acute myocardial infarction

^a Department of Cardiac Surgery, Kinki University School of Medicine, Osaka, Japan

Accepted for publication July 15, 2000.

Address reprint requests to Dr Iemura, Department of Cardiac Surgery, Kinki University School of Medicine, 377-2, Ohno-Higashi, Osaka-Sayama, Osaka 589-8511, Japan
e-mail: singe{at}med.kindai.ac.jp

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Left ventricular free wall rupture is usually fatal without surgical intervention. However, the most appropriate surgical procedure remains controversial.

Methods. Seventeen patients (14 men, 3 women) who developed left ventricular free wall rupture after acute myocardial infarction were treated surgically. Their mean age was 65.4 years (range, 55 to 79 years). The following surgical procedures were performed: infarctectomy and patch reconstruction in 1 patient, direct closure with or without patch covering in 4 patients, simple patch covering anchored by running suture in 4 patients, and a sutureless technique in 7 patients. Endventricular patch closure was performed in 1 patient with ventricular septal perforation.

Results. One of 3 patients with a blow-out type rupture and 1 of 13 patients with an oozing type rupture died shortly after operation. The overall surgical mortality rate was 11.8%.

Conclusions. Selection of the optimal procedure for each cardiac condition is important for obtaining good results. For patients with ongoing squirting bleeding, patch covering is the technique of choice. For oozing, the sutureless technique is preferable.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Left ventricular free wall rupture (LVFWR) is recognized as the second most lethal complication after myocardial infarction (AMI) [1, 2]. Under these conditions, emergency surgery is usually the only available treatment. However, which surgical procedure should be performed remains controversial. We report our surgical experience and the outcome, and discuss the optimal surgical procedure for each type of bleeding.

	Material and methods

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Patients
Between July 1989 and March 2000, 17 patients (14 men, 3 women) were treated surgically for LVFWR after AMI at our institute. They ranged in age from 55 to 79 years (mean age, 65.4 ± 7.5 years). Only 2 patients had experienced a prior myocardial infarction (MI). Fourteen patients (82%) were treated with thrombolytic agents or direct percutaneous transarterial coronary angioplasty (PTCA) before rupture. Ventricular rupture was diagnosed by echocardiography in 13 patients, by pericardial puncture in 1 patients, during catheterization in 1 patient, and was noticed at the time of operation in 1 patient. In the remaining patient, blow-out bleeding occurred just after pericardiotomy during operation. The period between development of MI and diagnosis of rupture was within 24 hours in 11 patients, within 48 hours in 3 patients, within 3 days in 1 patient, and within 6 days in 1 patient. Onset of rupture was unknown in 1 patient. Most patients developed rupture within 48 hours after AMI and underwent emergency operation on the day of diagnosis. The preoperative condition was shock including arrest in 7 patients, severe low cardiac output syndrome (LOS) in 4 patients, and relatively stable under inotropic support or drainage in 6 patients (Table 1). The rupture was localized in the anterior wall in 9 patients, anteroapical in 3 patients, lateral in 2 patients, posterolateral in 2 patients, and posteroapical in 1 patient (Table 2).

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Two patients (11.8%) died of severe LOS shortly after operation. One patient with a blow-out rupture could not be weaned from the cardiopulmonary bypass, whereas for the other patient the sutureless technique was applied for oozing after left main trunk occlusion. Neither recovered from severe heart failure and died 2 days and 4 days, respectively, after operation. The overall survival rates for patients with blow-out type ruptures and those with subacute or oozing type ruptures were 67% and 92%, respectively.

There were no left ventricular pseudoaneurysms detected by echocardiography performed in all surviving patients before discharge from the hospital. Left ventriculography or left ventricular scintillation scanning was performed in 12 patients. Mean left ventricular ejection fraction (LVEF) was 35.6% ± 16.7% (range, 10% to 63%). Postoperative left ventricular function was influenced by the severity of MI, and not by surgical procedure. One patient died of pneumonia after recurrent MI, 1 year 7 months after operation. This patient had a LVEF on only 17% after infarctectomy and patch repair and was repeatedly admitted for chronic heart failure.

None of the surviving patients showed neurologic deficit despite critical preoperative conditions such as arrest or shock in 7 patients (2 patients could not be evaluated because of early death).

Between January 1989 and March 2000, 760 patients who developed AMI within 24 hours were admitted to our coronary care unit and treated by cardiologists. Their clinical courses are shown in Figure 1. Twenty-four patients (3.2%) developed LVFWR, 12 of whom could be transferred immediately to the operating room (excluding 5 patients who suffered a previous rupture in another hospital, from 17 patients who underwent operation in this report).

View larger version (32K): [in this window] [in a new window]   Fig 1. Frequency of left ventricular free wall rupture (LVFWR) after acute myocardial infarction (AMI) and clinical course from January 1989 to March 2000. *Excluding 5 patients (pts.) who previously developed rupture before being brought to the coronary care unit (CCU) from another hospital.

	Comment

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Surgical procedures for this condition have shown advanced recently. In the conventional approach, infarctectomy is followed by replacement using a prosthetic patch or direct closure under cardiopulmonary bypass [6, 7]. Left ventricular free wall rupture can be treated more conservatively by direct mattress suture buttressed with Teflon felt with or without cardiopulmonary bypass [7–9]. In both techniques, the suture line must be along the nonischemic area and transmural stitches are required, resulting in further deterioration of left ventricular function due to damage to the nonischemic myocardium. Furthermore, if the sutures are placed in the necrotic myocardium, tearing could occur, particularly in the posterior wall of the left ventricle. Nunez and colleagues [10] reported the application of a patch covering the area of infarction and anchored to normal myocardium with continuous running sutures. Because the anchoring sutures are placed only in the epicardium and shallow surface of the myocardium, myocardial damage by this technique is minimal. More recently, sutureless techniques using fibrin glue and collagen hemostats with the patch have been developed with some degree of success [11]. However, fixing the patch with running sutures appears to be effective against bleeding and is more likely to prevent rerupture than sutureless techniques.

When bleeding is just oozing and the patient’s condition does not require cardiopulmonary bypass support, the sutureless technique is possible and feasible. Good control of hemorrhaging was achieved in all patients who underwent this procedure. However, there is a caution associated with the sutureless technique. If reoperation for coronary artery bypass grafting needs to be performed, identification and exposure of the coronary artery might be difficult due to the widely and deeply piled collagen hemostats.

Intraaortic balloon pump support was applied postoperatively in 15 patients. Even in the absence of hemodynamic instability or electrocardiographic changes, we now routinely use intraaortic balloon pump several days after operation to reduce afterload and left ventricular wall stress (Table 2). We believe it is useful to avoid rerupture especially when the sutureless technique is performed.

We obtained satisfactory results with surgical treatment using optimal techniques for each bleeding situation (Table 2). However, 12 patients died before operation. Some of these patients might have been saved with prompt institution of percutaneous cardiopulmonary support and pericardial drainage when acute hemodynamic deterioration occurred. This would have allowed for maintenance of acceptable hemodynamics until emergency surgery could be performed.

In conclusion, using patch covering anchored by running sutures (with or without direct closure) for patients with ongoing massive bleeding and using sutureless techniques for those with an oozing rupture, we were able to treat most patients successfully in cases in which they did not develop lethal wide MI and could be sent to the operating room before falling into an irreversible cardiac condition or coma.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Pollak H., Nobis H., Mlczoch J. Frequency of left ventricular free wall rupture complicating acute myocardial infarction since the advent of thrombosis. Am J Cardiol 1994;74:184-186.[Medline]
2. Reddy S.G., Robert W.C. Frequency of rupture of the left ventricular free wall of ventricular septum among necropsy cases of fatal acute myocardial infarction since introduction of coronary care units. Am J Cardiol 1989;63:906-911.[Medline]
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6. Anagnostopoulos E., Beutler S., Levett J.M., et al. Myocardial rupture/major left ventricular rupture treated by infarctectomy. JAMA 1977;238:2715-2716.[Abstract]
7. Zeebregts C.J., Noyez L., Hensens A.G., et al. Surgical repair of subacute left ventricular free wall rupture. J Cardiac Surg 1997;12:416-419.[Medline]
8. Stiegel M., Zimmern S.H., Robicsek F. Left ventricular rupture following coronary occlusion treated by streptokinase infusion: successful surgical repair. Ann Thorac Surg 1987;44:412-415.
9. Chemnitius J.M., Schmidt T., Wojcik J., et al. Successful surgical management of left ventricular free wall rupture in the course of myocardial infarction. Eur J Cardiothorac Surg 1991;5:51-55.[Abstract]
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Iemura, J. Articles by Kaneda, T. Search for Related Content PubMed PubMed Citation Articles by Iemura, J. Articles by Kaneda, T. Related Collections Myocardial infarction