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Ann Thorac Surg 2002;74:96-101
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Sutureless patch technique for postinfarction left ventricular rupture

^a Division of Cardiac Surgery, McGill University Health Centre, Montreal, Quebec, Canada

Accepted for publication March 1, 2002.

* Address reprint requests to Dr Lachapelle, Royal Victoria Hospital, Suite S8.30, 687 Pine Ave West, Montreal, Quebec H3A 1A1, Canada
e-mail: kevin.lachapelle{at}mcgill.ca

	Abstract

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. Left ventricular free wall rupture is an uncommon but catastrophic event after myocardial infarction and is associated with a high mortality. After prompt diagnosis some patients may be salvaged with immediate surgical intervention. Surgical techniques used to seal the rupture vary, as few surgeons have experience with this pathologic process. We report our experience using a sutureless patch technique to treat this entity.

Methods. A review of 6 consecutive patients during an 8-year period who were referred to one cardiac unit with postinfarction left ventricular rupture was conducted.

Results. There were 3 men and 3 women with an average age of 71.8 years. All were hemodynamically unstable, and 4 were in electromechanical dissociation. Echocardiography confirmed the diagnosis in 5 patients, and cardiac catheterization had been performed in 4 before rupture. All patients were treated promptly with fluid, inotropic agents, and, if needed, cardiopulmonary resuscitation and pericardiocentesis. Resuscitation was continued in the operating room, and the myocardial tear was sealed with a generous patch of unsupported felt secured to the heart with cyanoacrylate glue. Coronary artery bypass grafting was performed in 3 patients if the anatomy was known. All patients survived to the intensive care unit. One death occurred as a result of severe neurologic injury. Five patients were discharged from the hospital, and all were alive 2 months to 7.5 years after operation.

Conclusions. A sutureless patch technique for the treatment of postinfarction rupture is simple, effective, and associated with a favorable outcome.

	Introduction

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Left ventricular (LV) free wall rupture occurs in 1% to 4% of patients after myocardial infarction [1, 2]. Despite the overall reduction in postinfarction mortality during the last 20 years, the rate of LV rupture has not changed over time and may account for up to 20% of all deaths from infarction [1–4]. Most patients die shortly after rupture, and mortality after surgical repair has traditionally been high [4]. It may be possible to identify patients at risk for ventricular rupture [5], and with the availability of echocardiography, prompt premortem diagnosis is feasible. Consequently, there are increasing reports in the literature of successful surgical repair [6–14]; yet, the most appropriate surgical management remains controversial because each surgeon’s experience treating this entity is low [15]. Padro and colleagues [16, 17] described a sutureless technique for the treatment of cardiac rupture using a patch of polytetrafluoroethylene (Teflon) secured to the heart with cyanoacrylate glue with no mortality in 13 patients. We have adopted a similar sutureless technique to treat postinfarction LV free wall rupture and report on our experience and follow-up.

	Patients and methods

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Six consecutive patients were referred to one cardiac center between January 1993 and June 2001 with postinfarction LV free wall rupture. The clinical characteristics of the patients are outlined in Table 1. The average age was 71.8 years, with 3 men and 3 women. No patient had a prior history of coronary artery disease. All but 1 (no. 2) had been treated with thrombolytic agents for a recent myocardial infarction, and all patients had a baseline echocardiogram performed after admission to the hospital. Cardiac catheterization was performed before rupture in 4 patients owing to persistent anginal symptoms. The diagnosis of ventricular rupture was confirmed with echocardiography in 5 patients after an acute episode of hemodynamic decompensation. In 1 patient, rupture was identified during the LV angiogram injection at the time of catheterization. A diagnostic angiogram was not performed nor attempted in the 2 patients with unknown coronary anatomy once the diagnosis of rupture was made. At the time of diagnosis, all patients were unstable and were treated with immediate fluid infusion, inotropic agents (epinephrine, norepinephrine), vasoconstrictors (phenylephrine), and, if needed, pericardiocentesis and cardiopulmonary resuscitation. Four patients eventually exhibited electromechanical dissociation during the course of the resuscitation or during transfer to the operating room.

View larger version (42K): [in this window] [in a new window]   Fig 1. Schematic drawing depicting a left ventricular free wall rupture located on the anterior surface.

View larger version (40K): [in this window] [in a new window]   Fig 2. Schematic drawing depicting the use of an elliptical piece of unsupported felt applied to the ventricular rupture and the surrounding infarct followed by administration of cyanoacrylate glue.

	Results

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Cardiovascular stability as well as hemostasis was achieved in all patients. There was one postoperative death (1 of 6) owing to severe neurologic injury in a patient who had prolonged cardiopulmonary resuscitation before operation (no. 5), and care was discontinued at the family’s request. Prolonged ventilator support (> 3 days) occurred in 2 patients, and 1 had a deep wound infection treated with a 2-week course of antibiotics and local debridement. All 5 remaining patients survived and were discharged from the hospital at 24, 14, 12, 8, and 10 days (nos. 1, 2, 3, 4, and 6, respectively). The 2 patients who did not have coronary grafting at the time of the procedure had no reversible myocardial ischemia as determined by a Dip-Mibi scan, which was performed before discharge. On the whole, ventricular function as determined echocardiographically appeared to be preserved after operation. At follow-up ranging from 2 months to 7.5 years, all 5 patients were alive, with 4 exhibiting New York Heart Association class I symptoms and 1 exhibiting New York Heart Association class II symptoms. This last patient had an ejection fraction of 25% before discharge from hospital.

	Comment

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We have reported our experience using a sutureless technique to repair postinfarction LV free wall rupture in 6 unselected, consecutive patients. Although no patient had a concomitant ventricular septal defect or papillary muscle rupture, the initial outcome and follow-up of this small cohort is favorable despite having 4 patients in electromechanical dissociation before operation and 3 patients actively bleeding.

Surgical treatment of ventricular rupture has varied over time and is often individualized depending on the state of the tear and the presence of concomitant lesions. Standard and accepted repair involves supporting the patient with cardiopulmonary bypass, performing an infarctectomy including the area of rupture, and reconstructing the ventricle with a patch of Teflon or polyethylene terephthalate fiber (Dacron) sutured directly to the myocardium [19]. This technique continues to be reported and advocated by some authors [9, 12, 14, 15], especially if the rupture is of the "blow-out" type [12, 14, 15] or associated with a septal defect [20], or there is acute mitral regurgitation secondary to papillary muscle rupture [12]. Others have tried to avoid removing necrotic myocardium and have treated these ruptures with an on-lay patch of Dacron, Teflon, or pericardium secured with a running Prolene suture (Ethicon, Somerville, NJ) to the epicardium or healthy myocardium [12–14, 21]. When the area of necrosis has been small, simple Prolene Teflon-buttressed sutures have been used without the need for cardiopulmonary bypass support [9, 12, 14]. We do not have experience with these types of sutured repairs in the acute setting, but some authors have raised concerns regarding the difficulty with sewing into fragile myocardial tissue [14] and the potential ventricular cavity distortion that may occur, especially after infarctectomy.

With the advent of tissue adhesives many authors advocate a completely sutureless technique [11, 14, 16, 17, 22] in which a patch of pericardium, Dacron, or Teflon is glued to the infarcted myocardium, thereby avoiding issues related to myocardial friability and distortion. Another distinct advantage is the potential to perform this type of repair without cardiopulmonary bypass. Adhesives reported to be successful in the treatment of ventricular rupture have been of several types and include the biologic glues (fibrin based or gelatin hydrogels) as well as the synthetic cyanoacrylate monomers.

Fibrin glues function by reproducing the normal clotting cascade and result in a stable fibrin matrix after the degradation of exogenous fibrinogen. The main advantage is their lack of toxicity and complete biocompatibility such that healing is not affected and the material is naturally degraded [23]. Gelatin-based glues have greater bonding strength than fibrin glues owing to polymerization of the gelatin-resorcin component when in contact with formaldehyde or glutaraldehyde. Although commonly used in aortic operation, gelatin-resorcin formaldehyde is cytotoxic owing to the release of formaldehyde during degradation, raising concerns regarding potential long-term complications [24]. The major limitation of both these biologic glues is that they are only effective in the absence of bleeding. Both have been used to treat selected patients with ventricular rupture but usually if the tear is sealed or is of the oozing type [11, 14, 22]. Consequently, some authors advocate tailoring the type of repair to the status of the tear at the time of operation and favor using a sutureless technique if the tear is only oozing or has sealed but a sutured approach for actively squirting lesions, fearing that the lack of sutures may result in rerupture in actively bleeding lesions [12, 14].

Synthetic glues such as cyanoacrylate are monomers that polymerize in an exothermic reaction when in contact with fluid. Although they are cytotoxic and potentially mutagenic, acetylation has greatly reduced these concerns [18]. Histoacryl (n-butyl-2 cyanoacrylate) has been used in Europe and Canada for closure of skin lacerations and as an embolic agent for control of bleeding varices [25]. Dermabond (2-octyl cyanoacrylate; Ethicon Inc), which forms a stronger but more pliable bond, is packaged and colored in a similar fashion to Histoacryl and is approved by the US Food and Drug Administration for closure of skin lacerations. In 1993, Padro and coworkers [17] reported a 100% survival rate among 13 patients treated with a totally sutureless technique obtained by securing a patch of Teflon onto the myocardium using Histoacryl. No patient underwent a preoperative cardiac catheterization, and only 1 patient was placed on cardiopulmonary bypass because of a posterior tear. Most patients appeared to have sealed the rupture by the time the operation was performed. Five-year follow-up also demonstrated excellent functional status with 100% survival.

We have adopted this sutureless technique and have used it on all patients regardless of the location of the tear, the size of the tear, or the acuity with which the patient presented. Even patients with actively bleeding lesions can be treated using this technique provided they are supported with cardiopulmonary bypass. Technical considerations believed to be important to ensure a solid hemostatic patch using this technique include the following: (1) an appropriately large patch must be applied so that it borders on healthy myocardium; (2) the patch must be completely colored blue by the glue; and (3) the patch must held in place for 1 to 2 minutes using cotton-tip applicators until it becomes hot and adherent. The patch does become hot and may potentially cause a thermal injury if overlying a coronary artery. This artery, however, is usually the source of the infarct and in general is not bypassed. The simplicity of the technique makes it easy to master regardless of surgical experience. Although we have not yet used this technique in patients with a concomitant ventricular septal defect or papillary muscle rupture it would certainly be possible to buttress the ventricular suture line when approaching a septal defect through the infarct, or in the case of a papillary rupture, close the rupture with a patch and then replace the mitral valve using a standard approach.

In our patients, hemostasis was achieved in all, and all were transferred to the intensive care unit with cardiac stability. Postoperative echocardiograms demonstrated that ventricular function was generally preserved after operation, suggesting that emergent repair with this technique can salvage the myocardium. One patient did progress to moderate mitral regurgitation but was New York Heart Association class I at 1 year follow-up. Although 4 of 6 patients were placed on bypass, the need for bypass should be individualized and depends on the hemodynamic state of the patient, the location of the tear, and whether an additional cardiac intervention is necessary. Some groups routinely insert an intraaortic balloon pump and this may stabilize the patient further and allow one to perform the procedure without bypass. In addition, counter-pulsation will reduce afterload and may reduce the potential of recurrent rupture. We inserted only two intraaortic balloon pumps in this group but believe this probably should be standard care in these patients. As with others we perform concomitant coronary artery bypass grafting only if the coronary anatomy is known and believe strongly that rapid and expedient operation to close the rupture is the main goal of surgery [15].

We believe that this sutureless technique for the treatment of LV free wall rupture is simple, versatile, and associated with a good outcome. We will continue to use it.

	Acknowledgments

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The technical assistance of Joclyn Prince is greatly appreciated. Mr David Rolling of the Audiovisual Department of the Royal Victoria Hospital made the drawings.

	Footnotes

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
This article has been selected for the open discussion forum on the CTSNet Web site: http://www.ctsnet.org/doc/5499

	References

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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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 Author home page(s): Kevin Lachapelle Patrick L. Ergina Renzo Cecere Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lachapelle, K. Articles by Cecere, R. Search for Related Content PubMed PubMed Citation Articles by Lachapelle, K. Articles by Cecere, R. Related Collections Myocardial infarction Related Article