Ann Thorac Surg 2002;74:2194-2195
© 2002 The Society of Thoracic Surgeons
Case report
Use of intraaortic balloon pump in left ventricle rupture after mitral valve replacement
Qamar Abid, FRCS, CTha*,
Podila Sitarama Rao, FECTSa,
Simon W.H. Kendall, FRCS, CTha
a Department of Cardiothoracic Surgery, The James Cook University Hospital, Middlesbrough, United Kingdom
Accepted for publication June 20, 2002.
* Address reprint requests to Mr Abid, Department of Cardiothoracic Surgery, Victoria Hospital Blackpool, Whinny Heys Rd, Blackpool FY3 8NZ, United Kingdom.
e-mail: quamarabid{at}hotmail.com
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Abstract
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Over 6 years of a single surgeon experience, 3 patients had left ventricle rupture following mitral valve replacement, despite preserving the posterior leaflet. The valve was re-replaced on bypass in all patients. Intraaortic balloon pump was inserted electively before coming off bypass. There were no intraoperative deaths, reexploration, or excessive bleeding. An intraaortic balloon pump is an ideal adjuvant to left ventricle repair for ruptured ventricle following mitral valve replacement on cardiopulmonary bypass.
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Introduction
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Left ventricle rupture following mitral valve replacement is a major, frequently lethal, complication of mitral valve replacement. The incidence of ruptures varies from 0.5% to 14% with an average mortality as high as 65% [1]. The initial defect may be only a partial thickness defect, but the force of the left ventricular pressure and distension can extend the tear through the entire thickness of the myocardial wall. To avoid pressure load, the general consensus is that repair should be accomplished with the aid of cardiopulmonary bypass on a decompressed heart [2]. However, the same problem exists after coming off bypass. The left ventricle pressure invariably increases in the beating heart producing excessive tension on the suture line leading to often-fatal hemorrhage.
Afterload reduction in these critical situations will be beneficial to avoid tension on the left ventricle repair. This, in turn, helps the friable, edematous tissue to heal. Intraaortic balloon pump (IABP) is a well-known mechanical device used for decreasing afterload and increasing myocardial perfusion in cardiogenic shock [3]. We report its beneficial use in left ventricular rupture following mitral valve replacement.
Between 1994 to 2000, 163 patients underwent mitral valve surgery carried out by one surgical team. Three patients had left ventricle rupture following surgery (1.84%). The mean age was 61 years (43, 67, and 73 years) and all were women.
Two patients had significant calcification, involving both anterior and posterior mitral leaflets, and required excessive decalcification. Posterior mitral leaflet was preserved in all patients while 1 patients also had preserved anterior leaflet. All patients had bilealet mechanical valve with different sizes, ie, 25 (1 patient) and 29 (2 patients). The mean ischemic time was 118 minutes (59 + 70, 33 + 55, 86 + 53 minutes) with bypass time of 176 minutes (195, 48 + 95, 192 minutes).
In 2 patients, the rupture was noticed just after coming off bypass, prior to giving protamine, as bright red blood pouring out from the back of the heart. In 1 patient, it presented in the intensive care unit soon after return from the operating theater. To identify the exact site of the rupture, cardiopulmonary bypass was reinstituted in 1 patient, while the others were already cannulated and ready for bypass. The heart was arrested by using St. Thomas cold crystalloid cardioplegia in all cases, along with continuous cold circuit to protect the myocardium. The valve was excised and the exact site of the tear was identified as a defect along the posterior atrioventricular sulcus (type 1 rupture). The tear was repaired by pledgeted stitches, also incorporating the valve (Figs 1 and 2).
The valve was re-replaced with a smaller size in 2 patients (size 27 instead of 29), whereas the same valve was reimplanted in 1 patient (size 25).
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Fig 1. Repair of type 1 left ventricle rupture with pledgeted stitches incorporating the tear and mitral leaflet.
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Fig 2. Diagramatic representation of the repair with pledgeted stitches incorporating the tear and mitral leaflet.
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Percutaneous IABP was inserted, electively, in all 3 patients through the femoral artery before coming off bypass. All of these patients also needed a small amount of inodilator (dobutamine between 3–5 µg/kg).
All patients survived the acute catastrophic situation and were moved to the intensive care unit. None of these patients had any bleeding problem postrepair. One IABP ruptured on postoperative day 4 and was removed with difficulty. This patient had an unrecognized massive retroperitoneal hematoma leading to hemodynamic instability. She underwent surgical exploration and repair of the femoral artery. This patient subsequently developed sepsis, which led to multiorgan failure and death on the 11th postoperative day. One patient developed minor left hemiplegia, but had recovered fully within a month.
Both the surviving patients are enjoying good quality of life at 1 year and 5 years post-left ventricle repair. There is no evidence of pseudoaneurysm in either of these patients on follow-up echocardiogram.
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Comment
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Since its introduction in early 1960s [4], the IABP has become the most widely applied method in circulatory support. Bavaria and associates [5], in their animal studies, have proven a statistically significant reduction in left ventricle peak pressure and left ventricle end diastolic pressure with the use of IABP. Marks and colleagues [6] have similar observations with significant reduction in left ventricle peak pressure.
Our experience and successful outcome of the left ventricle repairs support the importance of afterload reduction in this situation. Although 1 of our patients died with sepsis and multiorgan failure, the left ventricle repair remained intact without any hemorrhagic problem. IABP should be inserted electively before coming off bypass. This will decrease the afterload and help to prevent excessive build up of intraventricular pressure. This, in turn, will decrease the tension along the repaired suture line and avoid the stitches cutting through the edematous and friable myocardium. All of our patients survived the acute catastrophic situation as compared with the immediate high mortality reported in the literature [1, 8].
Cobbs and coworkers [7] emphasized the importance of preservation of the supporting structures of the posterior ventricular wall, ie, the attached chordae and the posterior leaflet of the mitral valve. In our experience, despite preservation of the posterior mitral leaflet with attached chordae, left ventricle ruptures still occurred.
Although the number of cases are small to reach any definite conclusions, our experience suggests that the left ventricle rupture can occasionally occur despite taking all the precautions, and preserving the posterior mitral leaflet and its attachment. An IABP is an ideal adjuvant to left ventricle rupture repair, after mitral valve replacement, to avoid excessive tension on the suture line.
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Acknowledgments
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The authors appreciate the excellent illustrations by David Crawford.
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References
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- Katske G, Golding LR, Tubbs DO, Loop FD. Posterior mid ventricular rupture after mitral valve replacement. Ann Thorac Surg 1979;27:130–2
- Karlson K.J., Ashraf M.M., Burger L.R. Rupture of left ventricle following mitral valve replacement. Ann Thorac Surg 1988;46:590-597.[Abstract/Free Full Text]
- Kantrowitz A., Tjonneland S., Freed P.S., Phillips S.J., Butner A.N., Sherman J.L., Jr Initial experience with intraaortic balloon pumping in cardiogenic shock. JAMA 1968;203:135-140.
- Weber K.T., Janicki J.S. Intra-aortic balloon counterpulsation—a review of physiological principles, clinical results and device safety. Ann Thorac Surg 1974;17:249-254.
- Bavaria J.E., Furukawa S., Kreiner G., et al. Effect of circulatory assist devices on stunned myocardium. Ann Thorac Surg 1990;49:123-128.[Abstract/Free Full Text]
- Marks J.D., Pantalos G.M., Long J.W., et al. Myocardial mechanics, energetics and hemodynamics during intraaortic balloon and transvalvular axial flow hemopump support with a bovine model of ischaemic cardiac dysfunction. ASAIO J 1999;45:602-609.[Medline]
- Cobbs BW Jr, Hatcher CR Jr, Craver JM, et al. Transverse midventricular disruption after mitral valve replacement. Am Heart J 1980;99:33–50
- Dark J.H., Bain W.H. Rupture of posterior wall of left ventricle after mitral valve replacement. Thorax 1984;39:905-911.[Abstract/Free Full Text]
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Abstract
Introduction
