Ann Thorac Surg 2004;77:1070-1072
© 2004 The Society of Thoracic Surgeons
Case report
Left ventricular rupture after mitral surgery: repair by patch and sealing
Roland Fasol, MDa*,
Thomas Wild, MDb,
Salah El Dsoki, MDc
a Department of Cardiovascular Surgery, Hospital Lainz, Austria
b Department of Surgery, University of Vienna, Vienna, Austria
Accepted for publication April 1, 2003.
* Address reprint requests to Dr Fasol, International "Innovative Medical Care" Center, Krustettnerstrasse, A-3506 Krems/Hollenburg, Austria
e-mail: rfasol{at}imc-hospital.com
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Abstract
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Ventricular wall rupture after mitral valve replacement is an infrequent but dreaded complication. We have experienced this problem in two separate instances of type III left ventricular rupture and report the successful repair by a novel technique with the use of a new sealant, the AdvaSeal (FocalSeal), in a sandwitch repair procedure.
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Introduction
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Left ventricular rupture is a dreaded complication of mitral valve replacement. There is a controversial discussion regarding the ethiology of this fatal incidence, and various surgical intraoperative as well as predisposing factors have been investigated [1]. Depending on the site and location of rupture, this complication is classified as type I (posterior atrioventricular groove), type II (posterior wall of the left ventricle at the base of the papillary muscle), and type III (area between atrioventricular groove and papillary muscles) [2]. Furthermore, some authors introduced the additional classification by time patterns: early, delayed, and late rupture [3]. In larger series, the incidence of this complication averaged 1.2%, and surgical repair of the rupture with and without cardiopulmonary bypass (CPB) resulted in a 50% and 7% survival, respectively [2]. With the use of cardiopulmonary bypass, external repair was followed by a reported 67% survival, and the internal approach by a 27% survival [2].
We present two separate instances of successful treatment of early type III left ventricular rupture by sealing the site of rupture with the combination of a Teflon patch suture and the bioresorbable polymer-sealant AdvaSea(FocalSeal, Focal Inc, Lexington, MA). AdvaSeal is a polyethylene, glycol-based synthetic hydrogel that has been designed to seal air leaks associated with lung surgery and has received the CE Mark and is approved in the European Union.
Our experience consists of two such complications among 121 mitral patients in the last year, the incidence being 1.6%.
Two patients, 75- and 74-year-old women, underwent elective mitral valve replacement for rheumatic mitral stenosis. In both, after achieving cardiac arrest, the interatrial groove was incised and the right atrium dissected. With the left atrial roof exposed, the left atrial incision was carried out close to the mitral valve. A self-retaining retractor was used to expose the mitral valve. In both patients, a severely calcified valve and annulus was found. The calcified valve was excised, but two islands of tissue with the attached underlying chordae tendineae were spared. For the preservation of both, the anterior and posterior mitral subvalvular apparatus, these islands of leaflet tissue were sutured into the annulus using the pledget-reinforced sutures to implant the valve, using mattress sutures with pledgets on the ventricular side. In both patients, a porcine pericardial bioprosthesis (Carpentier-Edward, sizes 27 and 29) was implanted in the usual fashion. There were no complications during the procedure, and in both patients, bypass was terminated without further problems.
However, shortly after termination of CPB, massive bleeding occured, and in both patients, an extensive epicardial hematoma and a type III left ventricular rupture was detected. After instant reinstitution of extracorporeal circulation to relieve the strain of the pressure-loaded beating heart, the left atrial incision was reopened. After cross-clamping the aorta, the mitral bioposthesis was removed to allow careful localization of the site of rupture. Sutures were placed through Teflon patches and the ventricular myocardium at the site of rupture, carefully avoiding the circumflex artery (Figs 1, 2). The mitral bioprosthesis was reimplanted. This was followed by applying the liquid primer at the site of the ventricular rupture that penetrates into the crevices of the tissue, and then the sealant is applied. Both are exposed to a standard wavelength of visible light from a xenon arc lamp, and in 40 seconds, polymerize and change from liquid to a solid gel (photopolymerization). Then, the sutures placed through the Teflon patches were slightly knotted, avoiding a cut through the friable myocardium. This repair was finished after applying a second layer of the two components of AdvaSeal and the subsequent photopolymerization (Fig 2). The solid gel formed after the light has been applied is highly flexible, elastic, and transparent, and strongly adheres to moist or dry tissue.
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Fig 1. Intraoperative view into the left atrium showing the mitral prosthesis and the sutures placed through the Teflon patch and the ventricular myocardium at the site of rupture, carefully avoiding the circumflex artery. Inset shows the application of the two components of the sealant.
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Fig 2. Schematic drawing of a type III left ventricular rupture (arrow), showing the mitral annulus, the atrium, and ventricle, sketching the ventricular wall (VW) the Teflon-patched sutures (P), and the application of the components of AdvaSeal (S) for this sandwich repair procedure. (cx = circumflex artery.)
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After this sandwich repair procedure, both patients could be weaned off CPB without further complications, and both were taken to the intensive care unit in good condition. The postoperative courses were uneventful. Ventricular function was normal at echocardiography on postoperative day 10 in both patients, and both were regularly discharged from the hospital.
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Comment
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We are not the first to attempt the repair of left ventricular rupture complicating mitral valve replacement. A greater number of such cases are described in literature [1–4]. Most authors described their technique of suture. However, in the literature, we found only two references to the use of glue for the repair of left ventricular rupture, one using histoacryl glue [3] and the other fibrin glue [4]. However, there is a fast-growing market of numerous indications using all different kinds of glues in medicine and surgery, but some may even destroy the underlying tissues, like the gelatin-resorcine-formaline (GRF) biological glue, and may have carcinogenic effects [5]. Furthermore, most of the currently available glues are not effective under wet conditions. Fibrin glue, however, can be used under wet conditions, but its adhesiveness is unsatisfactory for repair of ventricular rupture.
To apply the biocompatible hydrogel sealant AdvaSeal, a bioabsorbable hydrogel that is effective also on wet tissue and biocompatible, is a novel approach to successfully repairing left ventricular rupture. However, AdvaSeal is designed to seal air leaks associated with lung surgery. Ranger and associates, among others, reported that AdvaSeal could effectively seal significant pulmonary air leaks [6]. Furthermore, it has been reported that this sealant was able to effectively seal vessel puncture sites and anastomotic junctions without augmenting thrombogenicity [7]. It therefore seems evident, because AdvaSeal adheres to tissue as a result of a proprietary two-step priming and sealing process and results in a highly flexible, elastic, and transparent gel formed after photopolymerization, to apply this technique of sealing also to blood leaks subsequent to left ventricular rupture after mitral valve replacement.
Preservation of both the anterior and posterior mitral subvalvular apparatus in mitral valve replacement surgery was demonstrated to play an important role in preserving left ventricular regional wall motion and global left ventricular function. However, a dreaded complication of mitral valve surgery, such as myocardial rupture, may be prevented by maintaining the tethering effect of the intact subvalvular apparatus, although myocardial rupture was not prevented in our 2 patients.
In conclusion, our novel approach of sealing left ventricular rupture using AdvaSeal in combination with Teflon patches and sutures in a sandwitch repair procedure allows successful repair of this type of otherwise fatal complications after mitral valve replacement.
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References
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- Karlson K.J., Ashraf M.M., Berger R.L. Rupture of left ventricle following mitral valve replacement. Ann Thorac Surg 1988;46:590-597.[Abstract]
- Bjork V.O., Henze A., Rodriguez L. Left ventricular rupture as a complication of mitral valve replacement. J Thorac Cardiovasc Surg 1977;73:14-22.[Abstract]
- Fuente A., Agudo O., Sánchez R., Fernández J.L., Moriones I. Repair of left ventricular rupture after mitral valve replacement: use of a Teflon patch and glue. Ann Thorac Surg 1999;67:1802-1803.[Abstract/Free Full Text]
- Otaki M., Kitamura N. Left ventricular rupture following mitral valve replacement. Chest 1993;104:1431-1435.[Abstract/Free Full Text]
- Kerns W.D., Pavkov K.L., Donofrio D.J., Gralla E.J., Swenberg J.A. Carcinogenicity of formaldehyde in rats and mice after long-term inhalation exposure. Cancer Res 1983;43:4382-4392.[Abstract/Free Full Text]
- Ranger W.R., Halpin D., Sawhney A.S., Lyman M., LoCicero J. Pneumostasis of experimental air leaks with a new photopolymerized synthetic tissue sealant. Am Surgeon 1997;63:788-795.[Medline]
- Dumanian G.A., dascombe W., Hong C. A new photopolymerizable blood vessel glue that seals human vessel anastomoses without augmenting thrombogenicity. Plast Reconstr Surg 1995;95:901-907.[Medline]
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Abstract
Introduction
