Ann Thorac Surg 2004;77:1439-1441
© 2004 The Society of Thoracic Surgeons
Case report
Endoventricular pocket repair of type I myocardial rupture after mitral valve replacement: a new technique using pericardial patch, Teflon felt, and BioGlue
Saqib Masroor, MDa,b,
John Schor, MDa,
Roger Carrillo, MDa,
Donald B. Williams, MDa*
a Mount Sinai Medical Center, Miami Beach, Florida, USA
b University of Miami/Jackson Memorial Hospital, Miami Beach, Florida, USA
Accepted for publication April 14, 2003.
* Address reprint requests to Dr Williams, Thoracic and Cardiovascular Surgery, Mount Sinai Medical Center, 4300 Alton Rd, Miami Beach, FL 33140, USA.
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Abstract
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Left ventricular (LV) rupture is an infrequent but potentially lethal complication of mitral valve replacement and repair. We report the case of an 82-year-old man who underwent mitral valve replacement and the repair of an atrial septal defect. Both valve leaflets were excised and the annulus was extensively decalcified, followed by the implantation of a bioprosthetic valve. LV rupture was diagnosed after weaning from cardiopulmonary bypass (CPB). CPB was resumed and the bioprosthetic valve was removed. The patient then underwent a unique repair using a pericardial patch, Teflon felt (Meadox Medical Inc, Oakland, NJ), and BioGlue (CryoLife Inc, Kennesaw, GA). A second valve was implanted with a successful outcome.
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Introduction
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Left ventricular (LV) rupture is a known complication of mitral valve replacement with an incidence of 1.2% and a mortality rate of up to 75% [1]. These injuries have been classified on the basis of their location into three types [2]: type I ruptures are located in the posterior atrioventricular groove, type II in the posterior ventricle at the base of the papillary muscle, and type III in the area between the first two types.
Different methods of repair have been recommended for acute ruptures, including external [3] and internal patch repair [4, 5]. This is a case report of an 82-year-old man with an acute type I ventricular rupture after mitral valve replacement. We describe the technique of endoventricular repair with a "pocket" of bovine pericardium, Teflon felt (Meadox Medical Inc, Oakland, NJ), and BioGlue (CryoLife Inc, Kennesaw, GA).
An 82-year-old man with hypertension and atrial fibrillation underwent mitral valve replacement and the repair of an atrial septal defect (ASD) using standard cardiopulmonary bypass (CPB) and retrograde cold crystalloid cardioplegia. The mitral valve annulus was severely calcified, especially posteriorly, requiring the excision of both leaflets. Careful decalcification of the annulus was then performed, and a 31-mm porcine valve was implanted. The ASD was repaired by right atriotomy. The patient was weaned from CPB uneventfully. After protamine administration, bright red blood was found leaking from the posterior atrioventricular groove.
CPB was resumed and the valve prosthesis was excised. There was a 1-cm tear on the ventricular side of the posteromedial part of the annulus (Fig 1).
A bovine pericardial patch was sewn over this area extending from the ventricular side of the tear out to the atriotomy. A pocket was thus created that was open at the atriotomy. Into this pocket a piece of Teflon felt saturated in BioGlue was inserted such that the felt lay over the ventricular tear (Figs 2, 3).
More BioGlue was poured into the pocket, and gentle pressure was applied to conform the pericardium-felt-BioGlue complex into the shape of the annulus while the BioGlue was congealing. A 35-mm porcine bioprosthesis was then sutured into place (Fig 4). The open pocket along the atrial suture line was closed with a running 4-0 Prolene suture (Ethicon Inc, Somerville, NJ) along with the atriotomy. The procedure was then completed uneventfully, and the patient was taken to the intensive care unit for postoperative care.
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Fig 1. Mitral annulus as seen after the excision of the implanted valve, showing the location of the left ventricular tear just beyond the atrioventricular (AV) groove. (LV = left ventricle; LA = left atrium.)
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Fig 2. Pericardial patch has been sewn, thus creating a pocket into which the Teflon felt patch (Meadox Medical Inc, Oakland, NJ) is introduced. (LV = left ventricle; LA = left atrium.)
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Fig 3. Cross-section through the atrioventricular groove at the repair site. The valve stitches go through the pericardial pocket. (Teflon felt: Meadox Medical Inc, Oakland, NJ; BioGlue: CryoLife Inc, Kennesaw, GA.)
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The patient was extubated the next day and except for third-degree heart block requiring a permanent pacer, he made an uneventful recovery. He was discharged on the ninth postoperative day.
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Comment
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First described in 1967 [6], LV rupture is a dreaded complication of mitral valve surgical procedures with a mortality rate of up to 75% [1]. Risk factors for type I injuries have included female sex, advanced age, mitral stenosis, small left ventricle, and small body size. Intraoperative factors include excessive stretching due to an oversized prosthesis or vigorous retraction and the radical excision of the posterior leaflet, particularly an extensively calcified leaflet [1, 5]. We routinely preserve the posterior leaflet, except in cases such as this with heavy calcification of the posterior annulus.
In the literature, both external and internal patch repairs of LV ruptures have been advocated [1, 3–5]. Karlson and colleagues [1] reviewed 125 cases of types I to III ruptures and reported survival rates of 67% and 27% for external and internal repairs, respectively. When CPB was not used, the survival rate was a dismal 7%. Also, the survival rate after type I ruptures was worse than that after type II or III ruptures.
We have reported the repair of a type I ventricular rupture using an endoventricular "pocket" of bovine pericardium, Teflon felt, and BioGlue. The use of Teflon felt and glue has been reported as an external repair only [3]. An aim of a good repair should be to rebuild a firm atrioventricular continuity that is able to withstand the shearing forces of ventricular contractions. We believe that the internal repair we have described, although longer and more technically challenging than an external repair, gives the best possible chance of accomplishing this aim. This technique is especially useful in older people with friable myocardia that do not hold sutures strongly.
In conclusion, LV ruptures occur now with less frequency than 15 years ago. When they do occur, they are still associated with a high mortality rate. We suggest that the above-described technique be recognized as a new strategy in the treatment of this most challenging and life-threatening complication.
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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]
- Treasure R.L., Rainer W.G., Sadler T.R. Intraoperative left ventricular rupture associated with mitral valve replacement. Chest 1974;66:511-514.[Abstract/Free Full Text]
- De La Fuente A., Agudo O., Sanchez R., Fernandez 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]
- Arena V., Alamanni F., Repossini A., Matteo S.D., Antona C., Biglioli P. Straddling endoventricular pericardial patch in prevention of type I myocardial rupture. Ann Thorac Surg 1993;56:163-165.[Abstract]
- Celemin D., Nunez L., Gil-Aguado M., Larrea J.L. Intraventricular patch repair of left ventricular rupture following mitral valve replacement: new technique. Ann Thorac Surg 1982;33:638-641.[Medline]
- Roberts W.C., Morrow A.G. Causes of early postoperative death following cardiac valve replacement: clinico-pathologic correlations in 64 patients studied at necropsy. J Thorac Cardiovasc Surg 1967;54(3):422-437.[Medline]
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Abstract
Introduction
