ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Toshiya Nishibe
Motomi Ando
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Muto, A.
Right arrow Articles by Ando, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Muto, A.
Right arrow Articles by Ando, M.
Related Collections
Right arrow Myocardial infarction

Ann Thorac Surg 2005;79:2143-2145
© 2005 The Society of Thoracic Surgeons

Case report

Sutureless Repair With TachoComb Sheets for Oozing Type Postinfarction Cardiac Rupture

Akihito Muto, MD*, Toshiya Nishibe, MD, Yuka Kondo, MD, Masato Sato, MD, Mituru Yamashita, MD, Motomi Ando, MD

Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Fujita Health University, Toyoake, Japan

Accepted for publication December 2, 2003.

* Address reprint requests to Dr Muto, Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Fujita Health University, 1-98, Dengakugakubo, Kutukake, Toyoake, Aichi 470-1192, Japan (E-mail: akiyann6108{at}yahoo.co.jp).


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Left ventricular free-wall rupture is a well recognized complication of myocardial infarction and a frequent cause of death. The appropriate surgical management varies significantly depending on the condition of the tear and the presence of concomitant lesions. We present a case of oozing type postinfarction cardiac rupture that was treated successfully by a sutureless patch technique using a fibrin tissue-adhesive collagen fleece (TachoComb [Torii Pharmaceutical, Tokyo, Japan]). This represents a quick, effective, and safe option for dealing with oozing type myocardial rupture due to myocardial infarction.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
Left ventricular free-wall rupture is a well recognized complication of myocardial infarction and a frequent cause of death [1]. However the most appropriate surgical management remains controversial, because the experience of any surgeon or surgical group tends to be quite small. We present a case of oozing type postinfarction cardiac rupture treated by a sutureless patch technique using a fibrin tissue-adhesive collagen fleece (TachoComb [Torii Pharmaceutical, Tokyo, Japan]).

A 78-year-old man visited his local hospital with acute onset chest pain and syncope. The electrocardiographic findings indicated lateral wall myocardial infarction. There was no history of angina pectoris or myocardial infarction. The chest radiograph was unremarkable. The echocardiography showed hypokinetic areas in the lateral wall of the left ventricle. The serum troponin-T level was high, and acute lateral wall myocardial infarction was diagnosed. Thrombolysis was undertaken by intravenous administration of recombinant tissue-type plasminogen activator. The patient went into shock several hours after thrombolysis. He was then transferred to the coronary care unit at our university hospital. On arrival he was found to have tachycardia with a blood pressure of 50/30 mm Hg. Echocardiography revealed moderate pericardial effusion. Coronary angiography revealed no obstruction or stenosis of the coronary arteries. Inotropic support as well as intraaortic balloon pumping was started, which improved his hemodynamic indices. Three days later while he was being weaned from an intraaortic balloon pump, he suddenly went into shock with a systolic blood pressure of 50 mm Hg. Echocardiography revealed a marked increase in pericardial effusion. Then he was immediately taken to the operating room with suspected rupture of the left ventricular wall. The pericardium was promptly opened through a standard median sternotomy. A large amount of blood was removed, which immediately improved his hemodynamic indices. A large myocardial infarction in the lateral aspect from the base to the apex was seen with free-wall oozing type bleeding. Under dry conditions, a 40 x 25 mm piece of TachoComb was positioned on the area and was pressed to the surface of the working ventricle for 5 minutes (Fig 1). This was repeated three times after which no bleeding was observed. The chest was closed and drained in the usual manner. A cardiopulmonary bypass was not instituted during the procedure. The operating time was 53 minutes.



View larger version (110K):
[in this window]
[in a new window]
  		Fig 1. Operative findings. Three pieces of TachoComb (Torii Pharmaceutical, Tokyo, Japan) were positioned on the oozing area, and no bleeding was observed.

 
The patient was transferred to the intensive care unit in stable hemodynamic condition with inotropic support and an intraaortic balloon pump. His operative course was uneventful. He was extubated 5 hours after surgery. The intraaortic balloon pump and inotropic support were stopped on postoperative days 1 and 2, respectively. He was discharged on postoperative day 13. By the 15-month follow-up, he had already resumed his daily life without limitations. The follow-up echocardiography showed slight hypokinetic areas in the lateral wall of the left ventricle, but it did not show another complication, extent of damages, or absence of a false aneurysm (Fig 2).



View larger version (45K):
[in this window]
[in a new window]
  		Fig 2. The area of the rupture (arrows) at the 15-month follow-up echocardiography did not show complications, extent of damages, or absence of a false aneurysm.

 

   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Myocardial rupture reportedly complicates 4% to 24% of cases with acute myocardial infarction, accounting for 12% to 21% of deaths after acute myocardial infarction [1]. The characteristics of these cases with myocardial rupture included patients who were 60 years or older, were female, had preexisting hypertension, and had their first myocardial infarction [1, 2]. Myocardial rupture generally occurs 1 to 7 days after myocardial infarction. The most common site of the rupture is the anterior or lateral wall of the left ventricle, in a midventricular position along the axis from the base to the apex [2].

The objective of surgical treatment is to save the patient’s life by relief of cardiac tamponade and closure of the ventricular defect. Various techniques for ventricular closure have been described to date, with the most appropriate technique generally depending on the state of the tear and presence of concomitant lesions. The conventional approach includes myocardiectomy of infarct followed by replacement using a prosthetic patch or direct closure under cardiopulmonary bypass as well as a direct mattress suture buttressed with Teflon felt with or without cardiopulmonary bypass [3, 4]. A sutureless technique may be feasible when bleeding is only oozing and the patient’s condition does not require cardiopulmonary bypass support. With the advent of tissue-adhesive materials, several authors have reported on a completely sutureless technique in which a patch of pericardium, Dacron, or Teflon is glued to the myocardium infarct, achieving good control of hemorrhage by avoiding issues related to myocardial friability and distortion [5–7]. Another distinct advantage is the potential to perform the procedure without cardiopulmonary bypass.

Several biological or synthetic glues have been used in sutureless techniques, including fibrin glues, gelatin-based glues, and cyanoacrylate. We used TachoComb, which is a ready-to-use collagen fleece coated with fibrin glue that contains fibrinogen, thrombin, and aprotinin, on the oozing myocardial rupture, thereby achieving complete hemostasis. An in vitro study previously showed that TachoComb provided reliable sealing and high adhesive strength [8]. The clinical efficacy of TachoComb in hemostasis has been established in surgery (both general and trauma); several studies have shown its usefulness in splenic trauma and in the hepatobiliary system, as well as in thoracic surgery.

The possible problems associated with a sutureless patch technique using TachoComb include the risk of recurrent rupture, pseudoaneurysm formation, and mitral valve regurgitation due to ischemic cardiomyopathy, as described by authors who have used other sutureless techniques [6, 7]. These authors suggest that an intraaortic balloon pump reduces afterload and left ventricular stress, thereby possibly reducing the likelihood of these complications.

We believe that the sutureless patch technique using TachoComb may be a possible surgical option to deal with oozing type myocardial ruptures due to myocardial infarction.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Reardon MJ, Carr CL, Diamond A, et al. Ischemic left ventricular free wall ruptureprediction, diagnosis, and treatment. Ann Thorac Surg 1997;64:1509-1513.[Abstract/Free Full Text]
  2. Batts KP, Ackermann DM, Edwards WD. Postinfarction rupture of the left ventricular free wallclinicopathologic correlates in 100 consecutive autopsy case. Hum Pathol 1990;21:530-535.[Medline]
  3. Angnostopoulos E, Beutler S, Levett JM, et al. Myocardial rupture/major left ventricular rupture treated by infarctectomy JAMA 1997;238:2715-2716.
  4. Stiegel M, Zimmern SH, Robisek F. Left ventricular rupture following coronary occulusion treated by streptokinase infusionsuccessful surgical repair. Ann Thorac Surg 1987;44:413-415.[Abstract]
  5. Prado JM, Mesa J, Silvestre J, et al. Subacute cardiac rupturerepair with a sutureless technique. Ann Thorac Surg 1993;55:20-24.[Abstract]
  6. Iemura J, Oku H, Otaki M, et al. Surgical strategy for left ventricular free wall rupture after acute myocardial infarction Ann Thorac Surg 2001;71:201-204.[Abstract/Free Full Text]
  7. Lechapelle K, de Varennes B, Ergina PL, Cecedo R. Sutureless patch technique for postinfarction left ventricular rupture Ann Thorac Surg 2002;74:96-101.[Abstract/Free Full Text]
  8. Carbon RT, Baar S, Kriegelstein S, Huemmer HP, Baar K, Simon SI. Evaluating the in vitro adhesive strength of biomaterials. Biosimulator for selective leak closure Biomaterials 2003;24:1469-1475.[Medline]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
G. Sakaguchi, T. Komiya, N. Tamura, and T. Kobayashi
Surgical Treatment for Postinfarction Left Ventricular Free Wall Rupture
Ann. Thorac. Surg., April 1, 2008; 85(4): 1344 - 1346.
[Abstract] [Full Text] [PDF]

Home page
 ICVTSHome page
K. Toda, M. Yoshitatsu, H. Izutani, and K. Ihara
Surgical management of penetrating cardiac injuries using a fibrin glue sheet
Interactive CardioVascular and Thoracic Surgery, August 1, 2007; 6(4): 577 - 578.
[Abstract] [Full Text] [PDF]

Home page
 ICVTSHome page
P. K. Mishra, V. Pathi, and A. Murday
Post myocardial infarction left ventricular free wall rupture
Interactive CardioVascular and Thoracic Surgery, February 1, 2007; 6(1): 39 - 42.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Toshiya Nishibe
Motomi Ando
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Muto, A.
Right arrow Articles by Ando, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Muto, A.
Right arrow Articles by Ando, M.
Related Collections
Right arrow Myocardial infarction

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS