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Ann Thorac Surg 2008;85:1344-1346. doi:10.1016/j.athoracsur.2007.12.073
© 2008 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Surgical Treatment for Postinfarction Left Ventricular Free Wall Rupture

Genichi Sakaguchi, MD, PhD*, Tatsuhiko Komiya, MD, Nobushige Tamura, MD, PhD, Taira Kobayashi, MD

Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki City, Okayama, Japan

Accepted for publication December 31, 2007.

* Address correspondence to Dr Sakaguchi, Department of Cardiovascular Surgery, Kurashiki Central Hospital, Miwa, Kurashiki City, Okayama, 710-8602, Japan (Email: gs8722{at}kchnet.or.jp).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Left ventricular (LV) free wall rupture is a catastrophic complication after acute myocardial infarction. The optimal therapeutic strategy is controversial and the midterm results are unknown.

Methods: Between June 1993 and May 2006, 32 patients with an average age of 73 years (range, from 55 to 96 years) were surgically treated for LV free wall rupture. Sutureless technique (gluing autologous patch to the tear) was applied in all patients.

Results: The interval between acute myocardial infarction and the rupture was 33 ± 42 hours and the interval between the rupture and the operation was 3.6 ± 2.6 hours. Preoperatively, cardiopulmonary resuscitation was performed in eight cases. Percutaneous cardiopulmonary support was placed in six cases and intraaortic balloon pumping in 20 cases preoperatively. The in-hospital mortality was 15.6%. Two patients died of rerupture within ten days. While there was no rerupture during the follow-up period, five patients developed dyskinetic LV aneurysm and one patient developed LV pseudoaneurysm.

Conclusions: The sutureless technique is a simple and effective option for the surgical treatment for LV free wall rupture. The preoperative moribund condition was highly associated with the operative mortality.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Left ventricular free wall rupture (LVFWR) is one of the most lethal complications after acute myocardial infarction (AMI), occurring in up to 2% of patients with AMI [1, 2]. The course of rupture varies from a catastrophic blow-out type to a subacute oozing type; however, most of the patients die shortly after rupture. Prompt diagnosis and management can lead to successful surgical treatment for LVFWR. Recently, a sutureless technique using a pericardial patch secured to the infarct area with surgical glue has been reported with improved clinical results [3–5]; however, little is known of the clinical results of this technique because of the limited number of cases in the previous reports. We report 32 consecutive cases of LVFWR and the early and midterm results.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
The Institutional Review Board of Kurashiki Central Hospital approved this study and waived the individual consent because this study was retrospective. Between June 1993 and May 2006, 44 patients were diagnosed with LVFWR in our hospital. Among the 44 patients, 12 patients were refused the surgery because of unsuccessful cardiopulmonary resuscitation and all of them died. The remaining 32 patients, with an average age of 73 years (range, 55 to 96 years) were surgically treated for LVFWR on an emergent basis. Fifteen patients were men and 17 women.

Surgical Technique
The surgical protocol was essentially the same throughout the series. Six patients were on percutaneous cardiopulmonary support (PCPS) before and during the operation. In the other 26 patients, the operation could be performed without cardiopulmonary bypass. The heart was exposed by median sternotomy.

An autologous pericardial patch (approximately 5 x 7 cm) was anchored to the heart surface by means of gelatin resorcin formaldehyde (GRF) glue. Active bleeding from the infarct area was noticed in 13 patients. Hemostasis was achieved by the sutureless technique alone in nine patients and by 4-0 polypropylene (Prolene; Ethicon, Somerville, NJ) sutures with two supporting Teflon pledgets (DuPont, Wilmington, DE) in addition to patch glue repair in four patients (blow-out type). Coronary artery bypass grafts (CABG) were performed in three patients.

Follow-Up
We examined the patients at our outpatient clinic or contacted the patients for follow-up. The follow-up was completed in all patients with a mean follow-up of 29 ± 13 months.

Serial echocardiographic study was undertaken at our outpatient clinic.

Statistical Analysis
Continuous variables were presented as means with standard deviations. Actuarial survival was calculated by the Kaplan-Meier method with StatView for Windows version 5.0 (SAS Institute Inc, Cary, NC).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
The interval between AMI and LVFWR was 33 ± 42 hours and the interval between LVFWR and the operation was 3.6 ± 2.6 hours. Eleven patients received percutaneous coronary intervention before LVFWR. Three-vessel disease was present in 2 cases, two-vessel disease in 8 cases, and single-vessel disease in 22 cases. Culprit coronary artery was as follows: left anterior descending artery in 17 cases, left circumflex artery in 10 cases, and right coronary artery in 5 cases. All patients presented cardiogenic shock due to cardiac tamponade and LV failure. Blood pressure when first treated was 59 ± 14 mm Hg. Preoperatively, cardiopulmonary resuscitation was performed in 8 cases. The PCPS was placed in 6 cases and intraaortic balloon pumping in 20 cases to stabilize hemodynamic condition. Six patients required percutaneous pericardial drainage prior to the operation because of cardiac tamponade. In-hospital mortality was 15.6 % (5 cases). Two of them were the blow-out type of LVFWR (50%). Two patients died of severe heart failure and one patient died of cerebral infarction. Two patients died of rerupture one day and ten days, respectively, after operation. One patient was reoperated for subsequent LV septal rupture three days after LVFWR. Follow-up echocardiography revealed dyskinetic LV aneurysm in five patients and LV pseudoaneurysm in one patient. One patient with the apical aneurysm underwent endoventricular circular patch plasty nine months after LVFWR and one patient with the pseudoaneurysm underwent the surgical resection two years after LVFWR. Figure 1 shows actuarial survival. Five-year survival was 74%. The hazard for death was highest within the first 30 days. During the follow-up, one patient died of myocardial infarction and two patients died of cerebral infarction. Three patients underwent percutaneous coronary intervention.


Figure 1
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  		Fig 1. Actuarial survival.

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
The course of LVFWR varies from catastrophic blow-out type to oozing type. Survival depends on the early diagnosis, hemodynamic stabilization of the patients, and prompt surgical repair. The aim of an emergent operation for LVFWR is to rescue the patients at risk of death by bleeding and cardiac tamponade.

Various types of surgical techniques for LVFWR have been advocated. The conventional approach, including infarctectomy followed by replacement using a prosthetic patch, or direct closure under cardiopulmonary bypass as well as a direct mattress suture buttressed with Teflon (DuPont) felt [6, 7], is sometimes indicated, especially in the cases with blow-out type of LVFWR; however, those techniques are still challenging because the sutures should be tied through friable necrotic muscle. Furthermore, use of cardiopulmonary bypass seems disadvantageous because systemic heparinization can aggravate an oozing type of bleeding from the infarct area. Padro and colleagues [3] reported excellent results with the sutureless technique by which a large patch of Teflon was glued on the pericardium. Furthermore, use of other types of patch including Dacron and autologous pericardium, have been advocated for the sutureless technique [8, 9]. These less invasive and simpler techniques have shown satisfactory clinical results with lower operative mortality; however, the patient populations in those reports were relatively small. We reported here our experience of 32 unselected, consecutive patients using a sutureless technique and our clinical outcome was as good as reported previously. Recently, we have been using the TachoComb (TachoComb, CSL Behring, Tokyo, Japan) sheet combined with the sutureless technique. This collagen fleece is coated with fibrin glue that contains fibrinogen, thrombin, and aprotinin, and hemostasis can be easily achieved by using TachoComb without additional sutures. Before gluing autologous pericardial patch on the infarct area, the tear was covered with it to achieve hemostasis. Muto and colleagues [10] reported that TachoComb itself was an effective and safe option for dealing with the oozing type of LVFWR.

There were two cases with rerupture of the LV free wall and one case with LV septal rupture within ten days after the initial LVFWR. These cases were oozing types of LVFWR, which were repaired only by gluing pericardial patches. Even after the infarct area was covered with a pericardial patch, there still existed risk for LVFWR in acute phase. In addition, a LV pseudoaneurysm developed in one patient. This patient underwent surgical resection of the pseudoaneurysm two years after the initial LVFWR operation. The outer layer of the pseudoaneurysm consisted mainly of the pericardial patch and there was a small hole between the LV cavity and the pseudoaneurysm (Fig 2). It is speculated that the pericardial patch prevented rerupture, resulting in the formation of LV pseudoaneurysm. Gelatin resorcin formaldehyde glue has been reported to cause redissection or pseudoaneurysm because of the toxic effect of its formalin component when it is used for the reapproximation of the dissected aortic layers in the surgery for acute aortic dissection [11–13]. However, it is unknown whether the cytotoxic effect of GRF can also cause LV pseudoaneurysm if it is applied on the necrotic infarct area of LV. Other types of glue can be applied instead of GRF. Fibrin glues are not as strong as GRF but have complete biocompatibility. Bioglue (biological bovine serum albumin and glutaraldehyde glue) is also useful [14]; however, it is not commercially available in Japan.


Figure 2
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  		Fig 2. Enhanced computed tomography of a LV pseudoaneurysm. There was a small hole between the LV cavity and the pseudoaneurysm (arrow). (An = pseudoaneurysm; LV = left ventricle; RV = right ventricle.)

 
Although the clinical results of this technique were satisfactory, 12 patients were refused surgery because of unsuccessful resuscitation and died. Those patients could have been saved with prompt institution of PCPS and pericardial drainage when acute hemodynamic deterioration occurred, especially in cases with blow-out type of LVFWR.

In conclusion, although there are some situations in which a more invasive approach is required, this simple and safe technique is promising in most cases. Prompt diagnosis and management is essential for successful surgical treatment for LVFWR.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Becker RC, Gore JM, Lambrew C, et al. A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction J Am Coll Cardiol 1996;27:1321-1326.[Abstract]
  2. Nishiyama K, Okino S, Andou J, Nakagawa Y, Kimura T, Nobuyoshi M. Coronary angioplasty reduces free wall rupture and improves mortality and morbidity of acute myocardial infarction J Invasive Cardiol 2004;16:554-560.[Medline]
  3. Padro JM, Mesa JM, Silvestre J, et al. Subacute cardiac rupture: repair with a sutureless technique Ann Thorac Surg 1993;55:20-23.[Abstract]
  4. Canovas SJ, Lim E, Dalmau MJ, et al. Medterm clinical and echocardiographic results with patch glue repair of left ventricular free wall rupture Circulation 2003;108(suppl 1):II237-II240.[Medline]
  5. Lachapelle K, deVarennes B, Ergina PL, Cecere R. Sutureless patch technique for postinfarction left ventricular rupture Ann Thorac Surg 2002;74:96-101.[Abstract/Free Full Text]
  6. Anagnostopoulos E, Beutler S, Levett JM, Lawrence JM, Lin CY, Replogle RL. Myocardial rupture. Major left ventricular rupture treated by infarctectomy. JAMA 1997;238:2715-2716.
  7. Stiegel M, Zimmern SH, Robisek F. Left ventricular rupture following coronary occlusion treated by streptokinase infusion: successful surgical repair Ann Thorac Surg 1987;44:413-415.[Abstract]
  8. Iemura J, Oku H, Otaki M, Kitayama H, Inoue T, Kaneda T. Surgical strategy for left ventricular free wall rupture after acute myocardial infarction Ann Thorac Surg 2001;71:201-204.[Abstract/Free Full Text]
  9. Pretre R, Benedikt P, Turina MI. Experience with postinfarction left ventricular free wall rupture Ann Thorac Surg 2000;69:1342-1345.[Abstract/Free Full Text]
  10. Muto A, Nishibe T, Kondo Y, Sato M, Yamashita M, Ando M. Sutureless repair with TachoComb sheets for oozing type postinfarction cardiac rupture Ann Thorac Surg 2005;79:2143-2145.[Abstract/Free Full Text]
  11. Bingley JA, Gardner MA, Stafford EG, et al. Late complications of tissue glues in aortic surgery Ann Thorac Surg 2000;69:1764-1768.[Abstract/Free Full Text]
  12. Kazui T, Washiyama N, Bashar AHM, et al. Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortic root Ann Thorac Surg 2001;72:509-514.[Abstract/Free Full Text]
  13. Ennker J, Ennker IC, Schoon D, et al. The impact of gelatin-resorcinol glue on aortic tissue: a histomorphologic evaluation J Vasc Surg 1994;20:34-43.[Medline]
  14. Alamanni F, Fumero A, Parolari A, et al. Sutureless double-patch-and-glue technique for repair of subacute left ventricular wall rupture after myocardial infarction J Thorac Cardiovasc Surg 2001;122:836-837.[Free Full Text]

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