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Original Articles: Adult Cardiac

Invited Commentary

Department of Cardiovascular Surgery, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oi 879-5593, Japan

(Email: smiyamot{at}med.oita-u.ac.jp).

Montegut [1] reported the first surgically treated survivor from left ventricular rupture associated with ischemic heart disease in 1972. Since then several different surgical techniques have been proposed. However, the most appropriate surgical procedure remains controversial because each report has a limited number of cases and various strategies were applied from individual to individual. This report is significant in presenting a series of 32 patients treated with almost the same procedure [2]. We are likely to see fewer excisions of infarct segments [3] and a shift toward the sutureless technique using glue because of its simplicity, effectiveness, and avoidance of myocardial friability issues. Re-ruptures occurring from oozing ruptures raise the question of using additional sutures. Although high adhesive glue can provide reliable sealing for this type of rupture [4], an additional running suture using the technique minimizing myocardial damage as described by Nunez and colleagues [5] will make re-rupture less likely [6]. With excellent devises for off-pump coronary artery bypass grafting (CABG) and heparin-less percutaneous cardiopulmonary support, we no longer worry about increasing the risk of rupture or hemodynamic instability during suturing. Synthetic glue has an advantage in comparison with fibrin glue in strength [7, 8], but it is important to minimize its dose of formaldehyde when gelatin resorcin formaldehyde glue is applied. TachoComb (Nycomed, Linz, Austria) should be used as the first line of defense to achieve hemostasis, followed by the glue and patch technique described in this article. The glue and patch technique leaves open the possible development of dyskinetic left ventricular aneurysm or pseudoaneurysm [9], but careful follow-up can indicate the timing for intervention to avoid losing patients by catastrophic event. Concomitant CABG is a controversial option, too. Fortunately, as left ventricular rupture tends to occur with single-vessel disease, as shown in this series [2], CABG to another lesion is seldom required. Simultaneous CABG might be preferred, considering the difficulty of exposure of coronary arteries due to the wide and deep pile of collagen left after use of the sutureless technique [4]. However, because most lesions can be treated intraluminally afterward and because even off-pump CABG requires heparinization, surgical revascularization should be limited to cases in which critical other lesion exist and steady hemostasis is obtained.

This effective and easy patch technique, used off pump, opens the operating room door a little wider for any patient after cardiopulmonary resuscitation. Walking through that door offers the uncertain chance of health restored or vegetative state, the quandary we must face now.

	References

Top References

 

1. Montegut FJ. Left ventricular rupture secondary to myocardial infarction Ann Thorac Surg 1972;14:75-78.[Medline]
2. Sakaguchi G, Komiya T, Tamura N, Kobayashi T. Surgical treatment for postinfarction left ventricular free wall rupture Ann Thorac Surg 2008;85:1344-1347.[Abstract/Free Full Text]
3. Stiegel M, Zimmern SH, Robicsek F. Left ventricular rupture following coronary occlusion treated by streptokinase infusion: successful surgical repair Ann Thorac Surg 1987;44:413-415.[Abstract]
4. 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]
5. Nunez L, dela Llana R, Lopez Sendon J, et al. Diagnosis and treatment of subacute free wall ventricular rupture after infarction Ann Thorac Surg 1983;35:525-529.[Abstract]
6. Okada K, Yamashita T, Matsumori M, et al. Surgical treatment for rupture of left ventricular free wall after acute myocardial infarction Interact CardioVasc Thorac Surg 2005;4:203-206.[Abstract/Free Full Text]
7. 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]
8. Amano H, Ohara K, Nie M, et al. New surgical technique of left ventricular free wall rupture; double patch sealing method Ann Thorac Cardiovasc Surg 2002;8:389-392.[Medline]
9. Hoffmann RT, Nikolau K, Boekstegers P, et al. Minimally invasive repair of a left ventricular pseudoaneurysm after surgical patch reconstruction of an infarct-related free posterior wall rupture: CT-guided intervention Cardiovasc Intervent Radiol 2007;30:1010-1012.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Shinji Miyamoto Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Miyamoto, S. Search for Related Content PubMed PubMed Citation Articles by Miyamoto, S. Related Collections Myocardial infarction Related Article