[Successful Treatment of Blow-out Type Left Ventricular Free Wall Rupture Using Sutureless Technique].

Blow-out type left ventricular free wall rupture is a serious complication of acute myocardial infarction, that carries high hospital mortality rates and poor surgical outcome. We report the case of an 88-year-old woman who developed cardiac tamponade following percutaneous coronary angioplasty for acute myocardial infarction. She was diagnosed with left ventricular free wall rupture, and rupture type was proved to be blow out after median sternotomy. To address this critical condition, we opted for the sutureless technique for its minimally invasive nature and ability to preserve left ventricular function. The patient was discharged from the hospital without any complications 22 days after surgery. Considering favorable, encouraging outcomes of this case, sutureless technique could be regarded as a viable option for blow-out type left ventricular free wall rupture.

[Successful Staged Repair of Double Rupture after Acute Myocardial Infarction:Report of a Case].

Double rupture is a very rare, and life-threatening complication after acute myocardial infection (AMI), which defined as the coexistence of any two of the three types of rupture include left ventricular free wall repture (LVFWR), ventricular septal perforation (VSP) and papillary muscule repture (PMR). We report here a case of successful staged repair of double rupture combined LVFWR and VSP. A 77-year-old woman with diagnosis of AMI in the anteroseptal area fell into cardiogenic shock suddenly just before starting coronary angiography. Echocardiography showed left ventricular free wall rupture, then an emergent operation was performed under intraaortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) assistance using bovine pericardial patch and felt sandwich technique. Intraoperative transesophageal echocardiography revealed ventricular septal perforation on the apical anterior wall. Her hemodynamic condition was stable, therefore we selected a staged VSP repair to avoid surgery on freshly infarcted myocardium. Twenty-eight days after the initial operation, VSP repair was performed using the extended sandwich patch technique via right ventricle incision. Postoperative echocardiography revealed no residual shunt.

[Left Ventricular Rupture after Mitral Valve Replacement].

Ventricular rupture after mitral valve surgery is rare but a serious complication associated with high mortality rate. Of the 2,338 patients who underwent mitral valve surgery, 8 patients (0.7%) suffered from left ventricular rupture in our institution. All developed left ventricular rupture after mitral valve replacement and 3 patients( 37.5%) died within 30 days. To prevent left ventricular rupture, preservation of the mitral loop, appropriate valve sizing, and perioperative hemodynamic management to unload ventricular pressure are needed. Surgical repair for left ventricular rupture should be performed under cardiac arrest. Combination of external approach and endoventricular repair is recommended but epicardial tissue sealing may be an only option for patients with friable ventricular muscles and undetermined location of ruptured site. Use of intraaortic balloon pumping (IABP), percutaneous cardiopulmonary support (PCPS) and Impella are also important technique to unload left ventricular pressure and to maintain systemic hemodynamics.

Acute aortic regurgitation due to fibrous strand rupture.

A 60-year-old male presented with sudden onset chest pain and pulmonary edema. The investigation confirmed torrential aortic regurgitation of a bicuspid valve. At surgery, a ruptured fibrous strand was identified which had been supporting the left-right cusp commissure with loss of attachment to the aortic wall. This case demonstrates that fibrous strands may be present as a supporting structure of the aortic valve, and rupture can be a rare cause of torrential aortic regurgitation, similar in pathogenesis to how it may be associated with acute severe mitral regurgitation and chordae tendineae rupture.

Left ventricular free wall rupture: A real nightmare.

Left ventricular free wall rupture (LVFWR) is a rarest but often lethal mechanical complication of acute myocardial infarction (AMI). The mortality rate for LVFWR is described from 75% to 90% and it is the cause for 20% of in-hospital deaths after AMI. Death results essentially from the limited time available for emergent intervention after onset of symptoms. Emergency surgery is indicated and normally the rupture site is easily identified, but it may not be apparent macroscopically, corresponding to transmyocardial or subepicardial dissection with an external rupture far from the infarction site, or already thrombosed and contained. Repair of the ventricular wall is usually achieved either by suturing the edges of the tear or closing it with patches of artificial material or biological tissues, usually using some kind of biological glue. However, several cases of successful conservative management have been described. In this Editorial, I comment on the metanalysis conducted by Matteucci et al, published in this issue of the Journal, including 11 nonrandomized studies and enrolling a total of 363 patients, which brings a great deal of new knowledge that can help not only in the prevention but also in the management of this dreadful complication of AMI.

Outcomes of emergency or urgent mitral valve repair in patients with papillary muscle rupture and active infective endocarditis.

BACKGROUND: Emergency or urgent surgery is often required in patients with papillary muscle rupture and active mitral valve infective endocarditis. The aim of this study was to analyze the outcomes of patients with active endocarditis who underwent emergency or urgent mitral valve repair. METHODS: From 2005 to 2014, 154 ischemic mitral regurgitation patients and 41 infective endocarditis patients underwent mitral valve repair in our institution; 23 had emergency operations due to papillary muscle rupture, and 18 with active infective endocarditis underwent urgent surgery. RESULTS: Cardiopulmonary bypass time (141.4 ± 43.3 versus 145.3 ± 46.5 min) and crossclamp time (77.7 ± 34.1 versus 79.2 ± 33.0 min) were similar in the papillary muscle rupture and elective ischemic mitral regurgitation subgroups, and major postoperative complications were comparable. Hospital mortality was 17.4% in the papillary muscle rupture subgroup and 8.4% in the elective ischemic mitral regurgitation subgroup. Cardiopulmonary bypass time (103.6 ± 37.0 versus 75.5 ± 20.8 min) and crossclamp time (61.7 ± 21.2 versus 45.3 ± 18.0 min) were significantly longer in infective endocarditis patients. There were no major complications or hospital deaths. Eight years postoperatively, overall survival was 94.4% and 86.5% in the papillary muscle rupture and elective ischemic mitral regurgitation subgroups, respectively (p = 0.730). Overall survival was 100% in both infective endocarditis subgroups. CONCLUSION: The feasibility and effectiveness of emergency or urgent mitral valve repair in patients with papillary muscle rupture and active infective endocarditis are satisfactory. Early and mid-term outcomes are comparable to those of elective operations.

Myocardial infarction-related left ventricular rupture with the tear across the ventricular wall detected on echocardiography.

A 79-year-old man underwent repair surgery for a left ventricular free wall rupture after an acute myocardial infarction. The surgical procedure followed for ventricular rupture was according to the rupture type. The patient showed slowly oozing bleeding through small holes. Epicardial echocardiography detected the color signals that crossed the left ventricular wall. Two channels were directly connected from the ventricular cavity to the epicardial hole. Although the bleeding hole was covered with collagen hemostats using a sutureless technique, the bleeding remained, probably because of the pressure exerted by the left ventricle on the channels connected to the epicardial hole. The suture closure technique might be better in cases with channels across the ventricular wall, as detected on echocardiography. We describe a case of left ventricular rupture followed by acute myocardial infarction in which the channel connected to the ruptured ventricular tear was detected on epicardial echocardiography.

Sutureless repair of spontaneous coronary dissection with free wall rupture and cardiac tamponade.

Left ventricular free wall rupture is a feared complication of acute myocardial infarction typically presenting with cardiogenic shock. We present a case of spontaneous coronary artery dissection with free wall rupture and cardiac tamponade in an uncommon demographic. Friable myocardial tissue frequently precludes suture technique making biological glue repair a suitable option.

Modified Cabrol Shunt for Atrioventricular Groove Rupture After Mitral Valve Replacement.

Rupture of the atrioventricular (AV) groove is the Achilles' heel of mitral valve replacement, and it has been associated with high rates of mortality. Here, we report successful management of a type 1 AV groove disruption using a modified Cabrol shunt to the right atrium in a patient with a severely calcified mitral annulus.

[Surgical Treatment for Myocardial Rerupture after Repair of Post Infarction Left Ventricular Free Wall Rupture].

A 73-year-old man was admitted for cardiac tamponade by oozing type left ventricular free wall rupture associated with acute myocardial infarction. Transthoracic echocardiography demonstrated moderate pericardial effusion and the presence of pseudoaneurysm within posterior wall. He went into shock with a systolic blood pressure of 60 mmHg. After introducing percutaneous cardiopulmonary support and intraaortic balloon pump, the sutureless repair was performed immediately. After having rehabilitation for right-sided hemiparesis, an elective pseudoaneurysm repair was planned. While a waiting an operation, 7 weeks later, he went into shock again with chest pain. Echocardiography and computed tomography demonstrated much amount of pericardial bloody effusion on the posterior aspect and 1.5 cm defect on the pseudoaneurysm wall. Emergently a patch closure with a bovine pericardium was performed using cardiopulmonary bypass under ventricular fibrillation through a left thoracotomy. Postoperative course was uneventful.

[Surgical Repair for Blunt Cardiac Rupture].

Blunt cardiac injury is a life-threatening condition. We report 3 successful cases in which we performed surgery for blunt cardiac injury. Three individuals were injured, 2 in traffic accidents and the other being caught between a crane and a steel frame. Echocardiograms and computed tomography scans revealed pooling of bloody pericardial fluid in all 3 patients, who underwent emergency surgery. Two patients needed sutures to control persistent bleeding. Although a heart-lung machine was prepared at the start of surgery in all 3 cases, we did not need to use it for any patient. Thus, prior to performing such surgery, it is necessary to ascertain its need.

Concealed resuscitation-related injuries as reversible cause of recurrent arrest following extracorporeal cardiopulmonary resuscitation.

A life-threatening cardiopulmonary resuscitation (CPR)-related injury can cause recurrent arrest after return of circulation. Such injuries are difficult to identify during resuscitation, and their contribution to failed resuscitation can be missed given the limitations of conventional CPR. Extracorporeal cardiopulmonary resuscitation (ECPR), increasingly being considered for selected patients with potentially reversible etiology of arrest, may identify previously occult CPR-related injuries by restoring arterial pressure and flow. Herein, we describe two cases of severe CPR-related injuries contributing to recurrent arrest. Each case had ECPR implemented within 60 minutes of the start of CPR. After the presumed cardiac etiology had been addressed with percutaneous coronary intervention, life-threatening cardiovascular injuries with recurrent arrest were noted, and resuscitative thoracotomy was performed under ECPR. One patient survived to hospital discharge. ECPR may provide an opportunity to identify and correct severe resuscitation-related injuries causing recurrent arrest. Chest compression depth >6 cm, especially in older women, may contribute to these injuries.

Successful Operative Repair of Delayed Left Ventricle Rupture From Blunt Trauma.

A 21-year-old female was found to have an enlarging pericardial effusion 10 days after a 40-foot fall. Initial cardiac evaluation was negative. Ten days after presentation she developed hemodynamic compromise and chest computed tomography was concerning for cardiac rupture. The patient was taken to the operating room where the ruptured posterior ventricle was repaired, perforation in the P1 leaflet was identified and the mitral valve was replaced. The patient survived. To our knowledge, this is the first report of survival after delayed presentation of atrioventricular rupture at the level of the mitral valve.

Echocardiography and Cardiac Rupture: Is Contrast Extravasation an Indication for Surgery?

Contrast echocardiography demonstrating microbubbles in the pericardial space has often been cited as evidence of ventricular rupture requiring emergent surgical intervention. We report a case where no myocardial perforation was found during post-myocardial infarction surgery despite prior echocardiographic evidence of contrast extravasation into the pericardial effusion. Clinical decision making requires balancing imaging evidence with clinical circumstances to determine the optimal timing for surgical intervention.