[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.

[Elective Mitral Valve Repair for Acute Mitral Regurgitation Due to Anterior Papillary Muscle Rupture:Report of a Case].

An 83-year-old woman with congestive heart failure due to severe mitral regurgitation was referred to our department. Because acute coronary syndrome was suspected, the patient underwent emergent coronary artery angiography, which showed 75% stenosis of segment 2 and 90% stenosis of segment 11. Subsequently, segment 11 was treated by percutaneous coronary intervention. Additionally, transesophageal echocardiography findings showed a prolapse of P2 due to papillary muscle rupture. After management of heart failure, a scheduled operation was performed under the diagnosis of acute mitral regurgitation due to papillary muscle rupture. Intraoperative findings demonstrated a rupture of the anterior papillary muscle, prolapse of P2, and no evidence of infection. The patient underwent mitral valve repair with artificial chordae through median sternotomy. Her postoperative course was uneventful.

Transcatheter Mitral Valve Edge-to-Edge Repair with the New MitraClip XTR System for Acute Mitral Regurgitation Caused by Papillary Muscle Rupture.

Treatment of patients presenting with cardiogenic shock due to acute mitral regurgitation related to papillary muscle rupture poses significant challenges, owing to the high risk associated with conventional surgery. We hereby report successful transcatheter mitral valve edge-to-edge repair with the new Mitraclip XTR device (Abbott Vascular, Santa Clara, CA) in a patient with acute myocardial infarction and cardiogenic shock. Although surgical intervention remains the standard of care, the new MitraClip XTR system offers a novel treatment option for patients with papillary muscle rupture by overcoming the anatomic challenges often seen in this pathology.

Mitral valve surgery for acute papillary muscle rupture.

BACKGROUND: Papillary muscle rupture (PMR) is a rare complication of a myocardial infarction. The aim of this study was to review our results of mitral valve surgery for acute PMR. METHODS: Data from patients undergoing emergent mitral valve surgery for acute PMR between 2011 and 2017 at our institution were reviewed. Outcomes included operative morbidity and mortality, mitral valve reoperation, and hospital readmission. RESULTS: A total of 2479 patients underwent mitral valve surgery during the study period including 24 (1.0%) for PMR. Mean age was 62 years, and two (8.3%) patients had prior open-heart surgery. Overall Society of Thoracic Surgeons predicted risk of mortality was 17.5%. Operative mortality was 12.5% (n = 3) with an observed-to-expected mortality ratio of 0.71. There were no strokes, and new onset dialysis was required in two (8.3%) patients. Mean follow-up was 2.40 ± 1.96 years. Three-year mortality, mitral valve reoperation, and readmission rates were 21.1%, 5.0%, and 45.4%. CONCLUSIONS: Expeditious operative intervention for PMR can be associated with acceptable operative and longer-term outcomes.

Left ventricular pseudoaneurysm formation in a patient presenting with a subacute myocardial infarction.

Left ventricular pseudoaneurysm is a rare mechanical complication of acute myocardial infarction. In the present case, an 80-year-old man presenting with a subacute non-ST segment elevation myocardial infarction was found to have an occluded second obtuse marginal branch of the left circumflex coronary artery. Following the implantation of two drug-eluting stents, the patient developed no-reflow phenomenon. Coronary angiography 6 weeks later revealed persistence of the no-reflow phenomenon. During the left ventriculogram, a massive pseudoaneurysm was diagnosed and the patient successfully underwent emergency surgery. The persistence of no-reflow was likely due to the fact that the myocardial territory supplied by the infarct-related artery was completely necrosed resulting in persistent flow impairment through the vessel.

[Emergency Mitral Valvoplasty for Papillary Muscle Rupture].

We experienced 2 emergency surgical cases of severe mitral valve regurgitation due to papillary muscle rupture. Case 1:a 69-year-old man presented with respiratory and cardiac failure due to mitral regurgitation. He had no history of myocardial infarction. Mitral valve repair with artificial cords was performed. The papillary muscle of the anterior leaflet was ruptured. The postoperative course was uneventful. Case 2:a 80-year-old man came to our hospital with cardiac arrest. Emergency coronary intervention was performed to the right coronary and intraaortic balloon pumping was inserted. However his condition remained unstable. Severe mitral regurgitation was found by teansesophageal echo cardiography, and he underwent emergency mitral valve repair and single coronary bypass grafting. His cardiac function recovered quickly, but severe brain damage remained.

Repair of left ventricular rupture in a patient with mitral annular calcification.

Left ventricular free wall rupture is a complication following acute myocardial infarction or mitral valve replacement. We report the case of a 56-year-old female patient with idiopathic left ventricular rupture confirmed by contrast-enhanced computed tomography (CT). CT also showed no coronary artery obstruction and severe mitral annular calcification. Left ventricular rupture was successfully repaired internally with bovine pericardium. Mitral valve replacement with annular decalcification was also performed.

Extensive Chest Wall Destruction Secondary to a Large Ventricle Pseudoaneurysm: A Surgical Challenge.

Left ventricular pseudoaneurysms have become a rare complication of acute myocardial infarction, occurring in approximately 2% of cases and even less frequently when primary percutaneous intervention can be performed. Regardless of treatment strategy, left ventricle pseudoaneurysms are associated with a high mortality rate. We report on the extremely rare occurrence of a patient surviving two episodes of free wall rupture associated with extensive chest wall destruction and secondary traumatic rib fractures. The key to success in this case is related to both the cardiac and chest wall repair.

A Case of Post Myocardial Infarction Papillary Muscle Rupture.

Papillary muscle rupture is a rare, life-threatening post myocardial infarction mechanical complication. Without surgical intervention, prognosis is very poor. Clinicians need to recognize this complication early, as prompt therapy is crucial. We present a case of inferior ST elevation myocardial infarction complicated by posteromedial papillary muscle rupture resulting in severe acute mitral regurgitation (flail anterior mitral leaflet), acute pulmonary edema and cardiogenic shock. In our patient, a new mitral regurgitation murmur suggested this mechanical complication. Complete disruption of papillary muscle was visualized by transesophageal echocardiography. This case illustrates the importance of good physical examination for early diagnosis of papillary muscle rupture, so that life-saving treatment can be administered without delay.

The novel use of heart transplantation for the management of a case with multiple complications after acute myocardial infarction.

Rupture of the interventricular septum after myocardial infarction (MI) is an uncommon but serious complication, usually leading to congestive heart failure and cardiogenic shock. Surgical repair is usually the only definitive treatment for these patients because medical management is associated with a 30-day mortality approaching 100%. However with conventional surgical repair, operative mortality rates range from 33% to 53%. Furthermore, outcomes in patients with posterior ventricular septal defect (VSD) have been reported to have mortality rates up to 86%. Therefore, alternative treatment should be considered to improve management of this mechanical complication. We report the case of a 63-year-old man in whom VSD developed after an inferior MI. The patient presented with shortness of breath and a recent ST-elevation inferior MI. Transthoracic echocardiography revealed a 50% left ventricular ejection fraction with mild-moderate right ventricular dysfunction. A posterior VSD (diameter ≥ 12 mm), moderate ischemic mitral regurgitation (MR), and a posterior pseudoaneurysm were also seen. The operative risk was considered to be too high for VSD repair because the surgery would have to include bypass grafting, mitral valve replacement, and pseudoaneurysm correction. Consequently, an urgent heart transplantation was considered the best option. The patient underwent heart transplantation 9 days after initial symptoms, and the recovery was unremarkable. To achieve a definitive optimal treatment, we propose that patients with posterior VSD with significant MR or pseudoaneurysm, or both, should be considered as heart transplant candidates.

Lateral left ventricular wall rupture following acute myocardial infarction: pathophysiological interpretation by multimodality imaging approach.

Lateral left ventricular wall rupture (LVWR) is a rare complication following acute myocardial infarction (AMI) less than 1%. After cardiogenic shock, LVWR constitutes the most common cause of in-hospital death in AMI patients. Around 40% of all LVWR occurred during the first 24 hours and 85% within the first week. In the present case, 76 hours following the intervention, LVWR was observed likely due to a small infarction at the lateral left ventricular wall possibly due to the marginal lesion. Our patient refused surgery and was followed clinically. Eighteen months later, real time three-dimensional echocardiography showed a pseudoaneurysm.

[Valve plasty for mitral regurgitation caused by partial papillary muscle rupture after acute myocardial infarction;report of a case].

A 58-year-old woman was referred to our hospital because of acute myocardial infarction. Percutaneous coronary intervention for total occlusion of the circumflex coronary artery was performed successfully. However, she had heart failure that was gradually getting worse because of mitral valve regurgitation. Therefore, we performed valve plasty using the resection and suture method for mitral regurgitation caused by partial papillary muscle rupture. Her postoperative course was uneventful, and she was discharged on postoperative day 26. At 6 months after the operation, her functional status was New York Heart Association(NYHA) class I and transthoracic echocardiogram showed no mitral regurgitation( MR).

Surgical treatment of ventricular septal defect following myocardial infarction: a case report.

Ventricular septal defect after myocardial infarction is a rare but often life-threatening mechanical complication. The keys of management are a prompt diagnosis of ventricular septal defect and an aggressive approach to stabilize patient's hemodynamics. Invasive monitoring, judicious use of inotropes and vasodilators, and an intra-aortic balloon pump are recommended for the optimal support of patient's hemodynamics. The best results are achieved if optimally medically managed patients survive at least 4 weeks before elective surgery necessary for scar formation in a friable infarcted tissue. We report a case of acute myocardial infarction complicated by the rupture of ventricular septum. Instead of attempting an immediate surgical closure of ventricular septal defect, the postponed surgery was successfully performed 3 weeks after the occurrence of ventricular septal defect. Preoperatively, clinical and hemodynamic conditions of the patient were maintained stable with the support of an intra-aortic balloon pump and inotropes.

Partial papillary muscle rupture: a cause of acute mitral regurgitation.

A 56-year-old woman presented to the cardiology clinic with a 7-day history of dyspnea and chest pressure. An echocardiogram showed a flail posterior mitral valve leaflet, and subsequent left heart catheterization showed complete occlusion of the first obtuse marginal coronary artery. Further investigation demonstrated the culprit lesion to be ischemic partial rupture of the posteromedial papillary muscle. Timely recognition of this condition allowed for an optimal clinical outcome. In this Cardiology Grand Rounds, the authors further describe the above presentation of ischemic partial papillary muscle rupture and provide a brief review of the pathophysiology, diagnosis and treatment of this condition.

Clinical outcome after mitral valve surgery due to ischemic papillary muscle rupture.

BACKGROUND: Severe mitral regurgitation secondary to papillary muscle rupture is an infrequent but catastrophic complication after myocardial infarction. Without surgical treatment, mortality can reach 80%, but surgical treatment also carries substantial perioperative morbidity and mortality. METHODS: We retrospectively analyzed 28 patients who underwent mitral valve surgery for ischemic papillary muscle rupture. RESULTS: The 30-day mortality rate was 39.3% (11 of 28). There were no significant differences in the baseline characteristics, and concomitant coronary artery bypass (CABG) was performed in 66.7% of the survivor group and in 61.5% of the nonsurvivor group (p = 0.245). Mortality predictors included low cardiac output (p = 0.05), renal failure (p = 0.005), and implementation of extracorporeal membrane oxygenation therapy (p = 0.005). The time between myocardial infarction and surgery showed no significant effects on survival. CONCLUSIONS: Papillary muscle rupture with severe mitral regurgitation carries a high operative mortality. Additional CABG does not influence the acute postoperative course. Postoperative development of low cardiac output with a need for extracorporeal membrane oxygenation therapy and renal failure with hemodialysis substantially reduces survival.

A large left ventricular pseudoaneurysm evaluated with multimodality cardiac imaging.

Rarely, the rupture of the free wall of the left ventricle is contained by an adherent pericardium, creating a pseudoaneurysm. This clinical finding calls for emergency surgery. However, true aneurysms, if no ruptures are detectable and myocardium wall integrity is confirmed, can often be managed medically. Therefore, the accurate diagnosis of these conditions is clinically important. In this report, we present a case of large left ventricular pseudoaneurysm evaluated with multimodality cardiac imaging.

Resuspension of the uninfarcted papillary muscle at the time of mitral valve replacement in a patient with post myocardial infarction papillary muscle rupture.

A 60-year-old woman was referred to the Department of Cardiovascular Surgery of Social Insurance Chukyo Hospital for the rupture of a postinfarction papillary muscle. The rupture was in the posterior part of the anterolateral papillary muscle, in which more than two-thirds of its posterior leaflet was prolapsed. Mortality from the surgical repair of a papillary muscle rupture is quite high. For this case, we resuspended the uninfarcted papillary muscle heads case to preserve mitral ventricular continuity because the mitral annulus was quite small and more than two-thirds of the posterior leaflet were detached from the papillary muscle. The post-operative course of the patient was uneventful. Resuspension of uninfarcted papillary muscle is a useful technique to repair a rupture in the papillary muscle.

[Interest of circulatory assistance mobile unit for cardiovascular surgical pathology support at distance of specialized centers: about a case of papillary muscle rupture]. / Intérêt des unités mobiles d'assistance circulatoires pour la prise en charge de pathologies chirurgicales cardiovasculaires à distance des centres spécialisés: à propos d'un cas de rupture de pilier mitral.

Papillary muscle rupture is a classical, but not frequent life-threatening complication of myocardial infarction. The only treatment consists in mitral valve surgical replacement. It should be performed in a hospital with specialized critical care and a cardiac surgery unit. The problem we are talking about in this article is the transfer of very instable patients in a specialized center before surgery. We also discuss the interest of mobile unit of cardiac assistance to manage patients in hospital without cardiac surgery then to transfer them. We discuss also the initial management in the cardiac surgery and critical care unit.

[Successful repair of left ventricular free wall rupture with repeated mydriasis and loss of light reflex].

A 73-year-old woman was transferred to our hospital because of loss of consciousness. Cardiac catheterization showed a left ventricular free wall rupture (LVFWR) due to acute myocardial infarction at the posterolateral region. Shortly after cardiac catheterization, she lost her consciousness again and went into cardiogenic shock. Repeated mydriasis and loss of light reflex was recognized during establishment of cardiopulmonary bypass. Direct suture closure using equine pericardial strips and 4-0 polypropylene mattress sutures was performed under cardiac arrest. The suture site was covered with TachoComb and fibrin glue. Post-cardiac arrest brain injury was prevented by postoperative mild hypothermia. Surgical repair of LVFWR should be performed even when the signs of severe cerebral ischemia are apparent.