Up against the wall - emergency double myocardial rupture repair.

BACKGROUND: Left ventricular free wall rupture (LVFWR) and interventricular septal rupture (VSR) are potentially catastrophic mechanical complications after acute myocardial infarction (AMI). When they occur together, "double myocardial rupture" (DMR), survival is unlikely. DMR is seen in only 0.3% of all AMIs. With or without surgical intervention, the odds are against the patient. CASE PRESENTATION: A 57-year-old male self-referred to the emergency department of a remote hospital 5 days after first experiencing chest pain. Investigations in ED confirmed an inferior ST-segment elevation myocardial infarction (STEMI) complicated by DMR. Coronary angiography revealed a mid-course total occlusion of the right coronary artery (RCA). He was rapidly transferred to our regional cardiac surgical unit, arriving straight into the operating theatre, in cardiogenic shock. He was briefly conscious, before arresting prior to intubation and being massaged onto bypass. Not only did he survive the all-night operation, requiring a mitral valve replacement in the process, but he survived multiple postoperative complications to be eventually transferred on postoperative day 66, neurologically intact, to a peripheral unit to complete his rehabilitation. He was subsequently discharged home 88 days after the operation and was able to ambulate with a walking frame into his first postoperative follow-up clinic appointment. CONCLUSIONS: Our patient, against all odds, has survived DMR and multiple postoperative complications. We present the details of his case and the literature surrounding the condition. The patient's mental fortitude and his supportive family played a significant role, along with excellent multidisciplinary team work, in assuring his survival.

Surgical Outcome of Postinfarction Left Ventricular Free Wall Rupture.

BACKGROUND: Left ventricular free wall rupture (LVFWR) is a rare and fatal complication after acute myocardial infarction. Early recognition and aggressive treatment are recommended. METHODS: Between August 1999 and February 2023, 11 patients aged between 64 and 79 years developed LVFWR after acute myocardial infarction (mean interval, 3.5 days). Three patients had active bleeding (blowout-type LVFWR), and the other 8 patients experienced the oozing or sealed state. Eight patients were treated using a sutureless technique with Teflon felt and glue, 2 patients were treated using the primary suture closure technique, and 1 was treated using both the primary suture and the sutureless technique with Teflon felt and glue. RESULTS: One patient died in the operating room as a result of bleeding. Cardiovascular stability and hemostasis were achieved in the other 10 patients. There were 3 early deaths (all 3 cases as a result of area bleeding; 1 was treated with primary suture, 2 with sutureless glue). Three patients received percutaneous coronary intervention before discharge. All 8 remaining patients survived and were discharged. Three patients were lost to follow-up. The follow-up period ranged from 2 to 97 months, with 4 patients exhibiting New York Heart Association class I symptoms and 1 exhibiting New York Heart Association class II symptoms. CONCLUSION: Optimal surgical treatment for postinfarction LVFWR remains controversial. The sutureless technique may be a promising strategy for treating postinfarction LVFWR.

Sutureless repair with Hydrofit® and bovine pericardial patch for oozing-type postinfarction cardiac rupture.

Left ventricular free wall rupture is a fatal complication of myocardial infarction for which infarctectomy and reconstruction of the left ventricle using a prosthetic patch under cardiopulmonary bypass are performed. However, these surgical treatments remain challenging. Left ventricular free wall rupture secondary to acute myocardial infarction was diagnosed in an 86-year-old man. We performed sutureless repair of the left ventricular free wall rupture without cardiopulmonary bypass. During the operation, a pre-gluing bovine pericardial patch with Hydrofit® was placed twice on the ruptured site and manually pressed to provide complete hemostasis. The postoperative course was uneventful. This sutureless technique has the benefit of avoiding sutures in the fragile infarcted myocardium and might be effective for left ventricular free wall rupture treatment.

[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.

VA-ECMO With Pericardiocentesis and Autologous Blood Transfusion - Stabilisation Strategy in Acute Cardiac Free Wall Rupture.

A 68-year old lady present with left ventricular free wall rupture and cardiac arrest post-myocardial infarction. This article illustrates a strategy combining pericardiocentesis with autologous transfusion together with VA-ECMO as a bridge to definitive surgical repair.

[Subacute Pseudoaneurysm Formation after Sutureless Repair for Postinfarction Left Ventricular Rupture:Report of a Case].

A 71-year-old woman was admitted for cardiac tamponade due to left ventricular free wall rupture after acute myocardial infarction. Sutureless repair was performed for bleeding from the inferior wall. Fifteen days later, computed tomography demonstrated enlargement of a left ventricular pseudoaneurysm. Patch closure using a vascular prosthesis was performed through left thoracotomy. No recurrence of the left ventricular aneurysm has been observed since.

Meta-analysis of surgical treatment for postinfarction left ventricular free-wall rupture.

BACKGROUND: Left ventricular free-wall rupture (LVFWR) is one of the most lethal complications after acute myocardial infarction (AMI). The optimal therapeutic strategy is controversial. The current meta-analysis sought to examine the outcome of patients surgically treated for post-AMI LVFWR. METHODS: A comprehensive literature review was performed to identify articles reporting outcomes of subjects who underwent LVFWR surgical repair. The primary endpoint was operative mortality. A meta-analysis was performed to assess the associations of predefined variables of interest and clinical prognosis. RESULTS: Of the 3132 retrieved articles, 11 nonrandomized studies, enrolling a total of 363 patients, fulfilled the inclusion criteria and were included in this analysis. The mean age of patients was 68 years. The operative mortality rate was 32% (n = 115). Meta-analysis revealed reduced operative risk in patients with oozing type rupture, as compared to blowout type (risk ratios [RR]: 0.47; 95% confidence interval [CI]: 0.33-0.67; p < .0001); RR was also significantly reduced in subjects in whom LVFWR was treated with sutureless technique, as compared to those undergoing sutured repair (RR: 0.59; 95% CI: 0.41-0.83; p = .002). Increased risk of operative mortality was demonstrated in patients who required postoperative extracorporeal membrane oxygenation (ECMO) support (RR: 2.39; 95% CI: 1.59-3.60; p < .0001). CONCLUSIONS: Surgical treatment of postinfarction LVFWR has a high operative mortality rate. Blowout rupture, sutured repair and postoperative ECMO support are factors associated with increased risk of operative mortality.

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.

[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.

Surgical Treatment of Post-Infarction Left Ventricular Free-Wall Rupture: A Multicenter Study.

BACKGROUND: Left ventricular free-wall rupture (LVFWR) is an uncommon but serious mechanical complication of acute myocardial infarction. Surgical repair, though challenging, is the only definitive treatment. Given the rarity of this condition, however, results after surgery are still not well established. The aim of this study was to review a multicenter experience with the surgical management of post-infarction LVFWR and analyze the associated early outcomes. METHODS: Using the CAUTION (Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort Study) database, we identified 140 patients who were surgically treated for post-acute myocardial infarction LVFWR in 15 different centers from 2001 to 2018. The main outcome measured was operative mortality. Multivariate analysis was carried out by constructing a logistic regression model to identify predictors of postoperative mortality. RESULTS: The mean age of patients was 69.4 years. The oozing type of LVFWR was observed in 79 patients (56.4%), and the blowout type in 61 (43.6%). Sutured repair was used in the 61.4% of cases. The operative mortality rate was 36.4%. Low cardiac output syndrome was the main cause of perioperative death. Myocardial rerupture after surgery occurred in 10 patients (7.1%). Multivariable analysis revealed that preoperative left ventricular ejection fraction (P < .001), cardiac arrest at presentation (P = .011), female sex (P = .044), and the need for preoperative extracorporeal life support (P = .003) were independent predictors for operative mortality. CONCLUSIONS: Surgical repair of post-infarction LVFWR carries a high operative mortality. Female sex, preoperative left ventricular ejection fraction, cardiac arrest, and extracorporeal life support are predictors of early mortality.

Post-infarction left ventricular free wall rupture: 12-years experience from the Cardiac Centre of the Institute of Clinical and Experimental Medicine in Prague, Czech Republic.

BACKGROUND: Post-infarction left ventricular free wall rupture (LVFWR) is a feared and catastrophic complication of myocardial infarction that carries a high surgical and hospital mortality. Due to the rarity of this complication, little information exists on surgical treatment and outcomes. Goal and Methods. The goal of this study was to present our experience with LVFWR. We present a retrospective cohort of 19 consecutive patients who were surgically treated in the Cardiac Centre of the Institute of Clinical and Experimental Medicine in Prague between January 2006 and December 2017. RESULTS: Thirty-day mortality was 26%. Five patients died. Four patients died in the operating theatre and one patient on the ninth postoperative day following re-rupture. Seventy-four percent of the patient cohort survived and were discharged from hospital. The median length of follow-up was 45 months (range 0.75-150). No patient died during follow-up. Median postoperative ejection fraction was 45% (range 25-65%). Angina pectoris and dyspnea were investigated during follow-up and graded according to the Canadian cardiology society (CCS) and the New York Heart Association (NYHA) classifications. Fourteen patients had CCS class I, eight patients had NYHA class I dyspnea and six patients had NYHA class II. Re-rupture occurred after hospital discharge in one patient one month after the original surgery. The patient was treated successfully by urgent surgical intervention. CONCLUSION: LVFWR is a catastrophic and challenging complication of myocardial infarction. Good outcomes can be achieved by rapid diagnosis and urgent surgical intervention as shown by our results.

Left ventricular free-wall rupture, a potentially lethal mechanical complication of coronaric angioplasty : an unusual case report.

The incidence of complications of coronary perforation varied significantly among studies probably due to population heterogeneity and interventional techniques applied in each centre. Free wall rupture, cardiac tamponade and miocardial infarction are the most  feared. The treatment of perforation remains a challenge of every cath- lab team. The management strategies range from observation to urgent operation depending on patient's hemodynamic status, severity and location of the perforation, coronary anatomy, interventional practice and equipment in each centre and operators' skills on-site. In this case an extracorporeal circulation and cardioplegic arrest with anterograde hot blood cardioplegia was done. A composite Dacron with autologous pericardium patch was used for left ventricular free wall rupture repair and the geometry of the left ventricle was restored. Subsequently aorta was declamped; the patient was weaned from CEC and a good spontaneous hemodynamic was recovered.

Left thoracotomy approach for left ventricular pseudoaneurysm due to myocardial infarction after mitral valve replacement for papillary muscle rupture.

A 59-year-old man with acute mitral regurgitation due to papillary muscle rupture after myocardial infarction was admitted to our hospital. He underwent emergent mitral valve replacement with a mechanical valve by median sternotomy. Although postoperative echocardiography showed no sign of a ventricular aneurysm, echocardiography performed 5 weeks after the surgery showed enlarging left ventricular pseudoaneurysm of the inferior to the posterior cardiac wall. He underwent dacron patch closure of the orifice by fifth intercostal left thoracotomy. The postoperative course was uneventful and he was discharged on postoperative day 10. The patient was successfully treated for two life-threatening complications occurring subsequently after myocardial infarction.

Collateral damage of COVID-19 pandemic: Delayed medical care.

During the COVID-19 pandemic, emergency room visits have drastically decreased for non-COVID conditions such as appendicitis, heart attack, and stroke. Patients may be avoiding seeking medical attention for fear of catching the deadly condition or as an unintended consequence of stay-at-home orders. This delay in seeking care can lead to increased morbidity and mortality, which has not been figured in the assessment of the extent of damage caused by this pandemic. This case illustrates an example of "collateral damage" caused by the COVID-19 pandemic. What would have been a standard ST-elevation myocardial infarction treated with timely and successful stenting of a dominant right coronary artery occlusion, became a much more dangerous postinfarction ventricular septal defect; all because of a 2-day delay in seeking medical attention by an unsuspecting patient.

Surviving Case of a Blowout-Type Left Ventricular Free Wall Rupture During Percutaneous Coronary Intervention for a Lateral Acute Myocardial Infarction.

A 76-year-old man suffering from chest pain was admitted to our hospital with a suspected acute myocardial infarction (AMI). Emergent coronary angiography revealed a totally occluded proximal left circumflex artery (LCX). During primary percutaneous coronary intervention, his blood pressure suddenly fell within seconds, and he developed pulseless electrical activity (PEA). Surprisingly, the 12-lead electrocardiogram (ECG) findings including the heart rate remained unchanged before and after the PEA, but a heart rate reduction and asystole occurred a few minutes after developing PEA. After tracheal intubation and mechanical assistance by venoarterial extracorporeal membrane oxygenation (VA-ECMO), the sudden onset of PEA appeared to be caused by cardiac tamponade due to a blowout-type left ventricular free wall rupture (BO-LVFWR) diagnosed by transthoracic echocardiography. While pericardiocentesis was performed and the drained blood was directly continuously perfused intravenously to keep the VA-ECMO flow, the patient was moved to the operation room. The surgical findings revealed a solitary BO-LVFWR due to a lateral AMI, and a direct closure was performed. Successful perioperative management, oral medication administration, and rehabilitation lead to the patient being transferred to a rehabilitation hospital without any serious cerebral damage. This case report suggested the detailed onset pattern of a BO-LVFWR followed by a rapid diagnosis by echocardiography and lifesaving treatment.