Successful Suture-Free Repair of Left Ventricular Rupture Using the EVARREST Patch.

Left ventricular free wall rupture is a lethal complication of myocardial infarction. Although emergent surgical repair is the treatment of choice, the method of repair remains highly individualized. This report presents a case of spontaneous coronary artery dissection in a patient with Turner syndrome that led to left ventricular free wall rupture and was successfully repaired on cardiopulmonary bypass using a suture-free technique with the EVARREST Fibrin Sealant Patch.

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.

Male adolescent with cardiac rupture after blunt thoracic trauma.

Blunt cardiac injury, including a rupture of the atria or ventricle, is most commonly caused by motor vehicle collisions and falls from great heights. A rupture of a cardiac chamber is an extremely rare diagnosis with a high mortality rate. The best chance at survival can only be accomplished with timely intervention.To raise awareness of this potentially life-threatening injury, we describe the case of a male adolescent with cardiac rupture after blunt thoracic trauma. While the focused assessment with sonography in trauma (FAST) examination was negative, an additional CT showed pericardial effusion. During the operation a rupture of the right ventricle was observed.Even though the physical recovery of our patient is remarkable, the traumatic event still affects his mental well-being and activities in daily life. This case emphasises the need of a multidisciplinary approach to achieve the best possible physical and psychological recovery in multitrauma patients.

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.

[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.

[Ventricular Free Wall Rupture].

Left ventricular free wall rupture( LVFWR) is a potentially fatal complication after acute myocardial infarction (AMI). Its onset is often unpredictable and circulatory collapse develops abruptly. When cardiac tamponade is detected after AMI, pericardial drainage should be performed promptly. If percutaneous drainage is ineffective, surgical drainage should be performed without hesitation. Veno-arterial extracorporeal oxygenation (VA-ECMO) cannot necessarily provide effective brain protection because of elevated venous pressure. Although suture-less repair often results in sufficient hemostasis, recurrent rupture sometimes develops. If any type of LVFWR is suspected, immediate surgical intervention can save lives.

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.

Acute Mitral Regurgitation Due to Chordae Tendineae Rupture: A Rare Presentation of Cardiac Amyloidosis.

BACKGROUND In cardiac amyloidosis (CA), misfolded proteins deposit in the extracellular space of cardiac tissue. These deposits classically cause restrictive cardiomyopathy with diastolic dysfunction. Although there are at least 30 proteins known to cause amyloid aggregates, 2 main types make up most diagnosed cases: light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR). Since CA is considered a rare condition, it is often underdiagnosed or recognized in the advanced stages. Once amyloid deposits involve the heart tissue, they are associated with a worse outcome and higher mortality rates, especially in patients presenting symptoms of heart failure. CASE REPORT We report a case of a 22-year-old man presenting with acute severe mitral regurgitation, secondary to posterior mitral leaflet chordae tendineae rupture (CTR). Surgical mitral valve replacement with a mechanical prosthesis was performed, and cardiac tissue biopsy samples were obtained. After surgery, the patient improved significantly but suddenly presented with hemodynamic deterioration, until he died due to severe hemodynamic compromise and multiorgan failure. Although the etiology of the CTR was not established before surgical intervention, the histopathological analysis suggested CA. CONCLUSIONS CA diagnosis can be complex, especially in a 22-year-old-man with atypical clinical and imaging manifestations. In this patient, other differential diagnoses were considered, since CA presenting in a young patient is a rare phenomenon and acute mitral regurgitation secondary to CTR presents more frequently in other heart conditions. Furthermore, rapid postoperative deterioration resulted in the patient's death before biopsy samples were available because suspicion of amyloidosis had not been raised until that point.

Acute mitral valve regurgitation secondary to papillary muscle rupture due to infective endocarditis.

BACKGROUND: Papillary muscle rupture due to infective endocarditis is a rare event and proper management of this condition has not been described in the literature. Our case aims to shed light on treatment strategies for these patients using the current guidelines. CASE PRESENTATION: This case presents a 58-year-old male with acute heart failure secondary to papillary muscle rupture. He underwent an en bloc resection of his mitral valve with a bioprosthetic valve replacement. Specimen pathology later showed necrotic papillary muscle due to infective endocarditis. The patient was further treated with antibiotic therapy. He recovered well post-operatively and continued to do well after discharge. CONCLUSION: In patients who present with papillary muscle rupture secondary to infective endocarditis, clinical symptoms should drive the treatment strategy. Despite the etiology, early mitral valve surgery remains treatment of choice for patients who have papillary muscle rupture leading to acute heart failure. Culture-guided prolonged antibiotic treatment is vital in this category of patients, especially those who have a prosthetic valve implanted.

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.

Treatment of severe acute mitral regurgitation following thoracoabdominal aortic aneurysm repair.

An asymptomatic 63-year-old male with chronic type B aortic dissection underwent repair of an expanding 6.1 cm extent I thoracoabdominal aortic aneurysm. His postoperative course was complicated by respiratory failure from severe acute mitral regurgitation likely due to papillary muscle rupture, which was corrected with transcatheter MitraClip edge-to-edge repair.

Survivor of Right Atrial Appendage Rupture Following Blunt Chest Trauma.

A 20-year-old woman presented to our trauma center with cardiac rupture after a motor vehicle collision. Our patient was the restrained driver in a high-speed collision. She arrived without external evidence of trauma but in obvious distress with tachycardia, tachypnea, and hypotension. Initial FAST was negative and chest x-ray; however, second FAST was equivocal for pericardial fluid. Computed tomography demonstrated a large hemopericardium, suspicious for cardiac injury. She underwent emergent operative exploration with a median sternotomy. A 1 cm right atrial appendage avulsion was identified and repaired primarily. She recovered uneventfully and was discharged home. Survival of blunt cardiac rupture is extremely rare and can occur in the absence of any external signs of trauma. Surgeons should maintain clinical suspicion for blunt cardiac injury in unstable trauma patients with deceleration injuries. Injury to the low-pressure right atrium likely contributed to her ability to survive transport to a trauma center.

Proposal of a new classification: "sealed type" postinfarction left ventricular free wall rupture.

OBJECTIVE: Postinfarction left ventricular free wall rupture (FWR) has been classified into blow-out type and oozing type. However, considering past papers, oozing type included the cases in which the bleeding had spontaneously stopped or sealed, and the distinction between blow-out type and oozing type was not always clear. We classified FWR into the BO type (combination of blow-out type and oozing type) with continuous bleeding and sealed type and clarified the pathophysiology of the sealed type. METHODS: Thirty-five patients who underwent surgical treatment for FWR during the past 21 years were retrospectively evaluated. RESULTS: Twenty-one patients (60%) were sealed. Comparing the sealed type with the BO type, the incidence of sudden collapse with acute onset was significantly lower (sealed type; 62%, BO type; 100%, P = 0.0118), and there were more cases of transport from outside the hospital (76%, 43%, P = 0.0453). Significantly few cases had electro-mechanical dissociation immediately before surgery (10%, 71%, P = 0.0001). In the sealed type, median sternotomy was performed in 9 patients (43%), and subxiphoid drainage was performed in 12 (57%). Fifteen patients (71%) were supported by IABP postoperatively, and re-rupture occurred in 3 patients without IABP. Long-term outcomes were significantly better in the sealed type than in the BO type. CONCLUSION: Sixty percent of postinfarction ventricular free wall rupture was the sealed type. Median sternotomy and sutureless repair with postoperative IABP support were reliable treatments. Subxiphoid drainage and strict blood pressure control with IABP may be acceptable surgical strategies in elderly, frail patients.