[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.

Papillary muscle rupture after transcatheter aortic valve implantation: A case report and literature review.

We present a case of posterior papillary muscle rupture associated with severe eccentric mitral regurgitation following transcatheter aortic valve implantation, that was successfully treated with transcatheter edge to edge mitral repair and review similar cases in literature.

[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.

An unusual case of mitral valve chordal rupture.

In this report, we present a rare case of severe mitral regurgitation due to isolated mitral valve chordal rupture without valve leaflet prolapse in a patient with Fabry cardiomyopathy. This finding could be due to subvalvular apparatus storage of glycosphingolipids rather than fibro-elastic deficiency, underlying how close cardiological follow-up of Fabry patients must be comprehensive and not only focused on left ventricular hypertrophy and arrhythmias.

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.

In utero fetal left ventricular rupture and pseudoaneurysm formation: a case report.

BACKGROUND: Cardiac ventricular aneurysms affect 1 in 200,000 live births. To the best of our knowledge, no reported cases of a left ventricular pseudoaneurym and in utero rupture exist to guide optimal management. CASE PRESENTATION: We present a case of fetal left ventricular rupture with a large pericardial effusion, cardiac tamponade and subsequent pseudoaneurysm formation with concerns for a poor prognosis. Interventional drainage of the pericardial effusion led to resolution of tamponade and significant improvement in fetal condition. A multidisciplinary team was utilised to plan birth to minimise risk of pseudoaneurysmal rupture and a catastrophic bleed at birth. CONCLUSION: For similar cases we recommend consideration of birth by caesarean section, delayed cord clamping and a prostaglandin E1 infusion, to reduce the systemic pressures on the left ventricle during transition from fetal to neonatal circulations, until definitive surgical repair. In this case, this resulted in a successful outcome.

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.

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.

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.