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J Thorac Cardiovasc Surg 2002;123:1014-1015
© 2002 The American Association for Thoracic Surgery

Letters to the Editor

Subacute left ventricular rupture complicated by free wall rupture: Repair with a TachoComb sheet and Tissucol glue

Z. Galajda, MDa, T. Fülöp, MDb, Á. Péterffy, MD, PhDa

Department of Cardiac Surgerya

To the Editor:

We read with interest the article titled "Sutureless Double-Patch-and-Glue Technique for Repair of Subacute Left Ventricular Wall Rupture After Myocardial Infarction, by Alamanni and associates,Go 1 which was published in the October 2001 issue of the Journal. The article provides valuable data for the use of biologic glues in the case of subacute left ventricular wall rupture. Several different types of surgical repair have been proposed for postinfarction left ventricular free wall rupture.Go Go 2-4 In connection with this we would like to present a case of postinfarction ventricular septal defect with subacute left ventricular rupture that became a postoperative acute left ventricular rupture after discontinuation of cardiopulmonary bypass (CPB). Repair was performed with CPB support and without aortic clamping. Tissucol biologic glue (Baxter Hyland Immuno Division, Wein, Germany) and a TachoComb patch (Nycomed Austria, GmbH, Linz, Austria) were used to reinforce the left ventricular repair.

A 73-year-old woman was admitted to our department on January 6, 2000, for emergency treatment with a diagnosis of acute myocardial infarction and postinfarction ventricular septal defect. The coronary arteriogram showed closure of the left anterior descending coronary artery and an anteroseptal ventricular septal defect, with a left-to-right shunt of 3. The patient was oliguric, in cardiogenic shock, with intra-aortic balloon support. The echocardiogram showed 20 mm of pericardial fluid.

After performing the sternotomy, we found blood in the pericardium with a right ventricular rupture. The defect was 5 to 8 mm in diameter, about 10 to 15 mm from the distal third of the left anterior descending artery in the right ventricular wall. We immediately cannulated the heart and closed the ventricular septal defect with a sandwich patchGo 5 (pericardium and Dacron fabric). The mural infarction was excised and the patch was sewn into place on the left ventricular side with pledget-supported mattress sutures, with the pledgets on the left ventricular side of the defect. The aorta clamping time was 100 minutes, and the CPB time was 158 minutes. We used antegrade and retrograde crystalloid cardioplegia.

After the clamp on the aorta had been released, the heart resumed sinus rhythm. Reperfusion was continued for 58 minutes, and then the CPB support was stopped. Before closing the sternum, we observed a lot of arterial bleeding. We immediately cannulated the heart and restarted CPB. We then observed that the left ventricle was bleeding in 6 positions on the lateral wall. These were left ventricular ruptures of 3- to 5-mm in size, positioned in an area of about 3 x 4 cm.

The heart was well drained with the aid of CPB, and the defects were closed with 2-0 Prolene U-shaped stitches (Johnson & Johnson, Ethicon, Inc, Somerville, NJ) over the polytetrafluoroethylene strips on the working heart, such that the rows of polytetrafluoroethylene strips were joined to each other with similar U-shaped Prolene stitches. A TachoComb sheet was positioned on this area under dry conditions (Figure 1) and was pressed to the surface of the working left ventricle for 10 minutes. Next, under similarly under dry conditions, the TachoComb surface was covered with 10 mL of Tissucol glue. After 60 minutes CPB was discontinued with no complications or bleeding.



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  		Fig. 1. Left ventricular rupture repair using direct suture and biologic glue technique.

 
The patient was transferred to the intensive care department with intra-aortic support with a blood pressure of 110/37 mm Hg. The balloon pump was removed after 3 days and mechanical ventilation was stopped after 5 days. The patient was placed in the cardiologic intensive care unit 14 days after the operation. From there she was discharged to her home on the 28th day after the operation.

The patient had a follow-up examination at our institution 21 months after the operation. She is living an active life in accordance with her age. The echocardiographic examination did not show a residual ventricular septal defect (Figure 2).



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  		Fig. 2. Echocardiogram 21 months after the operation.

 
12/8/122359

doi:10.1067/mtc.2002.122359

References

  1. Alamanni F, Fumero A, Parolari A, Trabattoni P, Cannata A, Berti G, et al. Sutureless double-patch-and-glue technique for repair of subacute left ventricular wall rupture after myocardial infarction. J Thorac Cardiovasc Surg. 2001;122:836-37.[Free Full Text]
  2. Pohjola-Sintonen S, Muller JE, Stone PH, Willich SN, Antman EM, Davis VG, et al. Ventricular septal and free wall rupture complicating acute myocardial infarction: experience in the Multicenter Investigation of Limitation of Infarct Size. Am Heart J. 1989;117:809-18.[Medline]
  3. Tomcsányi I, Hajdú L, Szilasy Z, Székely A, Medgyesy M. Successful new method for surgery of the postinfarctional left ventricular free wall rupture. Orv Hetil. 2001;142:1269-71. Hungarian.[Medline]
  4. Pretre R, Benedikt P, Turina M. Experience with postinfarction left ventricular free wall rupture. Ann Thorac Surg. 2000;69:1342-5.[Abstract/Free Full Text]
  5. da Silva JP, Cascudo MM, Baumgratz JF, Vila JHA, Macruz R. Postinfarction ventricular septal defect: an efficacious technique for early surgical repair. J Thorac Cardiovasc Surg. 1989;97:86-9.[Abstract]



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Surgical repair of left ventricular free wall rupture
MMCTS, January 1, 2005; 2005(0104): MMCTS.2004.000653 - MMCTS.2004.000653.
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