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J Thorac Cardiovasc Surg 2006;131:226-227
© 2006 The American Association for Thoracic Surgery
Brief Communication |
a Department of Thoracic and Cardiovascular Surgery, University Hospital Muenster, Muenster, Germany
b Department of Clinical Radiology, University Hospital Muenster, Muenster, Germany
Received for publication August 5, 2005; accepted for publication August 17, 2005. * Address for reprints: Stefan Klotz, MD, Department of Thoracic and Cardiovascular Surgery, University Hospital Muenster, 48151 Muenster, Germany (Email: Stefan.Klotz{at}ukmuenster.de).
Ventricular septum ruptures are known and severe complications after myocardial infarction with a corresponding high mortality. Ventricular free wall ruptures are less common because these patients often die before sufficient diagnostics can be performed.
1
If an examination is possible, diagnosis is most often performed by means of Doppler echocardiography.
2
However, detection of a ventricular free wall rupture by means of multislice computed tomography (MSCT) has not yet been published and is presented here.
Clinical Summary
A 51-year-old patient with hemodynamic deterioration after acute myocardial infarction was referred to our department in June 2005. The case history revealed aortic valve replacement with a Lillehei Custer valve in 1972, as well as aortocoronary bypass graftings in 1992 and 2001. The patient was admitted first to a cardiology unit with the diagnosis of acute myocardial infarction. A coronarangiography showed a stenosis of the right coronary artery (RCA), as well as occlusions of the left anterior descending coronary artery (LAD) and the circumflex artery. Also occluded were all bypass grafts. Stent implantation was then performed successfully in the LAD and RCA. However, hemodynamics deteriorated a day after the intervention, and the patient was referred to our department. Transthoracic echocardiography showed severely reduced cardiac function and an approximately 1.5-cm pericardial effusion. Repeated coronarangiography and ventriculography revealed open stents in the LAD and RCA and the suspicion of a ventricular wall perforation. Thus MSCT was performed. In this computed tomographic scan, 2 large ruptures (8 x 8 mm and 7 x 6 mm) in the lateral wall of the left ventricle were found (Figure 1). The patient probably survived up to that point because of pericardial adhesions, which might have prevented further massive perforation into the thoracic cavity. However, contrast enhancement in the pericardial wall and contrast flow in the pericardial cavity partly suggested perforation. Thus an emergency operation with the use of extracorporeal circulation was performed. Intraoperatively, we found 2 ruptures in the lateral myocardial wall, as well as blood in the pericardial cavity. Because of the freshly infarcted myocardial tissue, a direct closure of the ventricular defects was not possible. Therefore a polytetrafluoroethylene patch * was adapted to the lateral wall and secured with surgical glue. Because of the preoperative highly reduced left ventricular function, extracorporeal membrane oxygenation (ECMO) had to be implanted postoperatively. Because the hemodynamic condition recovered, ECMO explantation was performed on postoperative day 3. However, despite initial good clinical course, the patient died from septic multiorgan failure on postoperative day 12. Postmortem analysis showed a purulent pericarditis.
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MSCT is a fast and noninvasive tool for detection of ventricular ruptures, which sometimes are not sufficiently diagnosed by means of ventriculography or echocardiography. Dogan and colleagues
3
recently described the detection of a ventricular septum rupture by means of MSCT. However, detection of a ventricular free wall rupture by means of MSCT has not yet been published. These severe complications are often postmortem findings because of the extremely high mortality.
1
If detected early enough, cardiac surgery is often the only therapeutic option. However, despite surgical intervention, mortality remains extremely high.
4,5
The reason the diagnosis in the patient presented here could be achieved was the presence of massive pericardial adhesions caused by 3 cardiac operations previously performed, which probably prevented massive perforation. Despite immediate cardiac surgery and a promising clinical course after ECMO explantation, the patient died in septic multiorgan failure.
Conclusion
Free wall ventricular rupture after myocardial infarction is a severe complication with a high mortality. MSCT is a fast and noninvasive tool for detection of ventricular ruptures, which sometimes are not sufficiently diagnosed by means of ventriculography or echocardiography. Cardiac surgery is often the only therapeutic option, but mortality remains extremely high.
4,5
Footnotes
* Gore-Tex path, registered trademark of W. L. Gore & Associates, Inc, Newark, Del. 
References
This article has been cited by other articles:
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  Y. Yamamoto, T. Ushijima, M. Takata, and G. Watanabe Double-patch sandwich repair for left ventricular free wall rupture Interact CardioVasc Thorac Surg, May 1, 2011; 12(5): 872 - 874. [Abstract] [Full Text] [PDF]
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