MMCTS
(January 4, 2005). doi:10.1510/MMCTS.2004.000653
Copyright © 2005 European Association for Cardio-thoracic Surgery
Procedure
Surgical repair of left ventricular free wall rupture
Alejandro Aris*
Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
* Corresponding author: Cardiac Surgery Service, Hospital de la Santa Creu i Sant Pau, San A.M. Claret 167, 08025 Barcelona, Spain. Phone: +00 34 93 2919300, fax: +00 34 93 2919424, Email: aaris{at}santpau.es
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Summary
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The sutureless technique of repair of a free wall left ventricular rupture following myocardial infarction is described. The technique involves the attachment of a Teflon felt patch over the ruptured area glued to the epicardium with a synthetic biocompatible glue (cyanoacrylate). It is a simple, lifesaving procedure which can be done without the use of cardiopulmonary bypass in most of the cases.
Key Words: Cardiac rupture • free wall left ventricular rupture • biological glue • subacute left ventricular rupture • cardiac tamponade • complications of acute myocardial infarction
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Introduction
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Left ventricular free wall rupture is one of the most lethal complications following myocardial infarction. It occurs 4–10 times more often than rupture of the interventricular septum or a papillary muscle, two conditions for which surgical treatment is widely and successfully applied. However, surgical treatment of cardiac rupture still remains a challenge due to the high mortality that occurs even before the diagnosis can be made. Usually, the rupture is insidious, leading to bleeding into the pericardial sac with ensuing cardiac tamponade. Heart specimens obtained from patients dying of subacute cardiac rupture show an anfractuous path through the layers of the myocardium (Photo 1). Excellent reviews of clinical presentation, diagnosis and management can be found in the literature [1, 2, 3].
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Photo 1 Heart specimen from a patient dying of subacute cardiac rupture. At the bottom left of the image, the anfractuous tract between the layers of the myocardium and the opening into the pericardium can be seen (Courtesy of J.M. Mesa, MD).
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The appropriate surgical technique remains controversial. Infarctectomy has been performed successfully but involves extracorporeal circulation and suturing on an infarcted ventricle. A positive step towards control of the hemorrhage was done by Nuñez and associates who covered the bleeding area with a large patch, anchoring it to normal myocardium with a continuous suture [4]. Following this principle, Padro described a sutureless technique in which a Teflon patch was secured to the epicardium by means of a biocompatible (cyanoacrylate) glue [5]. The combined experience of our institution and of a leading center in the study of cardiac rupture with this technique was reported in 1993 [6]. Thirteen patients who presented with free wall ventricular rupture a mean of 3.8 days after a myocardial infarction were treated with the sutureless patch technique. All but one were operated without cardiopulmonary bypass. All survived the operation and were alive a mean of 26 months following surgery. Since this report, the sutureless technique has been applied widely. It is simple and does not require aortic crossclamping nor extracorporeal circulation in most of the cases. Coronary artery bypass grafts (CABGs) are not done at the time of surgery since coronary artery angiography is not performed preoperatively as a general rule. The operation is done as a lifesaving procedure in which, more than ever, the aphorism of 19th Century French surgeon Charles Clavell becomes relevant: "Before we save the function, we must save the functionary".
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Surgical technique
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The chest is opened via median sternotomy. The pericardium is opened and cardiac tamponade is relieved. Usually, there is a marked improvement in arterial blood pressure and a decrease in central venous pressure. Blood clots are removed from the epicardial aspect of the heart (contrary to what is taught in medical schools, blood does clot inside the pericardium) and this is inspected to localize the bleeding point. There is usually an oozing zone, without active squirting (Photo 2).
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Photo 2 Subacute rupture in the posterolateral aspect of the left ventricle. The arrowhead points towards a small tear in the surface of the heart without active bleeding.
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A few drops of glue (histoacryl blue, MMCTSLink 11) are placed over the oozing zone (Photo 3). Then a patch of Teflon felt (about 8 x 5 cm) is applied over the area. The corners of the patch are glued to the epicardium and extra drops of adhesive are applied over the patch until it is well soaked (Photo 4). After drying (less than 30 seconds) the area of the tear has a hard mass consistency.
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Photo 4 A Teflon felt patch is glued over the area. Note that the felt is soaked by the glue, giving it a bluish coloration.
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Alternative procedures
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Since our original communication, the sutureless technique has been applied worldwide with some modifications. We have continued to use the cyanoacrylate glue (butyl-2-cyanoacrylate monomer) which polymerizes in an exothermic reaction when in contact with fluid. Photo 5 shows the adhesive strength of this product. Histoacryl has been used in Canada and Europe to close skin lacerations. A similar product, Dermabond (2-octyl cyanoacrylate, MMCTSLink 12) has been approved by the FDA for the same purposes.
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Photo 5 A demonstration of the binding properties of cyanoacrylate glue. (A) Two drops are placed over a surgical glove. (B) A small piece of Teflon felt is placed over. The glue is absorbed by the felt. (C) Two minutes later, there is a firm bond between the glove and the felt, capable of holding the weight of five hemosthatic clamps (D).
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Several authors have used other products and glues for sutureless repair of free wall ventricular rupture. Pericardial patches [7, 8] and TachoComb sheet (equine collagen patch with human fibrinogen and human thrombin, MMCTSLink 13) [9, 10] have been used to treat this condition.
Other glues have been applied instead of the cyanoacrylate. Fibrin glues [7, 9, 10] are not as strong as others but have complete biocompatibility. BioGlue (biological bovine serum albumin and glutaraldehyde glue. MMCTSLink 14) was used by Alamanni et al. to secure a second patch over a first one glued to the epicardium with cyanoacrylate [8]. An excellent description of the different properties of biocompatible glues can be found in the article by Lachapelle et al. [11].
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Results
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A review of the largest series reported shows that the "glue and patch" procedure is safe. In our original series [6], 13 patients were operated with no deaths. Other authors [7, 8, 10, 11] have shown that the procedure can be performed with a very low mortality. In approximately 30 patients, the only reported deaths were in patients in whom the procedure was performed under CPB. In addition, in two patients who died, CABGs were performed. Thus, it seems wise to always use this technique if feasible. The use of CPB and concomitant coronary surgery entails risk of mortality.
As a word of caution, a recent article [12] warns of the use of the sutureless technique. The authors found a left ventricular pseudoaneurysm developing 1 year after the repair, an occurrence not found by us in a follow-up extending up to 5 years.
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References
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- Lopez-Sendon J, Gonzalez A, Lopez de Sa E, Coma-Canella I, Roldan I, Dominguez F, Maqueda I, Martin Jadraque L. Diagnosis of subacute ventricular wall rupture after acute myocardial infarction: sensitivity and specificity of clinical, hemodynamic and echocardiographic criteria. J Am Coll Cardiol 1992;19:1145–1153[Abstract]
- Sutherland FWH, Guell J, Pathi VL, Naik SK. Postinfarction ventricular free wall rupture: strategies for diagnosis and treatment. Ann Thorac Surg 1996;61:1281–1285[Abstract/Free Full Text]
- Reardon MJ, Carr CL, Diamond A, Letsou GV, Safi HJ, Espada R, Baldwin JC. Ischemic left ventricular free wall rupture: prediction, diagnosis, and treatment. Ann Thorac Surg 1997;64:1509–1513[Abstract/Free Full Text]
- Nuñez L, dela Llana R, Lopez-Sendon J, Coma I, Gil Aguado M, Larrea JL. Diagnosis and treatment of subacute free wall ventricular rupture after infarction. Ann Thorac Surg 1983;35:525–529[Abstract]
- Padro JM, Caralps JM, Montoya JD, Camara ML, Garcia Picart J, Aris A. Sutureless repair of postinfarction cardiac rupture. J Card Surg 1988;3:491–493[Medline]
- Padro JM, Mesa JM, Silvestre J, Larrea JL, Caralps JM, Cerron F, Aris A. Subacute cardiac rupture: repair with a sutureless technique. Ann Thorac Surg 1993;55:20–24[Abstract]
- Prêtre R, Benedikt P, Turina MI. Experience with postinfarction left ventricular free wall rupture. Ann Thorac Surg 2000;69:1342–1345[Abstract/Free Full Text]
- Alamanni F, Fumero A, Parolari A, Trabattoni P, Cannata A, Berti G, Biglioli P. Sutureless double-patch-and-glue technique for repair of subacute left ventricular wall rupture after myocardial infarction. J Thorac Cardiovasc Surg 2001;122:836–837[Free Full Text]
- Galajda Z, Fülöp T, Péterffy A. Subacute left ventricular rupture complicated by free wall rupture: repair with a TachoComb sheet and Tissucol glue. J Thorac Cardiovasc Surg 2002;123:1014–1016[Free Full Text]
- Imemura J, Oku H, Otaki M, Kitayama H, Inoue T, Kaneda T. Surgical strategy for left ventricular free wall rupture after acute myocardial infarction. Ann Thorac Surg 2001;71:201–204[Abstract/Free Full Text]
- Lachapelle K, deVarennes B, Ergina PL, Cecere R. Sutureless patch technique for postinfarction left ventricular rupture. Ann Thorac Surg 2002;74:96–101[Abstract/Free Full Text]
- Fukushima S, Kobayashi J, Tagusari O, Sasako Y. A huge pseudoaneurysm of the left ventricle after simple gluing of an oozing-type postinfarction rupture. Interac Cardiovasc Thorac Surg 2003;2:94–96[Abstract/Free Full Text]
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Summary
Introduction