Download postinfarction ventricular free wall rupture

POSTINFARCTION VENTRICULAR
FREE WALL RUPTURE
Romuald Cichoń
Incidence
Ø 
3,2% of all cases (56/1746 patients) of acute
myocardial infarction (AMI),
but in 17% of the
hospital deaths !
/Br Heart J 1985; 54: 11-6/!
!
Ø 
2,3 % cases (77/3284 patients with AMI)!
•  13% cases (13patients) had double rupture preceded by
ventricular septal perforation!
•  2,7% cases before routine management with PCI vs 1,1%
in the era of PCI !
/J Nippon Med Sch. 2002 Oct;69(5):481-8./!
!
Ø 
0,72% cases patients with AMI treated with PCI !
/Chest 2003; 124:565–571/!
Pathogenesis and Pathophysiology
Ø  Clinical categories:
acute
subacute
early (within first 48h of MI)
isolated
chronic
late (beyond the 2nd day)
simultaneous with the rupture of other heart stuctures
(interventricular septum, papillary muscles, or right ventricle)
Ø  occurs only with transmural myocardial infarctions
Ø  is more probable after extensive hemorrhagic transformation of the
acute infarct
Factors facilitating free wall rupture
ü  Delayed hospital admission (> 12–24 hours)
ü  Persistent systemic hypertension during first > 10–24 hours
ü  “Unusual” in-hospital physical eVort (agitation, repetitive vomiting or coughing, etc)
ü  Extension of myocardial infarction
ü  Expansion of myocardial infarction
Figueras J. et al. Heart 2000;83:499–504
Morphologic types of ventricular free wall rupture
Trindade ML et al. Cardiovasc Ultrasound. 2006; 4:7
Purcaro A. et al.. Am J Cardiol 1997;80:397–405)
Diagnosis
Clinical presentation
v  Acute
rupture
– acute tamponade with
sudden
electromechanical
dissociation or severe
hypotension
Figueras J. et al. Heart 2000;83:499–504
v  Subacute
rupture
- moderate to severe
pericardial efusion:
ü  with tamponade and
haemodynamic compromise
with modest or progressive
hypotension
ü  without tamponade
Sensitivity, Specificity, and Predictive Value of Different Variables,
Used Independently and in Combination, for Diagnosing a
Postinfarction External Cardiac Rupture
Purcaro A. et al..
Am J Cardiol 1997;80:397–405)
Raposo L. et al.
Cardiovasc Ultrasound. 2006;4:46
CT scan showing leakage of contrast from the left ventricle free wall
rupture (arrow).
Vohra HA. et al.. J Cardiothorac Surg. 2006;1:11.
The chest enhanced multislice computed
tomography (MSCT) shows that the lateral
wall of the left ventricule is dissected (arrow).
Kin H. et al..
Eur J Cardiothorac Surg 2007;31:1138.
Off-line coronary angiograms
review on posterolateralM view
showing a round-shaped contrast
persistence.
Off-line coronary angiograms review
on right oblique view showing a
round-shaped contrast persistence
at the site of early left ventricular
rupture.
Rigatelli G. et al. Peculiar angiographic predictors of impending left ventricular rupture
after
primary coronary angioplasty. Cardiovasc Revasc Med. 2008 Oct-Dec;9(4):235-7.
J. Figueras et al. Int J Card 200; 79:103–111
Pseudoaneurysm
G. Zoffoli et al. Journal of Cardiothoracic Surgery 2009, 4:11
Organized approach to the management of subacute ventricular free wall rupture
Purcaro A. et al.. Am J Cardiol 1997;80:397–405
Preoperative Management
v  pericardiocentesis
v  percutaneous
intrapericardial infusion of fibrin
glue (???)
v  inotropic agents and fluids
v  IABP (?)
v  ECMO (??) /Formica F. et al. ECMO support for the treatment of cardiogenic shock due
to left ventricular free wall rupture. 2005;4:30-32; Interact CardioVasc Thorac Surg/
Broken heart... can be fixed?
Surgical management
reference
No. of
patients
surgical technique
survival
rate
K. Tanaka (2002)
77
not described
10,4%
G. Sakaguchi (2008)
32
gluing autologous patch to the tear
84%
MH. McMullan (2001)
18
direct suture closure over felt strips with or without
preceding infarctectomy (16), patch/glue technique (2)
39%
SJ. Canovas (2003)
17
patch glue repair without extracorporeal circulation
76,5%
V. Mantovani (2002)
17
patch covering technique (13), infarctectomy with patch
reconstruction (3), direct suture without patch (1)
82%
C. Leva (2006)
9
Teflon patch applied with Bioglue
100%
PK. Mishra (2007)
6
infarctectomy+direct closure (2), direct closure (1), twolayer plication of the LV aneurysm (1), sutureless glue
repair (1), autologous pericardial patch closure (1)
67%
K. Lachapelle (2002)
6
sutureless patch technique
83%
R. Pretre (2000)
5
epicardial patching (2), direct suture (1), infarct-exclusion
(1), debridement and patch closure (1)
60%
CE. Nwogu (1998)
4
external patching techniques without resection of necrotic
myocardium
100%
Surgical techniques
epicardial patching
debridement and patch closure
direct suture
infarct-exclusion
R. Pretre et al. Ann Thorac Surg 2000;69:1342-1345
Infarctectomy + patch repair
A
(A) Infarction and area of rupture;
infarctectomy to good tissue.
B
(B)  Technique of patch repair.
Reardon M. J. et al.; Ann Thorac Surg 1997;64:1509-1513
Copyright ©1997 The Society of Thoracic Surgeons
patch over the
ruptured area glued to the
epicardium with a synthetic
biocompatible glue (cyanoacrylate)
Subacute rupture in the posterolateral aspect of the left ventricle.
The arrowhead points towards a small tear in the surface
A Teflon felt patch is glued over the area. Note that the felt
is soaked by the glue, giving it a bluish coloration.
The area has been covered by cyanoacrylate
glue.
Aris A. Surgical repair of left ventricular free wall rupture. MMCTS (January 4, 2005)
Patch/glue repair
v 
Teflon felt patch / cyanoacrylate glue (butyl-2-cyanoacrylate monomer)
Aris A. Surgical repair of left ventricular free wall rupture. MMCTS (January 4, 2005)
v 
Goretex patch /enbrucrilate surgical glue
Canovas SJ. Surgery for left ventricular free wall rupture: patch glue repair without extracorporeal circulation. Eur J
Cardiothorac Surg. 2003 Apr;23(4):639-41.
v 
pericardial patches / cyanoacrylate glue, biologic bovine serum albumin and glutaraldehyde
glue (BioGlue)
Alamanni F. 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
v 
TachoComb sheet (equine collagen patch with human fibrinogen and human thrombin)
Muto A. et al. Sutureless repair with TachoComb sheets
for oozing type postinfarction cardiac rupture.
Ann Thorac Surg. 2005 Jun;79(6):2143-5
Surgical Experience With Left Ventricular Free Wall
Rupture!
MH. McMullan et al. Ann Thorac Surg 2001;71:1894 –9)!
4 out of 16 patients
who underwent in whom repair was performed with direct
suture closure over felt strips with or without preceding
infarctectomy
died as a result of rerupture 1 to 12 hours after operation!
Myocardial Laser Coagulation for Free Wall Rupture
Following Acute Infarction
T. Mizutani et al. Asian Cardiovasc Thorac Ann 2003;11:157-159
Continuous
blood effusion
from the
apical wall
Fibrinogen–thrombin glue
sprayed over the coagulated site
Noncontact laser
directed at the
hemorrhagic
myocardium
Patch reinforcement of the site
Long term prognosis
only patients who survived early postoperative period
v 
postdischarge survival - 85% (11/13), follow-up: median of 2.2 years (interquartile range
of 1.1–4.3 years) Eur J Cardiothorac Surg. 2003 Apr;23(4):639-41.
v 
no late cardiac deaths occured during mean follow-up: 45.8 +/- 6.6 months; range: 7–84
(11patients) Eur J Cardiothorac Surg. 2002 Nov;22(5):777-80
v 
all of 7 patients who survived the early postoperative period were long-term survivors,
follow-up was 79 months (range 1-15 years) there were 2 cardiac deaths – at 10, and 15
years postoperatively Ann Thorac Surg 2001;71:1894-1899
v 
on follow-up at a median of 2.2 years (interquartile range, 1.1 to 4.3 years), two deaths
occurred (2/13), one from myocardial infarction and another of undetermined etiology
Circulation. 2003;108[suppl II]: II-237-II-240
Long term prognosis
Ø  Five-year survival was 74%. The hazard for death was highest within the first 30 days.
Ø  While there was no rerupture during the follow-up period, 5 patients (out of 27)
developed dyskinetic LV aneurysm and one patient developed LV pseudoaneurysm
G. Sakaguchi et al. Ann Thorac Surg 2008;85:1344 –7)!
Summary
v 
free ventricular wall rupture is rare but related to high
mortality complication of myocardial infarction
v  early
v 
diagnosis is a key issue
patch/glue repair provides satisfactory long term results
Thank you for your attention