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Surgical Treatment of Post-Infarction Left Ventricular Free Wall Rupture: Three Cases Review

Left ventricular free wall rupture (LFWR) is rare, but is one of the most serious complications of myocardial infarction and is associated with high mortality. Several operative techniques have been attempted, but early diagnosis and prompt surgical management are crucial for a positive patient outcome. We report three cases of LFWR successfully treated with surgical methods.


CASE REPORTS
Left ventricular free wall rupture (LFWR) is rare but one of the most serious complications of myocardial infarction, and is associated with high mortality. Early diagnosis and prompt surgical management are crucial for a positive patient outcome. We report three cases of LFWR successfully treated with surgical methods.

1) Case 1
A 66-year-old her patient was admitted to the emergency department with chest pain and dyspnea. His initial vital signs were a blood pressure of 94/63 mmHg with a pulse rate of 111 beats/min. Electrocardiographic (ECG) findings showed ST elevation in leads II and III and ST depression in lead V2. A chest X-ray showed increased pulmonary vascular markings suggestive of pulmonary edema. His serum tropo-nin-I levels were elevated. Echocardiography showed regional wall motion abnormalities of the lateral wall, and the left ventricular (LV) ejection fraction was less than 30%.
Emergency cardiac catheterization showed total occlusion of the mid-portion of the left anterior descending artery (LAD) and 75% focal stenosis of the diagonal branch ostium. There was also total occlusion of the distal left circumflex artery (LCX). Up to 50% diffuse luminal irregularity was observed from the proximal to the distal right coronary artery (RCA).
An intra-aortic balloon pump (IABP) was inserted due to the patient developing cardiogenic shock during cardiac catheterization. Three days later, the patient went into cardiac arrest after IABP removal. IABP and extracorporeal membrane oxygenation (ECMO) were instituted. Echocardiography showed cardiac tamponade, indicating that LFWR had occurred. An emergency operation was performed.
The operation was performed with a median sternotomy

2) Case 2
An 88-year-old female patient was admitted to the emergency department with loss of consciousness. She had only been treated for hypertension (HTN). Her initial vital signs were stable except that her body temperature had decreased to 32.8°C. Her blood pressure dropped suddenly to 67/23 mmHg. Septic shock was suspected and early goal-directed therapy was started. However, ECG findings showed T-wave inversion in leads V4-6, II, III, and aVF. Her serum troponin-I level was elevated, and echocardiography showed regional wall motion abnormalities of the lateral wall and pericardial effusion. Emergency cardiac catheterization showed total occlusion of the LCX and OM branches. The echocardiography was suggestive of a LV pseudoaneurysm and increased pericardial effusion (Fig. 1). An emergency operation was decided upon, with the suspicion of a concealed LV rupture.
The operation was performed with a median sternotomy.
After an inverted Y-shaped pericardiotomy, the hematoma was removed and irrigation was performed. Under CPB, multiple rupture points were observed in the LV lateral wall. The rupture was directly repaired with Prolene 5-0 continuous sutures. Aseptic industrial glue was applied and a Teflon patch was used to cover the rupture site. Furthermore, the bovine pericardium was sutured with 5-0 polypropylene running sutures with a 2-cm-long lateral margin. Tisseel (Baxter Healthcare, Deerfield, IL, USA) was injected between the bovine pericardial patch and the epicardium to enhance the compressing sutured tear point and to prevent blood leakage.
Tachocomb (Nycomed Pharma, Linz, Austria) was placed over the suture site. The patient was successfully weaned from CPB and transferred to the intensive care unit (ICU).
On the second postoperative day, the patient was extubated.
On the third postoperative day, the patient was reintubated because of desaturation and dyspnea, and extubated again on the fourth postoperative day. On the 10th postoperative day, the patient was transferred to the general ward. The patient was discharged on the 17th postoperative day.

3) Case 3
A 48-year-old male patient was admitted to the emergency

DISCUSSION
LFWR is a life-threatening complication of myocardial infarction. The incidence is 2% to 4% after acute myocardial infarction, and mortality has been reported to range from 12% to 20% [1].
Old age, being female, experiencing the first myocardial infarction or transmural infarction, a high systolic blood pressure, an absence of heart failure before rupture, prolonged angina, delay of hospitalization, excessive in-hospital physical activity, a lower body mass index, and a longer time to reperfusion are all reported to be risk factors of LFWR [2].
Early intervention reduces the infarct size and incidences of ventricular rupture [2].
Two types of rupture have been noted based on intraoperative findings. In blow-out type ruptures, a macroscopic tear or defect in the epicardium with free communication between the LV cavity and the pericardial space can be seen; in oozing type ruptures, no macroscopic tears can be detected [3].
Patients can present with any of the following: chest pain, syncope, jugular vein distention, hypotension, arrhythmias, nausea, or pulsus paradoxus. A sudden onset of shock, hemodynamic instability due to cardiac tamponade, or cardiac arrest can occur. Our patients also each showed a different presentation, specifically, delayed rupture 3 days after acute myocardial infarction presenting as cardiac arrest, concealed rupture resulting in pseudoaneurysm and misdiagnosis as septic shock, and an oozing type rupture accompanied by embolic stroke and altered mental state.
Echocardiography is the diagnostic method of choice for LFWR. A localized pericardial effusion over the infarcted akinetic area is the most common echocardiographic finding in cases of LFWR. Echogenic 'specks' within the effusion and visible wall defects are other signs of LFWR [4].
Contrast echocardiography is helpful in the direct visualization of myocardial tears and in demonstrating the extent of a pseudoaneurysm [5].
The definitive treatment for LFWR is emergency surgical repair. Various operative techniques have been applied, including pericardial patch placement with biological glue or epicardial sutures, infarctectomy with patch placement and ventricular wall reconstruction, pledgeted sutures without infarctectomy, and pericardial, Dacron, Goretex, or Teflon patches adhered with biologic glue or sutures [6]. Sutureless techniques include gelatin-resorcin-formalin (GRF glue: Cardial, Saint-Etienne, France) applied to a bovine pericardial  Table 1). All of the methods were successfully performed without any operative mortality. The first and third patient had early postoperative complications and the second patient had no early postoperative complications, even though she was of old age and a female patient who had been treated for HTN. The postoperative course of the first patient was the worst because the diagnosis was delayed to the third hospital day and cardiac arrest occurred after IABP removal.
In conclusion, LFWR is rare, but one of the most serious complications of myocardial infarction, and is associated with high mortality. The surgical treatment of LFWR remains challenging. We report three cases of LFWR successfully treated with surgical management without mortality. Early di-agnosis and prompt surgical intervention can increase patient survival.