Simple methods to repair postinfarction ventricular free wall rupture

Recent methods in the managemant of acute myocardial infarction have decreased the overall mortality, but the number of cardiac rupture among these patients remained relatively high. Surgical approach has also changed, and in its sub-acute form a lifesaving intervention is often possible.

From 1. of January 2003 to December 2005 we have performed 3842 percutaneous ballon dilatation on patients with developing myocardial infarction. During this period we recognized 31 cases of cardiac free wall rupture (0.81%). 12 patients died almost immediately, autopsy revealed complete cardiac rupture. Other patients (average age: 73 years) presenting with sudden hypotension and electromechanical dissociation underwent echocardiographic examination, where the diagnosis of cardiac tamponade was comfirmed. Stabilizing the status with pericardiocentesis, inotropic support, intra-aortic ballon pump assistance and mechanical ventilation, and controlling hemostasis, bleeding ceased in 13 cases, and no further intervention was necessery. At six patients bleeding has continued, and intrapericardial haematoma increased, so they were delivered to the operating room.

Operative technique was chosen according to the intraoperative findings. Median sternotomy was performed, but extracorporeal circulation was not established. One patient 4 hours after left anterior descending artey stenting had a split-like lesion on the anterior wall of the left ventricle with a pulsatile bleeding. A pledgeted stitch was placed around it, and then covered with absorbable hemostat (TachoComb Nycomed Austria GmbH). This hemostat alone was used in three other cases with an oozing type of rupture on the posterolateral left ventricular wall. Two other patients with right coronary occlusion had large posterior wall necrosis with more profuse bleeding. In these cases activated thrombin solution was injected intramurally, and the whole surface was covered with autologous pericardium adhered with fibrin glue (Beriplast, Aventis Pharma, AG, Frankfurt, Germany).

There were no on table deaths, one patient died 10 days after the operation due to low cardiac output syndrome, at autopsy no blood was found in the pericardium. Six patients were discharged with acceptable cardiac function. At followup aneurysm formation or false aneurysm formation could not be detected.

Early diagnosis and adequate interventional and surgical treatment of cardiac free wall rupture can decrease the very high mortality of complication of myocardial infarction.