Repair of spontaneous rupture of the posterior wall of the left ventricle after mitral valve replacement

Abstract

One of the most serious complications in cardiac surgery is the occurrence of a rupture of the posterior wall of the left ventricle after mitral valve replacement. This is a challenging and often humbling experience to the cardiac surgeon, carrying a significant morbidity and mortality. The original reports of this complication were documented in the late 60s and early 70s. 1-3 Since then, multiple reports of isolated cases or short series have appeared in the literature, describing the events and proposing different technical approaches to prevent and correct the problem. The etiologic factors have become well recognized, and preventive measures, including new developments and technical approaches to mitral valve surgery, have reduced markedly the incidence of this problem and virtually eliminated the potential occurrence of certain types of left ventricular rupture. Three specific types of rupture are described (Fig 1) and they have been classified according to their anatomic location. 2,4 TYPE I A Type I rupture is located at the atrioventricular groove. This remains the most common site and can be seen in the following circumstances: ● Heavily calcified mitral valve annulus requiring considerable dissection and debridement of calcium sediment from the atrioventricular groove. ● Cases of bacterial endocarditis with mitral valve annular abscess, requiring extensive debridement at the time of mitral valve replacement.5 ● Resection of the posterior leaflet with placement of subannular sutures for valvular replacement, with consequent local trauma, hematoma, and rupture. ● Improper inspection of the left ventricular posterior wall after mitral valve replacement, by lifting the heart from the pericardial cavity, erroneously using the atrioventricular groove as a fulcrum.