Left Ventricular Free Wall Rupture Research Articles

急性心筋梗塞に合併した左室自由壁破裂の修復術1カ月後の再破裂が疑われた1例

症例は67歳，女性．冷汗を伴う胸痛を主訴に当院へ救急搬送され，心電図および心エコー所見より急性前壁心筋梗塞の診断にて緊急入院した．緊急冠動脈造影にて左冠動脈前下行枝近位部の完全閉塞を認め，ベアメタルステント留置にて再灌流に成功した．第2病日にoozing typeの左室自由壁破裂を発症し緊急左室自由壁破裂修復術を施行した．左冠動脈前下行枝から約5 cm離れた左室自由壁に破裂孔を認め，フィブリノーゲンシートにより止血した．術後経過は良好であり，リハビリを進めていた．第27病日に突然心停止を来し，心エコー所見より左室自由壁の再破裂と診断し，心肺蘇生を行ったが救命困難であった．剖検では，梗塞巣にフィブリノーゲンシートが癒着し急性期の破裂孔の閉鎖が確認された．2度目の破裂孔は確認できなかったが，左室前壁から中隔にかけての出血壊死および後縦隔と胸腔内への出血を認め，同部位の修復術1カ月後の再破裂と考えられた．

心筋梗塞後の左室自由壁破裂についての検討

左室自由壁破裂(LVFWR)は心筋梗塞(AMI)後の重篤な合併症であり，予後は悪いとされている．今回，当院でのLVFWR症例の手術成績と，リスク因子を検討した．1996年1月から2012年8月までに，LVFWRと診断し，緊急手術を施行した12例(男性9例，女性3例)を対象に検討を行った．破裂型は，oozing型が7例，blow-out型が5例であった．手術はoozing型に対してsutureless法を，blow-out型に対して直接縫合閉鎖を施行した．手術死亡は4例であり，oozing型で1例，blow-out型で3例であった．Blow-out型で救命できた症例では，死亡症例より有意に手術時間が短かった．Oozing型症例におけるsutureless法は有用であると考えられた．また，blow-out型症例に対しては，手術は止血を優先し，可及的短時間で手術を終えることが肝要と考えられた．

Left ventricular free wall rupture during late mechanical reperfusion for acute myocardial infarction

Left ventricular free wall rupture during late mechanical reperfusion for acute myocardial infarction

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.

Pseudoaneurysm after sutureless repair of left ventricular free wall rupture: Sequential magnetic resonance imaging demonstration

Sutureless repair is an effective procedure for acute left ventricular free wall rupture; however, it may be complicated with a left ventricular pseudoaneurysm during the late postoperative period. We present a case of a large ventricular pseudoaneurysm that occurred after the sutureless repair of an inferior myocardial infarction with oozing left ventricular free wall rupture. The patient underwent aneurysmectomy successfully. Serial magnetic resonance imaging (MRI) indicated that the necrotic left ventricular wall, which was covered by Teflon felt, had ruptured and developed a pseudoaneurysm. Therefore, after simple gluing for a left ventricular free wall rupture, patients should undergo careful follow-up evaluation for potential pseudoaneurysm. Moreover, early detection by MRI and prompt surgical repair of the complication are important in patients with left ventricular free wall rupture.

Clinical manifestation of early phase left ventricular rupture complicating acute myocardial infarction in the primary PCI era

ObjectiveBefore reperfusion therapy was introduced, the incidence of ventricular septal and left ventricular free wall rupture complicating acute myocardial infarction (AMI) was 1–3%. Primary percutaneous coronary intervention (PCI) was expected to reduce the incidence of such mechanical complications. MethodsWe retrospectively analysed 1290 AMI patients referred to our institute from January 2005 to January 2011. Primary PCI was done in 1002 cases of the study patients (77.7%). ResultsVentricular septal rupture (VSR) occurred in 19 cases (1.5%) and left ventricular free wall rupture (LVFR) in 17 cases (1.3%). Mean observation periods from onset to VSR and LVFR were 2.6 days. We demonstrated that risk factors for LV rupture were advanced age, female sex, absence of history of angina or myocardial infarction, lack of previous PCI, and absence of previous hypertension. Coronary angiography revealed that the culprit lesions of the left anterior descending artery or single vessel disease were the risk factors for LV rupture. Furthermore, in the present observation, 9 patients (47.4%) with VSR and 8 patients (47.1%) with LVFR developed LV rupture within 24h after symptoms onset (early rupture). The early rupture demonstrated extremely poor outcome compared with late rupture (in-hospital mortality was 88.2% in early rupture and 63.1% in late rupture). ConclusionEven in the patients’ cohort with higher prevalence of primary PCI, LV rupture cases were not decreased in contrast to our expectations. More attention should be paid to early LV rupture cases within 24h from symptom onset in those cases.

Surgery for left ventricular pseudoaneurysm: thoracotomy or sternotomy

We experienced 2 cases of left ventricular pseudoaneurysm located at the posterolateral wall. Case 1 was an 80-year-old woman who developed a left ventricular pseudoaneurysm 4 months after sutureless repair of left ventricular free wall rupture due to acute myocardial infarction. The pseudoaneurysm was repaired through a left thoracotomy. Case 2 was a 77-year-old woman who was diagnosed with left ventricular pseudoaneurysm incidentally by computed tomography. Aneurysmorrhaphy was conducted through a standard median sternotomy.

Off-Pump Multilayered Sutureless Repair for a Left Ventricular Blowout Rupture Caused by Myocardial Infarction in the Second Diagonal Branch Territory

A left ventricular (LV) free wall rupture is a highly lethal condition. A 78-year-old female, who collapsed while riding a bike, was admitted to our emergency service 7 days after experiencing chest pain. During admission, she had cardiopulmonary arrest. Though cardiopulmonary resuscitation was successful, computed tomography (CT) showed cardiac tamponade. Emergency surgery was then performed. Pericardiotomy revealed a postinfarction blowout rupture of an aneurysm (2 × 3 × 1 cm) on the anterolateral wall of the LV. The top of the aneurysm had a 2-mm wide blowing blood column. Intra-aortic balloon pumping was initiated. An off-pump multilayered sutureless repair using squares of collagen fleece with fibrinogen-based impregnation (i.e., TachoComb) and gelatin-resorcin-formalin glue (GRF glue) was performed. Postoperative coronary angiography revealed occlusion of the second diagonal branch. The patient was free from re-rupture or aneurysm enlargement. An LV blowout rupture, which was caused by myocardial infarction with a limited tear and necrotic area at the second diagonal branch territory, was successfully treated with an off-pump multilayered sutureless repair by using a TachoComb and GRF glue patch. The thickness of the hemostatic material seemed to help control the bulging of the aneurysm and to prevent further LV aneurysm enlargement and re-rupture.

症例 急性心筋梗塞後左室自由壁破裂および心室中隔穿孔の術後低心拍出量症候群により,治療に難渋した1例

症例 急性心筋梗塞後左室自由壁破裂および心室中隔穿孔の術後低心拍出量症候群により,治療に難渋した1例

Left ventricular rupture without obstructive coronary artery disease

A 48-year old man complained of dyspnoea and palpitation for 6 h. There was no history of trauma and angina. The initial ECG and laboratory tests showed no evidence of myocardial infarction. Computed tomographic angiography revealed left ventricular free wall rupture while coronary angiography was negative. Surgical intervention was carried out, and the perforation was repaired (Figs 1 and 2). He recovered uneventfully.

Early pseudoaneurysm formation after the sutureless technique for left ventricular rupture due to acute myocardial infarction

Left ventricular free wall rupture is a fatal and catastrophic complication after acute myocardial infarction. The sutureless technique with a fibrin tissue-adhesive collagen fleece is reportedly safe and effective in the oozing type of left ventricular free wall rupture. However, late pseudoaneurysm formation after this technique has been reported. We herein report a 65-year-old male patient who presented with pseudoaneurysm formation 8days after the sutureless technique for the oozing type of left ventricular free wall rupture. Successful repair of the pseudoaneurysm was subsequently performed. Pseudoaneurysm formation should be recognized even early after the sutureless technique.

Idiopathic Left Ventricular Rupture in the Absence of Coronary Artery Disease

Idiopathic cardiac rupture in the absence of coronary artery disease is rare. We describe a case of idiopathic left ventricular free wall rupture with successful surgical repair.

PP-173 LEFT VENTRICULAR PSEUDOANEURYSM FORMATION DUE TO FREE WALL RUPTURE

A 66 year old male patient admitted with chest pain on exertion. His coronary angiography revealed total occlusion of first obtuse marginal branch. Cardiac CT and MRI were performed and demonstrated left ventricular free wall rupture leading to pseudoaneurysm formation (Figure 1, Video 1). Cardiac CT image (Figure 1B) illustrates left ventricular free wall rupture on posterolateral aspect with pseudoaneurysm formation. Cardiac MRI (Figure 1C) revealed the defect on left ventricular free wall. The size of the defect was 20.4 mm in cranio-caudal direction. The dimensions of the pseudoaneurysm sac were measured as 49.5X42.4X46.7 mm. The patient refused surgical treatment. Figure1. Chest X-ray image (A), Cardiac CT image (B), Cardiac MRI image (C) Video 1. Cardiac MRI demonstrating the defect on left ventricular free wall and pseudoaneurysm formation.

Successful infarct exclusion for postinfarction left ventricular free wall rupture

The mortality of postinfarction left ventricular free wall rupture is still high. Several surgical techniques have been used for repairing such ruptures. Here, we describe using an infarction exclusion technique to successfully treat a case of a blow-out type postinfarction left ventricular free wall rupture. This technique has frequently been used for repairing postinfarction ventricular septal perforation. In this case, infarcted myocardial tearing was prevented, and complete haemostasis was achieved by infarct exclusion.

Hemolytic Hyperbilirubinemia After Percutaneous Device Closure of Left Ventricular Pseudoaneurysm: A Disregarded Complication

Surgical repair of a left ventricular pseudoaneurysm is challenging. Percutaneous closure with an AMPLATZER Septal Occluder (AGA Medical Corporation, Golden Valley, MN) has evolved to be an effective alternative to conventional surgery with less complication. We report a case of severe hemolytic hyperbilirubinemia and acute renal failure after percutaneous left ventricular pseudoaneurysm endoprothesis repair, which required conventional surgical repair through a left thoracotomy to treat this complication. The rationale and results of such an off-the-label usage of AMPLATZER Septal Occluder were reexamined. Residual leakages were not rare findings in the reviewed literature. The indications for this approach should be individualized.

自転車にて来院した心筋梗塞後左室自由壁破裂の1例

症例は69歳の男性で，全身倦怠感を主訴に前医を自転車で受診した．心電図，心エコー，CTにて急性心筋梗塞後の左室自由壁破裂が疑われ，当院に救急搬送された．循環動態は非常に安定しており，意識消失やショック症状は認めなかった．冠動脈造影検査にて左前下行枝の閉塞が認められた．緊急手術を行ったが，循環動態が安定していたため，まず左内胸動脈を採取した．心嚢内は血腫で充満しており，心尖部に約2cmの亀裂がありblow out型の左室自由壁破裂であったと診断したが，出血は認めなかった．タココンブ®とフィブリン糊によるsutureless法による修復を行った．同時に大動脈内バルーンパンピングにて左室圧を軽減した．体外循環を用いることなく左内胸動脈を左前下行枝に縫合する冠動脈バイパス術を行った．術後経過は良好で術後25日に軽快退院した．自転車で受診した循環動態の安定した左室自由壁破裂の稀な症例であった．

Transcatheter closure of left ventricular free wall rupture with Amplatzer atrial septal defect occluder

Left ventricular free wall rupture is a dramatic complication of acute myocardial infarction and is presumably responsible for as much as 20–30 % of all infarct-related deaths [1]. Surgical management is essential [2]. Needle pericardiocentesis is the conventional treatment of cardiac perforation [3]. A 79-year-old man in evolving cardiogenic shock (BP 70/40) mmHg, sinus tachycardia (120 beats/ min) was transferred to our regional cardiac center. ECG showed ST-segment elevation in II, III, aVF and V4–6 leads. Emergency coronary angiography was performed, and totally occluded obtuse marginalis and nonsignificant stenosis in others coronary arteries were detected (Fig. 1a). Bedside transthoracic echocardiography (TTE) revealed LV regional wall motion abnormality and cardiac tamponade. Cardiac rupture was detected at the LV apex. TTEguided pericardiocentesis was performed immediately. However, there was no drainage from the catheter. Hemoglobin decrease was approximately 4 mg/dL during this time. We have decided to try percutaneous closure due to lack of 7/24 surgical backup. The procedure was applied in order to gain time; as a bridge for surgery. The procedure was an emergency and the defect size was only measured with transthoracic echo and a standard Amplatzer TorqVue delivery system was used through a 7F sheath. A 10, 5-mm Amplatzer occluder (Amplatzer occluder is from St. Jude Medical) was deployed (Fig. 1b). The operation was finished in 15 min. A subsequent TTE showed the defect was successfully occluded with only a trivial residual leak (Figs. 2a, 3). The patient slightly recovered after the procedure, blood pressure could be recorded but he was still in cardiogenic shock due to the impossibility of removing the agglutinant pericardial effusion. Therefore, the patient was transferred to the operation room (Fig. 2b). A large haemorrhagic pericardial effusion was seen and the entire heart was covered in a thick fibrinous peel. But he died 6 h after the initial chest pain. This case confirms that transcatheter closure of ventricular free wall rupture with an occluder device is a bailout strategy in very skilled centers for selected cardiogenic shock patients in the absence of on-site cardio-thoracic support.

Intra-pericardial thrombin injection for post-infarction left ventricular free wall rupture

Left ventricular free wall rupture (LVFWR) is a fatal complication of acute myocardial infarction. Different modalities of treatment were previously described, including surgical intervention and medical treatment. We report a case treated with intra-pericardial thrombin injection that gave a favourable outcome for a patient who presented with LVFWR and cardiac tamponade, following acute myocardial infarction.

Pulseless electrical activity after myocardial infarction: not always a left ventricular free wall rupture

Pulseless electrical activity (PEA) after acute myocardial infarction is classically caused by ventricular free wall rupture. We report the case of a 76-year-old woman who presented a cardiac arrest with PEA 5 days after an embolic acute myocardial infarction. Transthoracic echocardiogram showed a massive mitral regurgitation due to posterior papillary muscle rupture. This case demonstrates that other causes potentially treatable than cardiac tamponade must be sought in patients with PEA after myocardial infarction.

Takotsubo cardiomyopathy resembling acute high lateral myocardial infarction

A 65-year-old female patient admitted to the emergency department was diagnosed with acute high lateral myocardial infarction, but later Takotsubo cardiomyopathy (TC) was discovered. She had squeezing chest pain that started shortly after an emotional stress. The electrocardiogram revealed a loss of R wave voltage in leads V1 to V4 and an ST-segment elevation in I and aVL. After an urgent coronary angiography and ventriculography, TC was considered, and supportive anti-ischemic treatment was started. The severe left ventricular systolic dysfunction improved and normalized during the follow-up. She was discharged without any complications. TC is a new entity of acute cardiac events, and patients usually recover completely without sequelae with proper diagnosis and management. An exact diagnosis may also prevent an inappropriate application in the setting of recurrences.