Left Ventricular Perforation Research Articles

Giant Left Ventricular Aneurysm Perforation: Appearance in Echocardiography, 64-Slice Spiral Computed Tomography, Magnetic Resonance Imaging, and Coronary Angiography before Successful Surgical Treatment

Giant Left Ventricular Aneurysm Perforation: Appearance in Echocardiography, 64-Slice Spiral Computed Tomography, Magnetic Resonance Imaging, and Coronary Angiography before Successful Surgical Treatment

Percutaneous closure of a postinfarction ventricular septal defect and an iatrogenic left ventricular free‐wall perforation using two Amplatzer muscular VSD occluders

A 83-year-old woman underwent percutaneous closure of postinfarction ventricular septal defect following anteroseptal myocardial infarction and percutaneous coronary intervention with stent implantation of the left anterior descending coronary artery. Postinfarction percutaneous ventricular septal defect closure was initially complicated by an iatrogenic left ventricular free-wall perforation. Both defects were closed using two Amplatzer muscular VSD occluders during the same session.

Left ventricular perforation during cardiac catheterization in a case of severe calcific aortic stenosis. Should we cross the valve?

With the availability of better hardware and refinements in catheterization techniques, perforation of cardiac structures at cardiac catheterization is a rare event. We report, a 54-year old male who developed LV rupture during a pre-aortic valve replacement catheterization with ensuing tamponade, after several attempts were made to cross a heavily calcified aortic valve. The issues regarding whether the calcific aortic valve should be crossed when reliable echo and color Doppler information is available are discussed along with recent recommendations.

Transcatheter repair of iatrogenic left ventricular free‐wall perforation

Left ventricular free-wall perforation can complicate catheter-based diagnostic or interventional procedures and may require immediate needle pericardiocentesis followed by surgical repair in about 20% of the cases. We describe the transcatheter closure of a left ventricular free-wall perforation as an option in the event of maintained access to the perforation site after defect creation.

A Blinded, Randomized, Placebo-Controlled Trial of Percutaneous Laser Myocardial Revascularization to Improve Angina Symptoms in Patients With Severe Coronary Disease

This study was a randomized, patient- and evaluator-blinded, placebo-controlled trial in patients treated using percutaneous myocardial laser revascularization. Previous studies using similar therapies have been confounded by placebo bias. A total of 298 patients with severe angina were randomly assigned to receive low-dose or high-dose myocardial laser channels or no laser channels, blinded as a sham procedure. The primary end point was the change in exercise duration from baseline examination to six months. The incidence of 30-day death, stroke, myocardial infarction, coronary revascularization, or left ventricular perforation occurred in two patients in the placebo, eight patients in the low-dose, and four patients in the high-dose groups (p = 0.12); 30-day myocardial infarction incidence was higher in patients receiving either low-dose or high-dose laser (nine patients) compared with placebo (no patients, p = 0.03). At six months, there were no differences in the change in exercise duration between those receiving a sham (28.0 s, n = 100), low-dose laser (33.2 s, n = 98), or high-dose laser (28.0 s, n = 98, p = 0.94) procedure. There were also no differences in the proportion of patients improving to better than Canadian Cardiovascular Society class III angina symptoms at six months. The follow-up visual summed stress single-photon-emission computed tomography scores were not significantly different from baseline in any group and were no different between groups. The modest improvement in angina symptoms assessed by the Seattle Angina Questionnaire also was not statistically different among the arms. Treatment with percutaneous myocardial laser revascularization provides no benefit beyond that of a similar sham procedure in patients blinded to their treatment status.

Emergency surgery after percutaneous transmitral commissurotomy: Operative versus echocardiographic findings, mechanisms of complications, and outcomes

This study was undertaken to determine the clinical profile of patients undergoing emergency surgery after balloon mitral valvotomy, to note operative findings and compare them with those of transthoracic echocardiography, to describe the mechanisms of complications, and to describe outcomes. A retrospective study was undertaken of patients requiring emergency surgery after percutaneous mitral valvotomy with an Inoue balloon from January 1990 to December 2003. The data analyzed included demographic variables, causes and clinical presentations of complications, and outcome. In 14 consecutive cases of mitral regurgitation, an observational study comparing the operative findings with echocardiography was also undertaken. In 1388 cases of valvotomy, complications necessitating urgent surgery occurred in 31 cases (2.2%). Acute mitral regurgitation occurred in 23 cases (74.2%), and cardiac tamponade occurred in 8 cases (25.8%). Mitral regurgitation was due to leaflet tearing in all cases: anterior leaflet in 20 cases and posterior leaflet in 3 cases. Hypotension, orthopnea, and pulmonary edema were the clinical presentation for mitral regurgitation. Transthoracic echocardiography underestimated the severity of mitral valve pathology. Bilateral severe commissural fusion and pliable leaflet with paracommissural calcium was seen in anterior leaflet tearing. Cardiac tamponade with hemodynamic compromise occurred as a result of left atrial perforation in 6 cases, right atrial perforation in 1 case, and left ventricular perforation in 1 case. High septal puncture led to atrial perforation. Operative mortality was 9.6%, and low cardiac output developed in 29%. Acute mitral regurgitation and cardiac tamponade were the causes of emergency surgery after balloon valvotomy. Transthoracic echocardiography underestimated the severity of valve pathology.

Surgical treatment for complications of acute myocardial infarction

We report the results of surgical repair for postinfarction left ventricular free wall rupture (LVFR) and ventricular septal perforation (VSP) complicating acute myocardial infarction. We experienced 14 LVFRs and 10 VSPs from January 1991 to December 2002. The mean age of patients with LVFR was 74+/-8.1 years. There were 6 oozing cardiac ruptures and 8 blowout cardiac ruptures. An intraaortic balloon pump (IABP) was inserted in 8 patients, and percutaneous cardiopulmonary support (PCPS) was inserted in 5 patients. The mean age of patients with VSP was 72+/-5.1 years. The rupture was located within the anterior septum in 8 patients and within the posterior septum in 2 patients. All patients required IABP, and one of them needed PCPS. We employed a sutureless technique in 8 patients, direct closure in 5 patients, and infarct exclusion in 1 patient with LVFR. Infarct exclusion was conducted in 9 patients, and the da Silva technique was used in 1 patient with VSP. The patient survival rate of LVFR was 36% (blowout 13%; oozing 67%). Residual shunt occurred in 4 patients with VSP postoperatively. The overall survival rate for VSP was 70%. The operative prognosis of blowout cardiac rupture was poor. Good results were obtained with the infarct exclusion technique for patients with VSP. Although some patients had postoperative residual shunts, the infarct exclusion technique was generally a safe and excellent procedure.

Type 2 diabetes mellitus

A clinical or pathologic event caused by myocardial ischemia when there is evidence of myocardial injury or necrosis is named as myocardial infarction. Acute ST elevation myocardial infarction (STEMI) is a medical emergency that requires application of multiple therapies at the same time. The first step in the management of the patient with an acute STEMI is early diagnosis, because reperfusion therapy can result in great benefit when performed early. In the emergency department, STEMI can be diagnosed in patients with chest pain suspicious for an acute coronary syndrome, by the electrocardiogram. Biomarkers may be normal in the first examination. The reperfusion approach of infarct-related artery by either percutaneous coronary intervention or fibrinolytic therapy can improve survival in comparison with no reperfusion approach. STEMI complications include arrhythmia (especially ventricular tachyarrhythmia) and conduction abnormalities, mechanical complications (left ventricular free wall rupture, mitral regurgitation, and perforation of the interventricular septum), and pericardial complications of myocardial infarction.

Surgical management of complications after transcatheter closure of an atrial septal defect or patent foramen ovale

Objective: During recent years, transcatheter closure has become an alternative to operations for the treatment of atrial septal defects and patent foramen ovale. However, this procedure may be unsuccessful or complicated and requires surgical treatment. Methods: We retrospectively analyzed the outcomes of patients who needed surgical treatment after failed or complicated transcatheter closure of an atrial septal defect or a patent foramen ovale. Results: Between April 1994 and March 1999, 124 patients were treated with transcatheter closure of an atrial septal defect or a patent foramen ovale at our institution. We report the results of 10 (8%) patients of this series who required operations after transcatheter closure attempts. In 8 of these 10 patients a significant shunt caused by malposition or dislocation of the device persisted, leading to surgical closure of the defect. In 2 patients injury of the femoral artery at the puncture site required surgical repair. In one patient the device had to be removed surgically from the iliac vein after retraction. One patient died of left ventricular perforation after dislocation of the device and several surgical attempts to close the left ventricular rupture. All other patients recovered well. Conclusion: An operation was required after transcatheter closure of an atrial septal defect or a patent foramen ovale in 8% of patients. After device complications, the atrial septal defect and the patent foramen ovale can still successfully be closed surgically with good results and low morbidity. However, serious complications like cardiac perforation may have a fatal outcome. Residual shunt, dislocation, or vascular complications are the most frequent problems that require surgical interventions. (J Thorac Cardiovasc Surg 2000;120:1034-9)

Evaluation of the acute and chronic safety of the biosense injection catheter system in porcine hearts.

Direct myocardial injection of therapeutic agents has been explored as a new method for myocardial revascularization. The integration of a 3D electromechanical mapping catheter with a retractable injection needle should allow for intramyocardial injection to identified sites, obviating the need for open heart surgery. This study assessed the procedural safety and performance characteristics of a novel guided catheter-based transendocardial injection system. The electromagnetic guidance system was coupled with a retrievable 27G needle for left ventricular endocardial injection. Using this system, we injected, transendocardially, methylene-blue (MB) dye tracer at a volume of 0.1 or 0.2 ml per injection in eight normal pigs. Animals were sacrificed acutely, at 1, 3, and 7 days (two animal in each time). Three animals served as controls. The injections were followed by coronary angiography and echocardiogram to assess possible ventricular or coronary perforation and wall motion abnormalities. CK-MB levels were measured up to 24 hr following the procedure. The animals were sacrificed at the assigned time for gross and histopathology evaluation. A total of 101 injections were made in all regions of the heart except the apex and the mitral valve. No animal died as a result of the mapping or injection procedures. Vital signs did not change relative to baseline after the mapping and injection procedures. CK-MB values did not increase over time and there was no evidence of sustained arrhythmia or hemodynamic compromise. There was no evidence of left ventricular or coronary perforation, global or regional wall motion abnormalities, or hemopericardium. On histologic evaluation, the estimated volume of tissue staining was greater than the volume of the injected MB dye due to dispersion of the injectate in the interstitial and intracellular fluid compartments. It is concluded that using this magnetic guidance catheter-based navigational system, it is feasible and safe to perform the transendocardial injection procedure. Thus, if it is determined that direct intramyocardial injection of drugs is a valid therapeutic strategy, this approach offers a clear advantage over surgically based transepicardial injection procedures. Cathet. Cardiovasc. Intervent. 48:447-453, 1999.

Percutaneous closure of a left ventricular perforation post balloon mitral valvotomy

Percutaneous closure of a left ventricular perforation post balloon mitral valvotomy

Left Ventricular Perforation During Percutaneous Balloon Mitral Valvuloplasty With Emergency Surgery

Two cases of left ventricular (LV) perforation by balloon catheter following successful balloon mitral valvuloplasty are presented. The first patient was dilated first with a single straight‐tip balloon catheter and after with a double balloon catheter. The second patient underwent a valvuloplasty with a double balloon catheter only. The subsequent tamponade was treated by immediate aspiration but without hemodynamic improvement. Both patients required emergency surgery with surgical repair of the LV apex, and both of them could be weaned. Both patients are well 18 months after the procedure. We discuss the mechanism of this serious complication and technical considerations to prevent it.

Mechanisms of cardiac perforation leading to tamponade in balloon mitral valvuloplasty.

Mechanisms of cardiac perforation in 10 cases of cardiac tamponade encountered in a single-center series of 903 balloon mitral valvuloplasty procedures were elucidated by precise localization of the site of perforation at subsequent surgery. These mechanisms were perforation of the aortic root and adjacent right atrium by sliding up of the transseptal set (2), apical tears by straight-tip balloon catheters driven distally during mitral valve dilatation (3), apical perforations by guidewires introduced through catheters wedged in the apex (2), tear of the posterior right atrial wall by dilatation of the track produced by very low septal punctures (2), and right ventricular perforation by a pacing catheter (1). Multivariate analysis showed cardiac perforation to be significantly related to the total experience at the center (inversely) and to patient age (directly). Left ventricular perforation occurred exclusively in patients > 40 yr of age. Understanding these mechanisms has enabled formulation of effective strategies to prevent cardiac perforation.

Letter to the Editor

The recent article on left ventricular perforation with Gensini catheters by Davis et al. [ 1 Davis GK, Au J, Roberts D. Myocardial perforation associated with the use of the Gensini ventriculography catheter. Int J Cardiol 1996;53:103–106. Google Scholar ]and the accompanying editorial remark by de Bono [ 2 de Bono D. Safety of left ventriculography in aortic stenosis. Int J Cardiol 1996;53:107–108. Google Scholar ]deserve a few comments.

941-20 Safety of Cardiac Biopsy Based on the 32-year Experience in Japan

In order to estimate the safety of cardiac biopsy, questionnaires were sent to 852 Japanese institutions, where cardiac specialists work. We received replies from 214 institutions (25%), which were considered to include almost all major institutions performing cardiac biopsy in Japan. Cardiac biopsy was carried out in 134 institutions (63%), 5.5 times more than in Sekiguchi's survey in 1980. A total of 19,964 biopsies were performed in Japan from 1960 to 1992, 2,452 in one recent year. Diseases submitted included dilated cardiomyopathy (27.3%), hypertrophic cardiomyopathy (29.6%), constrictive cardiomyopathy (0.6%), myocarditis (13.0%), other specific heart muscle diseases (11.8%) and the others (17.7%). One hundred thirteen institutions took specimens from the right ventricle and 76 institutions from the left ventricle. The Konno-Sakakibara bioptome was used in only 32 institutions and the long sheath method in the others. The average number of specimens was 2.8 from right ventricle and 2.2 from left ventricle. Ventricular perforation occurred in 146 (115: right ventricle, 31: left ventricle) of the 19,964 cases (0.7%). No other major complication was reported. The mortality during the procedure was 0.05% (10/19,964 cases). Six of the 115 cases (5.2%) of right ventricular perforation and 4 of the 31 cases (12.9%) of left ventricular perforation died. The mortality was significantly higher in the case of left ventricular perforation (p < 0.05). Based on the experience in Japan for 32 years, the mortality associated with cardiac biopsy was 0.05%, which was the same as for coronary angiography and considered sufficiency low.

Emergent percutaneous cardiopulmonary bypass in patients having cardiovascular collapse in the cardiac catheterization laboratory

Percutaneous cardiopulmonary bypass (PCB) was instituted in 30 initially stable patients who developed either cardiac arrest refractory to resuscitation (n = 7) or cardiogenic shock (mean arterial blood pressure <50 mm Hg unresponsive to fluid resuscitation or vasopressors) (n = 23) after a cathetertzation laboratory complication. Events leading to collapse included abrupt closure during percutaneous transluminal coronary angioplasty (PTCA) (n = 22), complications from diagnostic cardiac catheterization (n = 6), left ventricular perforation during mural valvuloplasty (n = 1), and right ventricular perforation during pericardiocentesis (n = 1). PCB was initiated within 20 minutes of cardiovascular collapse in 83% of patients (arrest: 21 ± 13 minutes [range 10 to 50]; and shock: 17 ± 6 minutes [range 10 to 30]). Mean arterial blood pressure increased on PCB from 0 to 56 mm Hg in patients with cardiac arrest and from 37 to 63 mm Hg in those with cardiogenic shock at mean PCB flow rates of 2.5 to 5.0 liters/min. Subsequent therapy on PCB included emergent cardiac surgery (n = 14), PTCA (n = 13) and medical therapy (n = 3). Six patients (20%) survived to hospital discharge (3 with cardiac surgery, 2 with PTCA, and 1 with medical therapy). All 7 patients with refractory cardiac arrest died despite further interventions on PCB, whereas 6 of 23 (26%) with cardiogenic shock survived to hospital discharge. Thus, in response to cardiovascular collapse in the catheterization laboratory, PCB does not salvage patients who do not regain a stable cardiac rhythm. PCB can stabilize patients who develop cardiogenic shock for further interventions which are lifesaving in only a minority of patients.

Balloon dilatation (valvoplasty) as first line treatment for severe stenosis of the aortic valve in early infancy: medium term results and determinants of survival.

To assess the results of balloon dilatation of the aortic valve as first line treatment for infants presenting in the first two months of life with cardiac failure caused by severe aortic stenosis. A prospective study of all such infants presenting to a single centre over a three year period. Of 14 consecutive infants aged < 2 months presenting with heart failure due to severe stenosis of the aortic valve, 12 underwent balloon dilatation of the valve. Two infants with hypoplastic left heart syndrome were excluded. Six patients had other significant cardiac malformations, nine had endocardial fibroelastosis. Four infants were moribund at presentation. Balloon dilatation was performed through the femoral artery under general anaesthetic, with heparin and antibiotic prophylaxis. Maximum inflated balloon size was selected as equal to or slightly less than the diameter of the aortic valve measured echocardiographically. In two infants balloon dilatation of coexistent severe coarctation was performed at the same time. Dilatation was achieved in all cases. Early survival rate (up to one month) was 75%; 50% survive up to three years. The two deaths occurring < 24 hours after dilatation probably related to the infants' poor condition at presentation and the presence of significant left ventricular hypoplasia. The other early death was due to severe mitral regurgitation from papillary muscle dysfunction. All later deaths were related to associated malformations. The difference in left ventricular size (diameter and length) measured echocardiographically at presentation between survivors and those that died is significant (p < or = 0.002). 83% of deaths occurred in infants with associated malformations. Cusp perforation occurred in one infant, which may have contributed to this patient's death. Left ventricular perforation and cardiac tamponade were treated successfully by prompt pericardiocentesis in another. Balloon dilatation of the aortic valve is an acceptable first line treatment for neonates with severe symptomatic stenosis of the aortic valve. Outcome depends principally on left ventricular size and on the presence, severity, and timing of treatment of associated malformations. Severe endocardial fibroelastosis was not a risk factor for early death but may have implications for long term survival. The survival rate for this high risk group might be improved by a stratified approach where patients with adequate left ventricular size have balloon dilatation whereas those with severe ventricular hypoplasia are managed like patients with the hypoplastic left heart syndrome.

Left Ventricular Perforation Due to Catheter Recoil during Aortoperipheral Angiography

Left Ventricular Perforation Due to Catheter Recoil during Aortoperipheral Angiography

Fatal left ventricular perforation during mitral balloon valvoplasty

Percutaneous balloon dilation of left-sided cardiac valves is being performed with increasing frequency. We describe and document the mechanism of injury of left ventricular perforation during mitral balloon valvoplasty. Despite a technically successful surgical repair with hemodynamic restoration, the patient was brain dead. We emphasize (1) the risk and the potentially catastrophic nature of left ventricular perforation during mitral balloon valvoplasty and (2) the need for surgical standby and rapid operative decompression for this complication.

Palliative Percutaneous Aortic Balloon Valvuloplasty Before Noncardiac Operations and Invasive Diagnostic Procedures

Percutaneous aortic balloon valvuloplasty (PABV) is useful in palliating symptoms of severe aortic stenosis in patients who are not candidates for aortic valve replacement. In 15 patients who had severe aortic stenosis and a contraindication to aortic valve replacement, PABV was performed before a noncardiac procedure, in an attempt to improve their hemodynamics and reduce the risks associated with the operation or preoperative diagnostic test. The mean aortic gradient was reduced from 58.1 +/- 6.0 mm Hg to 32.2 +/- 4.0 mm Hg (P less than 0.0002), and the aortic valve area was increased from 0.49 +/- 0.04 cm2 to 0.85 +/- 0.10 cm2 (P less than 0.0002). Complications associated with PABV included left ventricular perforation in three patients (which resulted in death in one of them), transient congestive heart failure in one, and development of femoral pseudoaneurysms in one. After PABV, nine patients underwent the planned surgical procedure under general anesthesia without complications. Five patients underwent surgical diagnostic procedures after PABV that resulted in a change in treatment strategy. Three of these patients required no further treatment, and two required resection of the colon for bleeding, which was preceded by aortic valve replacement. This study demonstrates that PABV may be useful in reducing the risks of noncardiac procedures in selected patients with severe aortic stenosis who are otherwise not candidates for aortic valve replacement.