Ventricular Wall Rupture Research Articles

Peer review report 2 on “Pericardial salmonella with cardiac tamponade and ventricular wall rupture: A case report”

Peer review report 2 on “Pericardial salmonella with cardiac tamponade and ventricular wall rupture: A case report”

Peer review report 1 on “Pericardial salmonella with cardiac tamponade and ventricular wall rupture: A case report”

Peer review report 1 on “Pericardial salmonella with cardiac tamponade and ventricular wall rupture: A case report”

Разрыв сердца: cлучай успешного консервативного лечения разрыва свободной стенки левого желудочка в ходе острого инфаркта миокарда с последующей хирургической коррекцией.

Разрыв свободной стенки левого желудочка – тяжелое осложнение острого трансмурального инфаркта миокарда с высоким уровнем летальности, требующее хирургического вмешательства – экстренного ушивания дефекта. В статье приводится описание клинического случая длительного консервативного лечения пациента с диагностированным постинфарктным разрывом свободной стенки левого желудочка и выпотом в полость перикарда. Нестабильное состояние больного затруднило его транспортировку в кардиохирургический стационар. Однако аккуратное медикаментозное лечение больного под тщательным контролем параметров гемодинамики привело к формированию ложной аневризмы левого желудочка, стабилизации состояния больного, что позволило успешно выполнить комплексное оперативное вмешательство: аортокоронарное шунтирование, пластику левого желудочка и пластику митрального клапана в плановом порядке.

Unsuspected large left ventricular pseudoaneurysm: rapid bedside diagnosis by contrast-enhanced echocardiography: Figure 1:

An asymptomatic 72-year-old man with cardiomegaly was referred to our centre for assessment. His medical history comprised metastatic colonic cancer and granulomatosis with polyangiitis. Transthoracic echocardiography was performed. In the apical four-chamber view, a large cavity was identified adjacent to the apex, measuring 45 × 54 mm (Fig. 1A and Supplementary Video 1). All apical segments of the left ventricle were thin and akinetic. On colour Doppler, bidirectional blood flow due to swirling of blood was observed within the cavity (Fig. 1B and Supplementary Video 2). Contrast-enhanced echocardiography established the site of rupture within the thinned apical wall of the left ventricle, measuring 15 mm in width, communicating freely with a large, thrombus-free pseudoaneurysm (Fig. 1C and Supplementary Video 3). Cardiovascular magnetic resonance imaging confirmed the finding of an apical pseudoaneurysm (Fig. 1D and Supplementary Video 4). Late gadolinium enhancement was limited to the apical segments in a transmural distribution. The remaining segments of the left ventricle were functioning and viable with no evidence of inducible ischaemia. Coronary angiography demonstrated unobstructed arteries. Figure 1: (A) Transthoracic echocardiogram; four-chamber view. (B) Colour Doppler showing bidirectional flow of blood within the left ventricular pseudoaneurysm. (C) Contrast-enhanced transthoracic echocardiogram, zoomed on the left ventricular pseudoaneurysm. ... In this case, the likely primary event was an unrecognized myocardial infarction, followed by ventricular wall rupture contained within pericardial tissue. Possible mechanisms for the myocardial infarction include acute coronary artery occlusion with spontaneous recanalization, coronary thromboembolism and coronary vasculitis. This patient's case was discussed in a multidisciplinary team meeting. The consensus view was that the risk of rupture of the pseudoaneurysm was small. Furthermore, the patient's survival was estimated to be 1 year due to his metastatic colonic cancer. Consequently, medical treatment was advised. The natural history of left ventricular pseudoaneurysms is not known. If left untreated, left ventricular pseudoaneurysms predispose to ventricular rupture, thromboembolism, compression of local structures and arrhythmia. Most pseudoaneurysms require surgical intervention [1] or percutaneous closure [2]. When a left ventricular pseudoaneurysm is chronic, there are limited outcome data to guide the need for surveillance and timing of intervention. This case illustrates the value of contrast-enhanced echocardiography as a low cost adjunct to complex imaging modalities, to rapidly distinguish left ventricular pseudoaneurysms from other cardiac pathology. No ethical approval is required. The patient provided written consent. R.S. is nominated as the guarantor of this work.

Late Chronic Tamponade after Intraoperative Right Ventricular Rupture Repair with Mediastinal Fat.

Advanced age and female sex are known risk factors for ventricular wall rupture during open-heart procedures. We present the case of an 83-year-old female patient with an intraoperative traumatic right ventricular free wall rupture during an aortic valve replacement procedure. Pledgetted interrupted sutures reinforced with large pieces of mediastinal fat were used for rupture repair. After 6 months, the patient was readmitted with the diagnosis of a retrosternal mediastinal mass and clinical signs of cardiac tamponade that required reoperation.

Intramyocardial Dissection following Postinfarction Ventricular Wall Rupture Contained by Surrounding Postoperative Adhesions.

Introduction. Dissection of the myocardium is a rare form of cardiac rupture, caused by a hemorrhagic dissection among the spiral myocardial fibers, its diagnosis is rarely established before the operation or death, and extremely few cases have been reported in the literature and none of these cases seem to have a history of previous cardiac surgery which makes our report unique. Case Presentation. A 61-year-old female patient was admitted into the emergency room with complaints of progressive chest pain for 2 days. She had a history of second time prosthetic aortic valve replacement and was under anticoagulation therapy. She was diagnosed with an acute inferoposterior myocardial infarction and underwent emergency coronary angiography revealing spontaneous recanalization of the right coronary artery. During the follow-up, she developed cardiogenic shock and a new occurring systolic ejection murmur. Transthoracic echocardiography showed a left ventricular free wall rupture; then, she was taken in for emergency surgery. During the operation, a rupture zone and a wide intramyocardial dissecting area were detected. Intraventricular patch repair technic with autologous pericardial patch was used to exclude the ruptured area. Following the warming period, despite adequate hemostasis, hemorrhage around suture lines progressively increased, leading to the patient's death. Conclusion. Pericardial adhesions might contain left ventricular rupture leading to intramyocardial dissection.

Use of bovine pericardium and sutureless biological glue in left ventricular rupture after mitral valve replacement, five years of follow-up

Rupture of the left ventricular wall after mitral valve replacement is an infrequent but lethal complication. Reporting correction technique of ventricular rupture with bovine pericardium patch secured with glue and without suturing: a 51 years-old female patient, with double rheumatic mitral lesion, severe stenosis and discrete insufficiency, who had a mitral valve replacement. During surgery, the patient presented a ventricular rupture of the posterior wall (atrioventricular disruption), which was successfully repaired using bovine pericardium with sutureless biological glue over the epicardium of the damaged area. Sixty months after surgery the patient has no symptoms.

Successful repair of the left ventricular wall rupture after mitral valve replacement : A case report

Successful repair of the left ventricular wall rupture after mitral valve replacement : A case report

Self-limiting left ventricular wall rupture following myocardial infarction: a case report and literature review

We report the case of a 62-year-old woman presenting with symptoms and findings of myocardial infarction and a left ventricular free wall rupture.Coronary angiography revealed a critical stenosis in the middle right coronary artery. A contrast left ventriculogram revealed extravasation of contrast through the inferolateral wall of the left ventricle.Left ventricular free wall rupture is a rare complication of acute myocardial infarction, occurring in approximately 2% of cases. It is often fatal because of the development of haemopericardium and tamponade.Some patients, like the one described in this case, may present with small leaks that might close spontaneously by epicardial fibrin deposits, thus selflimiting, without requiring surgical intervention. This patient received only intense medical treatment. Indeed, blood clots at the endocardial and theepicardial site of the rupture have often been identified, suggesting protection for further rupture.

Successful surgery for lateral left ventricular wall rupture with severe mitral insufficiency resulting in cardiogenic shock

A 68-year-old female was admitted to the intensive cardiac care unit with acute (6 h from pain onset) lateral myocardial infarction (MI) with ST elevation and cardiogenic shock, treated with successful circumflex stenting. On day 5, she developed pulmonary oedema and new systolic murmur 4/6 over apex. Transthoracic echocardiography (TTE) revealed a wide rupture of the left ventricular (LV) lateral wall with pseudoaneurysm entry of 46 mm (Fig. 1). A severe mitral regurgitation due to extreme mitral leaflets restriction was the predominant haemodynamic disorder (Fig. 2). The patient was supported with an intraaortic balloon and immediately transferred by air to the cardiosurgical unit, where successful reconstruction of the left ventricle with Dor’s method and mitral annuloplasty with a 28 mm ring was performed. Control contrast TTE and magnetic resonance imaging two weeks later showed a small pericardial patch leak with residual pseudoaneurysm of 18 mm diameter with LV ejection fraction of 34% and insignificant mitral regurgitation (Figs. 3, 4). This case illustrates the successful treatment of a severe mechanical complication with unusual pathophysiology resulting in functional NYHA class II eight months after surgery. A delay in hospital admission for acute MI is often associated with higher mortality, severe complications such as heart rupture (HR) with an incidence as high as 6% in the prereperfusion era, 1–4 accounting for up to 30% of hospital mortality. A free wall HR occurs in 0.45% of patients with MI treated with percutaneous coronary intervention (PCI), although primary PCI is not independently related to HR. The main risk factors for HR are: ST-segment elevation/left bundle branch block; ST-segment deviation; female sex; previous stroke; positive initial cardiac biomarkers; and older age. TTE is the first line tool for a suspected myocardial rupture, and intravenous echocardiographic contrast agent may be useful for the evaluation of the development of an LV pseudoaneurysm (LVP). However, contrast-enhanced myocardial resonance imaging helps to delineate the location and extent of the myocardial rupture, providing valuable structural and functional information in the assessment of LVP. Prompt diagnosis and early surgical intervention is essential for patients with a large or expanding LVP due to the high propensity for fatal rupture.

Chronic contained rupture of the posterior left ventricular wall two years after balloon dilatation of a degenerated mitral bioprosthesis

An 83-year old woman suffered from restenosis of a mitral bioprosthesis with extensive annular calcification extending into the left ventricle. During successful balloon dilatation, perforation of the ventricular wall occurred. Two years later, computed tomographyscan and preoperative findings during valve replacement showed a chronic pseudoaneurysm in the posterior mediastinum (Figs 1 and 2).

A ballooning heart-giant left ventricular apical pseudoaneurysm presenting as congestive heart failure

Left ventricular (LV) pseudo aneurysm is a contained rupture of ventricular wall by adherent pericardium or scar tissue. We present a case of a 70 year-old male presented with exertional dyspnea for 2 months and found to have giant LV pseudo aneurysm on transthoracic echocardiogram, cardiac MRI and angiogram. To our knowledge such a large pseudo aneurysm involving LV apex and presenting as congestive heart failure is the first case in literature.

Cardiac death by rupture of the right ventricular wall and hemopericardium

Abstract Right Ventricular (RV) rupture is a rare and dangerous complication of acute myocardial infarction. There are limited reports on RV free wall rupture. In this paper we describe the outcome of an autopsy case of cardiac death by rupture of the free wall of the right ventricle in a 51-year-old man with coronary artery disease and hypertrophic-sclerotic cardiomyopathy.

Cardiac Rupture Following Myocardial Infarction - A Case Report

Ventricular wall rupture occurs in 1–3% cases with acute myocardial infarction (AMI) and is the third most common cause of death caused by AMI. This most sever mechanical complication of the AMI often remains undiagnosed and constitute a necropsy finding. Acute free wall rupture complicating AMI is defined as an abrupt and complete transmural rupture of the infracted region, causing cardiac temponade and death within 30 minutes. Ventricular free wall rupture occurs up to ten times more frequently than septal or papillary muscle rupture. The pathophysiological process involves thinning of the myocardial wall with the intensity of necrosis occurring at the terminal end of the vessel (watershed area) where there is often poor collateral flow. Here we described in brief about this fatal complications presentation, pathophysiology and diagnosis.

Left ventricular rupture after double valve replacement in a patient with myocarditis due to myasthenia gravis : case report

Myasthenia gravis is an autoimmune disease characterised by a weakness of the skeletal muscles, with remissions and exacerbations due to antibodies acting on the acetylcholine receptors. This leads to the characteristic defect transmission in the neuromuscular junction. Treatment includes anticholinesterase agents, thymectomy, and immunosuppression. Surgical thymectomy can induce remission or improvement, allowing for reduction in the immunosuppressive treatment. The case of an 84-year-old female patient with myasthenia gravis, aortic valve stenosis, mitral valve regurgitation and myocarditis is described. The development of myocarditis was related to inflammatory cell infiltration, and progressive and additive focal cellular necrosis associated with reactive myocardial fibrosis. After replacement of the mitral valve, complications arose whereby a rupture of the left ventricular posterior wall occurred, which caused massive bleeding and sudden death on the operating table.

FREQUENCY OF MECHANICAL COMPLICATIONS IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION

Objective: To document the frequency of mechanical complications in patients with acute myocardial infarction. Methodology: The study was conducted from February 2009 to October 2011 in Cardiology department LRH. In this study, 5120 patients with acute ST elevation myocardial infarction (STEMI) were evaluated for mechanical complications. Acquired ventricular septal rupture (VSR), moderate to severe mitral regurgitation (MR), free left ventricular wall rupture, were considered as post-AMI mechanical complications. Diagnosis of VSR and MR were made on 2D and Color Doppler Echocardiography. Frequency, percentages and Mean±SD were used for categorical and numerical variables, respectively. Results: A total of 5120 patients were enrolled in the study,males were 54.4% , mean age was 61±9.7 years (45 to 85 years). Smokers were 21%, positive family history for coronary artery diseases was in 32%, hyperlipidemia in 18.5%, hypertensives were 14%, diabetics were 35% and 31.1% had history of coronary artery disease. Among these 68 (1.32%) patients had either acquired VSR and/or MR. VSR 44 (65.6%), MR 21(30.1%), while both VSR and MR were seen in 3(4.0%) patients. The number of patients who were timely thrombolysed with streptokinase was 30 (44.1%), half of these had either VSR or MR. More patients with mechanical complications had acute anterior MI, (52.9). The in-hospital mortality was 17.4%. Conclusion: Mechanical complications after acute myocardial infarction are a less common finding. Majority of the patients were in advanced age group. More patients with anterior MI had both VSR and MR. All those patients who died in hospital had acquired VSR.

In-hospital refractory cardiac arrest treated with extracorporeal membrane oxygenation: A tertiary single center experience

We retrospectively assessed the experience of our tertiary care center on the use of venous-arterial extracorporeal membrane oxygenation (VA-ECMO) in 16 adult patients with refractory cardiac arrest. Cardiac arrest was due to acute coronary syndrome in 10 patients (62.5%), Takotsubo Syndrome in 1 patient (6.25%), dilated cardiomyopathy in 4 (25%) patients and massive pulmonary embolism in 1 patient (6.25%). The device was implanted in the catheterization laboratory in 14 patients (87.5%), in the operating room in 1 patient (6.25%) and in the emergency department in 1 patient (6.25%). During support, 7 patients were submitted to percutaneous coronary intervention, while coronary artery bypass grafting was performed in 1 patient, and cardiac surgery for repair of left ventricular wall rupture was performed in 1 patient. The device was successfully weaned in 6 patients (37.5%), among whom 2 patients died and 4 patients (25%) were discharged alive. In our institution 2/16 (12.5%) patients treated with VA-ECMO for refractory cardiac arrest survived to hospital discharge neurologically intact, and a good neurological function was observed in 3/16 (18.8%) at six-month follow-up.

EComment. Percutaneous closure of post-myocardial infarction septal defect

We read with great interest the paper by Papalexopoulou et al. regarding the best timing of surgery in patients with post-infarct ventricular septal rupture [1]. After carefully reviewing the literature, the authors conclude that the best strategy is to delay the surgery by 3-4 weeks if the haemodynamic status of the patient allows. However, current guidelines advocate immediate surgical closure of the ventricular septal defect (VSD) irrespective of the patient's haemodynamic status to circumvent further haemodynamic decline [2]. First described by Lock et al. in 1988, the transcatheter closure of VSD has gained a widespread use, and devices originally intended to close the patent foramen ovale or atrial septal defects, have been modified for closure of muscular VSD. This less-invasive interventional approach allows, in the majority of cases, rapid haemodynamic stabilization by reducing the left-to-right shunt [3]. Anatomical considerations, best depicted by echocardiography, represent a major limitation of this procedure. Large VSDs exceeding 35 mm, apical VSDs without suitable rim or basal VSDs in the vicinity of mitral apparatus or the aortic valve represent a contraindication to the percutaneous closure with Amplatzer devices [4]. Another important drawback is the limited number of centres with sufficient expertise in performing these challenging procedures, because percutaneous closure of an acute postinfarct VSD remains one of the most demanding procedures in interventional cardiology. Costache et al. used an Amplatzer occluder as a bridge-to-surgical procedure in a 79-year old woman in cardiogenic shock secondary to a post-infarct VSD [5]. The combined approach enabled them to perform surgery on a more stable patient. Recently, Thiele et al. [4] evaluated, in a prospective study, the outcomes of primary interventional closure of postinfarction VSD in an acute setting as an alternative to surgical closure. The overall 30-day mortality of this less-invasive approach was 35%. Not surprisingly, the mortality rate was higher in patients with cardiogenic shock. Major complications occurred in 41% and these included free ventricular wall rupture, device embolization or dislocation and residual left-to-right shunting. Despite advances in medical and surgical care intervention, mortality of postinfarction VSD remains high, especially in patients with haemodynamic compromise. Future multicentre studies are warranted to identify patients best suited for surgical or interventional closure, in the era of evolving alternative technologies. Conflict of interest: none declared

Ischemic VSD

Background: Ischemic VSD or ventricular septal rupture (VSR) is a rare but lethal complication of myocardial infarction (MI). Multi-system coronary disease is present in more than 50% of these patients. The event occurs 2-8 days after an infarction and often precipitates cardiogenic shock. The differential diagnosis of postinfarction cardiogenic shock should exclude free ventricular wall rupture and rupture of the papillary muscles. To avoid the high morbidity and mortality associated with the disorder, patients should undergo emergent surgery. Concomitant coronary artery bypass may be required.Objective: This study stressed on a very serious complication of a common pathology (myocardial infarction), despite it,s lethal complication but still it is treatable and still surgery is the only salvageable option.Patients & methods: Retrospective study of 7 consecutive cases with ischemic VSR encountered from (1st Jan. 2008-30 of September 2011). All of the cases were carefully assessed & fully investigated preoperatively (by echocardiography study, catheterization ...etc) & for all of them emergency open heart surgery was done with heart lung machine to close a post infract VSD using synthetic patch and ventriculotomy closed with reinforced Teflon felts , all of them(except the last case which died immediately post operatively) stayed for 2-3 days in the CICU under follow up .Results: Seven patients have been operated upon, 4 males (57%) and 3 female (43%), and their ages ranged between 50-63 years (75% in the 6th decade). Three of them (43%) were diabetic only but all of them were hypertensive. All of them were haemodynamically unstable so operation carried on emergently within 12-18 days post infarction (one operation done within 27 hours of infarction) and in none of them the clinical status helped to postpone them until more than 3 weeks post infarct. Five Out of the seven patients survived the operation, one died immediately post operatively &another one died 7 days post operatively due to renal failure (due to pre operative impaired renal function). Operative & early post operative mortality is (28%).Conclusion: We need to be more aware about this fatal complication of acute MI taking in consideration its late presentation (2-8) days.We have to work hardly to improve early revascularization to decrease the incidence of VSR. Improvement in surgical technique using double patch and glue improve mortality & morbidity rates. More cases need to have a better understanding & management of these cases.

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.