Subacute cardiac rupture: repair with a sutureless technique

Spontaneous cardiac rupture

An 83-year-old woman had a sudden onset of loss of consciousness with no detectable blood pressure. Pulseless electrical activity was present in the electrocardiogram and massive pericardial effusion was found by echocardiography. Emergent subxiphoid pericardiotomy and drainage was immediately performed to release the cardiac tamponade at bedside and was followed by rushing the patient to the operating room for exploration. As a result a ruptured hole was identified on the posterior-lateral wall of the left ventricle and the defect was successfully repaired. The patient had an uneventful postoperative recovery and received postoperative study by cardiac catheterization, which disclosed coronary artery disease.

Surgery for left ventricular free wall rupture: patch glue repair without extracorporeal circulation

Left ventricular free wall rupture is a dramatic complication after myocardial infarction. We present our experience with the simple, expedient technique of patch glue repair without extracorporeal circulation. Access is obtained via median sternotomy. Evacuation of blood and haematoma is undertaken and a Goretex patch exceeding the size of infarct is fashioned. The patch is applied to the epicardium using enbrucrilate surgical glue instilled with gentle pressure against the beating heart. We performed this technique on 17 patients from 1993 to 2001, with a operative (30-day) mortality of 23.5% with a post-discharge survival of 85% at 2.2 years.

Treatment strategies for postinfarction left ventricular free wall rupture: stabilization with peri-operative IABP and off-pump repair

BACKGROUND

Perioperative management of post-infarction left ventricular free wall rupture (LVFWR) is not clearly standardized and surgical repair is the only therapeutic option. Role of off-pump surgery and stabilization with perioperative intraaortic balloon pumping (IABP) were here analysed.

METHODS

Seven patients underwent surgery for LVFWR between 1990 and 2002. Clinical picture included electromechanical dissociation (3 patients) and sudden hypotension (4 patients). Except in one patient who was reanimated through femoro-femoral cardiopulmonary bypass, off-pump repair through on-lay patching technique was always performed. IABP was employed in the immediate postoperative period in five cases.

RESULTS

A satisfactory hemodynamic state was restored in all cases and there were no reoperations for bleeding or rerupture. Hospital survival was 100%. One patient underwent successful surgical myocardial revascularization two months after LVFWR. Two patients died at follow-up. The survivors present with good NYHA and CCS functional classes.

CONCLUSIONS

When the anatomy of the LVFWR is favourable, off-pump external patching repair proves a good choice. Postoperative IABP provides satisfactory hemodynamic support.

Nature and progression of pericardial effusion in patients with a first myocardial infarction: relationship to age and free wall rupture

BACKGROUND

Left ventricular free wall rupture (FWR) usually develops within the first days of acute myocardial infarction (AMI) without warning, but it is uncertain whether a mild pericardial effusion might herald this complication.

METHODS

A 2-dimensional echocardiogram (2DE) was performed in patients with first AMI with (1149) or without (324) ST-segment elevation within 2 days. A second 2DE was performed 2 to 4 days later in 300 patients, 100 with and 200 without an initial mild PE (3-9 mm), and in those with initial moderate-severe PE (> or =10 mm) (MSPE) or who developed hypotension or died.

RESULTS

The first 2DE showed mild PE in 177 patients and MSPE in 51 patients, whereas a late (>2 days) MSPE occurred in 27 with a second routine 2DE, 15 (15%) with and 12 (6%) without initial mild PE (P =.01). Fourteen additional patients, 5 of 77 (6%) with and 9 of 1045 (1%) without initial PE, presented with hypotension and late MSPE (P <.002). Of 92 patients with MSPE, 90 had ST-segment elevation (98%), 60 had tamponade (65%), and 38 died of FWR or were operated on (41%). Results of pericardiocentesis performed in 64 patients were positive in 58, with hemopericardium in 57 (98%). Multivariant analysis showed mild PE on first 2DE and age of >60 years as the only independent predictors of late MSPE or late tamponade.

CONCLUSIONS

Mild PE within the first 2 days in patients aged >60 years with a first ST-segment elevation AMI is associated with an increased risk of late MSPE. Moreover, in this setting MSPE is most frequently associated with hemopericardium, and two thirds of these patients may develop tamponade/FWR.

Sutureless patch technique for postinfarction left ventricular rupture

BACKGROUND

Left ventricular free wall rupture is an uncommon but catastrophic event after myocardial infarction and is associated with a high mortality. After prompt diagnosis some patients may be salvaged with immediate surgical intervention. Surgical techniques used to seal the rupture vary, as few surgeons have experience with this pathologic process. We report our experience using a sutureless patch technique to treat this entity.

METHODS

A review of 6 consecutive patients during an 8-year period who were referred to one cardiac unit with postinfarction left ventricular rupture was conducted.

RESULTS

There were 3 men and 3 women with an average age of 71.8 years. All were hemodynamically unstable, and 4 were in electromechanical dissociation. Echocardiography confirmed the diagnosis in 5 patients, and cardiac catheterization had been performed in 4 before rupture. All patients were treated promptly with fluid, inotropic agents, and, if needed, cardiopulmonary resuscitation and pericardiocentesis. Resuscitation was continued in the operating room, and the myocardial tear was sealed with a generous patch of unsupported felt secured to the heart with cyanoacrylate glue. Coronary artery bypass grafting was performed in 3 patients if the anatomy was known. All patients survived to the intensive care unit. One death occurred as a result of severe neurologic injury. Five patients were discharged from the hospital, and all were alive 2 months to 7.5 years after operation.

CONCLUSIONS

A sutureless patch technique for the treatment of postinfarction rupture is simple, effective, and associated with a favorable outcome.

Internal use of n-butyl 2-cyanoacrylate (Indermil) for wound closure: an experimental study

n-Butyl 2-cyanoacrylate glue (Indermil) was used for the closure of dorsal wounds on rabbits. A 4-cm-long and 1-cm-wide laceration was created bilaterally on the back of 15 rabbits. One side was closed with absorbable 2-0 subcutaneous sutures and fast absorbable 3-0 skin sutures, whereas the other side was closed with cyanoacrylate glue applied on both deep and superficial tissues. A partial wound dehiscence occurred on the glue side in one animal at 2 weeks. The animal was killed at this time and considered a bad result in the glue group. In all other animals, no seroma, partial dehiscence, or wound infection occurred. Histopathologic analysis revealed that Indermil induced edema and a mild acute inflammatory reaction and resorbed almost completely within 2 months when applied to well-vascularized tissues. The application of glue on the cutaneous wound edges is a fast and easy procedure that does not seem to delay or inhibit the healing process or its quality.

Surgical experience with left ventricular free wall rupture

BACKGROUND

Autopsy studies reveal that left ventricular free wall rupture (LVFWR) accounts for 7% to 24% of deaths after myocardial infarction. The condition occurs up to 10 times more often than papillary muscle or interventricular septal rupture. A high index of suspicion must be maintained to differentiate LVFWR from infarct extension, cardiogenic shock, pulmonary embolus, and even Dressler's syndrome.

METHODS

Since 1980, we have operated on 18 patients with LVFWR. Fourteen patients had experienced "blow-out" rupture associated with cardiogenic shock. Four patients had "stuttering" ruptures, a less spectacular occurrence. Echocardiography was the most important diagnostic tool. Repair was performed, usually using infarctectomy and direct suture closure.

RESULTS

Eleven patients (61%) died after operation, 4 patients as a result of rerupture 1 to 12 hours after operation. Recently, we have used a "patch/glue" technique to repair ruptures in 2 patients. We believe this technique is superior to direct suture closure in preventing rerupture. There have been 7 long-term survivors (39%) from 6 months to 15 years.

CONCLUSIONS

Left ventricular free wall rupture is not always sudden and dramatic. Yet, the operating staff must be willing to race to the operating room even with the patient in full resuscitation. Echocardiography is the most sensitive and efficient diagnostic tool. All rupture sites should be aggressively repaired, possibly combining direct suture and patch/glue techniques.

Echocardiographical demonstration of a progressively expanding left ventricular aneurysm preceded by endomyocardial tearing

A 70-year-old woman with acute myocardial infarction (AMI) had a narrow necked left ventricular (LV) aneurysm and pericardial effusion. Although there had been no obvious sign of pseudoaneurysm at the first operation on the 13th day after onset, LV volume increased so dramatically that dyspnea on mild exertion was induced only 2 months after the onset of AMI. She underwent Dor's operation for the expanded LV aneurysm. The histological findings of the resected tissue, which were fibrotic epicardial lesion with small myocyte islands, indicated a true aneurysm. The ultrasound manifestation of a narrow necked aneurysm with abrupt thinning of the myocardium at the hinge point may be a valuable predictor of free wall rupture in the early phase and severely progressive LV remodeling in the late phase. Such aneurysms need to be considered as high risk.

Surgical strategy for left ventricular free wall rupture after acute myocardial infarction

BACKGROUND

Left ventricular free wall rupture is usually fatal without surgical intervention. However, the most appropriate surgical procedure remains controversial.

METHODS

Seventeen patients (14 men, 3 women) who developed left ventricular free wall rupture after acute myocardial infarction were treated surgically. Their mean age was 65.4 years (range, 55 to 79 years). The following surgical procedures were performed: infarctectomy and patch reconstruction in 1 patient, direct closure with or without patch covering in 4 patients, simple patch covering anchored by running suture in 4 patients, and a sutureless technique in 7 patients. Endventricular patch closure was performed in 1 patient with ventricular septal perforation.

RESULTS

One of 3 patients with a blow-out type rupture and 1 of 13 patients with an oozing type rupture died shortly after operation. The overall surgical mortality rate was 11.8%.

CONCLUSIONS

Selection of the optimal procedure for each cardiac condition is important for obtaining good results. For patients with ongoing squirting bleeding, patch covering is the technique of choice. For oozing, the sutureless technique is preferable.

Successful repair of myocardial free wall rupture after thrombolytic therapy for acute infarction

BACKGROUND

Controversy exists regarding the timing of thrombolytic administration and rupture rate.

METHODS

Hospital records at St. Luke's-Roosevelt Hospital of the 4 study patients were reviewed and compared with those of 41 patients from a group of 537 patients concurrently admitted with a diagnosis of myocardial infarction (MI).

RESULTS

Four patients experienced ventricular free wall rupture after having a MI between November 17, 1993, and July 28, 1995. All received tissue plasminogen activator. In 1 patient, pericardial effusion associated with a pseudoaneurysm was discovered in the operating room. The 3 others developed clinical pericardial tamponade before surgery. All 4 patients survived and left the hospital on postoperative days 10, 11, 11, and 82, respectively. During this same time period, 537 patients were admitted with MI, 41 of whom died; the study's 4 patients were compared with these 41.

CONCLUSIONS

These data demonstrate that rupture of the ventricular free wall can occur early after thrombolytic therapy and may have a subacute course. Prompt diagnosis and surgery offer excellent chances of surviving this fatal condition.

Surgical treatment of acquired left ventricular pseudoaneurysms

BACKGROUND

We present a review of our experience with acquired pseudoaneurysms of the left ventricle in order to establish the risk of surgical repair.

METHODS

Ten patients operated upon for a left ventricular pseudoaneurysm in our clinic between 1984 and 1999 were reviewed. The pseudoaneurysm, a complication of myocardial infarction (four acute and three chronic) or previous cardiac surgery (three chronic), was resected in all patients and the ventricular wall defect closed with direct sutures (five cases) or a patch (five cases). Coronary artery bypass graft was performed in 6 patients.

RESULTS

Three patients died (postoperative mortality 30%) after repair of an acute postinfarction (2 patients) or a chronic postsurgical (1 patient) pseudoaneurysm. Three patients died during follow-up (median 4 years) of a carcinological (2 patients) or cardiac (1 patient) cause. Two years after repair, 5 patients were in New York Heart Association class I or II, and 1 patient was in class III.

CONCLUSIONS

Repair of left ventricular pseudoaneurysms can be performed with acceptable results, although mortality is significant in acute myocardial infarction and redo operations. Propensity for fatal rupture, however, is higher than the surgical risk in acute pseudoaneurysms or in large or expanding chronic ones and warrants surgical repair. The best approach to small asymptomatic chronic pseudoaneurysm is unsettled.

Pericardial hood repair of cardiac rupture secondary to extended myocardial infarction

A surgical technique for simple and safe repair of oozing-type postinfarction cardiac rupture secondary to extended myocardial infarction is described. A hood-shaped pericardium was glued with gelatin-resorcinol and formaldehyde glue to cover the extended oozing infarcted myocardium. This technique was used on 3 elderly patients with good results.

Experience with postinfarction left ventricular free wall rupture

BACKGROUND

Postinfarction rupture of the left ventricle is a rare event in which approach is not clearly standardised and outcome after repair is unknown. Our experience with this pathology was reviewed to analyze methods of repair and assess outcome beyond the patient's hospitalisation.

METHODS

Five patients underwent surgical repair of a postinfarction ventricular rupture between 1990 and 1998. Electromechanical dissociation (3 patients) and sudden hypotension and bradycardia (2 patients) were clinical indicators of rupture. Four patients underwent repair with cardiopulmonary bypass and 1 patient without. Repair consisted of epicardial patching (2 patients), direct suture (1 patient), infarct-exclusion (1 patient), and debridement and patch closure (1 patient) of the rupture. Myocardial revascularization was performed in 3 patients and mitral valve repair in 1 patient.

RESULTS

A satisfactory hemodynamic state was restored and bleeding was controlled in all patients. Two patients died postoperatively and another patient died 4 months after hospital discharge as a result of cardiac failure and/or sepsis. The other 2 patients are alive and in excellent condition 6 and 30 months respectively after repair.

CONCLUSIONS

Postinfarction rupture of the left ventricle bears a high mortality, but survival with an excellent quality of life is possible after surgical repair.

Life-saving strategy for left ventricular free wall rupture after acute myocardial infarction. Infarction-covering repair on the ruptured site under the beating heart

OBJECTIVE

Left ventricular free wall rupture after acute myocardial infarction is a serious complication with high mortality. For life-saving, it is important how to maintain poor hemodynamics till operation. We have consistently made it our strategy to attach percutaneous cardiopulmonary support system and intra-aortic balloon pumping immediately after the diagnosis regardless of the type of left ventricular free wall rupture and of the hemodynamic conditions, and perform an infarction-covering repair under the beating heart. We have studied the short-term and middle-term results after the operations, and have evaluated the efficacy and problems of this procedure.

METHODS

Since September 1994, we have performed this method in six of eight patients with left ventricular free wall rupture.

RESULTS

As results, five of the six patients (83%) were saved including two cases of blow-out type. Our strategy for left ventricular free wall rupture showed several advantages for preoperative and intraoperative maintenance of the hemodynamic conditions, and for preservation of some reversible myocardium by the simple technique of infarction-covering repair under the beating heart. These resulted in shortening the operation time, decreasing the incidence of low cardiac output syndrome, and obtaining a satisfactory rate of life-saving.

CONCLUSION

We believe that this infarction-covering repair based on our strategy is effective for life-saving during the acute period.

Ventricular aneurysm repair: a new approach

Repair of chronic left ventricular aneurysm or acute rupture of the heart after myocardial infarction is associated with technical difficulties and major morbidity and mortality. We describe a new endoventricular repair for both conditions. The repair consists of externally covering a Duran ring with Dacron and internally lining it with autologous pericardium. The modified ring is then sewn into the neck of the lesion. The technique is rapid, simple, and hemostatic. After repair of the chronic aneurysm, ventricular hemodynamics are improved during both diastole and systole. We have performed this technique in two patients with chronic aneurysm and one with subacute rupture.

[The practical clinical guidelines of the Sociedad Española de Cardiología on coronary surgery]

Surgery in coronary disease, including myocardial revascularization and the surgery of mechanical complications of acute myocardial infarction, has shown to improve the symptoms, quality of life and/or prognosis in certain groups of patients. The expected benefit in each patient depend on many well-known factors among which the appropriateness of the indication for surgery is fundamental. The objective of these guidelines is to review current indications for cardiac surgery in patients with coronary heart disease through an evaluation of the degree of evidence of effectiveness in the light of current knowledge (systematic review of bibliography) and expert opinion gathered from various reports. Indications and the degree of recommendation for conventional coronary artery bypass grafting have been established for each of the most frequent anatomo-clinical situations defined by clinical symptoms (stable angina, unstable angina and acute myocardial infarction) as well as by left ventricular function and extend of coronary disease. Furthermore, the subgroups with the greatest surgical risk and stratification models are described to aid the decision making process. Also we analyse the rational basis and indication for the new surgical techniques such as minimally invasive coronary surgery and total arterial revascularization. Finally, the indication and timing of surgery in patients with mechanical complications of acute myocardial infarction are considered.

[Case report of surgical repair of left ventricular free wall rupture using GRF glue and pericardial patch]

A 73-year-old woman with acute myocardial infarction (Seg. 6: 100%) was admitted to our hospital. She underwent percutaneous transluminal angioplasty (PTCA) and stent insertion to Seg. 6 on that day and anticoagulant therapy with urokinase and heparin was started in CCU. On the 4th day, chest pain developed suddenly and echocardiography revealed cardiac tamponade, so we suspected left ventricular free wall rupture. When blood pressure increased to 100 mmHg in the operating room, the left ventricular free wall rupture became "blow out" type. After establishing extracorporeal circulation, we glued Xenomedica and autologous pericardium using gelatin-resorcin-formaldehyde glue (GRF glue) to the linear tear without damaging the myocardium and coronary arteries and reducing left ventricular volume. Bleeding was completely controlled. This experience suggests that this procedure might be effective for left ventricular free wall rupture.

Surgical repair of subacute left ventricular free wall rupture

BACKGROUND

The natural course of subacute ventricular free wall rupture (FWR) as a complication of acute myocardial infarction (MI) is usually lethal. The aim of this study was to investigate the curability of this entity and to report on five patients successfully treated by rapid diagnosis, hemodynamic stabilization, and emergency surgical repair.

METHODS

Five patients with subacute FWR of the left ventricle after previous MI were operated on. Infarctectomy with subsequent closure of the ruptured area was carried out in two patients with anterolateral infarction. Three other patients (two with posterior and one with lateral infarction) were treated by direct closure and the application of a patch. Furthermore, in two patients, concomitant myocardial revascularization was performed.

RESULTS

All patients survived the procedure and were alive and well at long-term follow-up (mean 36.4 months). None of the patients suffered recurrent MI.

CONCLUSIONS

Our experience and a review of the literature shows that prompt diagnosis and emergency surgical intervention may save the patient. Anterior rupture (with a moderate sized infarcted area) is best treated by infarctectomy and subsequent closure of the ventriculotomy with sutures buttressed with felt, whereas posterior rupture may be treated by direct closure and the application of an epicardial patch. Considering our results, we cannot conclude whether additional coronary artery bypass grafting is beneficial or not. Our suggestion is to perform additional myocardial revascularization only if indicated.

Diagnostic criteria and management of subacute ventricular free wall rupture complicating acute myocardial infarction

In this prospective study we evaluated the value of the main diagnostic criteria for postinfarction subacute rupture of the ventricular free wall. Two-dimensional echocardiograms and recordings of right atrial pressure and waveform were immediately obtained in every patient exhibiting rapid clinical and/or hemodynamic compromise in the acute infarction setting. The same protocol was applied to patients referred from other hospitals for suspected myocardial rupture. In 28 cases a subacute free wall rupture was identified. In most of the patients the diagnosis was based on the demonstration of hemopericardium and cardiac tamponade by echocardiography, cardiac catheterization and, occasionally, by pericardiocentesis. In 2 instances, the identification of intrapericardial echo densities suggesting clots, in the absence of cardiac tamponade, allowed a diagnosis of subacute rupture. Direct, but indistinct visualization of myocardial rupture was obtained in 4 cases. Among the 28 patients with this complication, 4 died while awaiting surgery and 24 underwent surgical repair (mortality rate 33%). Long-term outcome of survivors was favorable. Various myocardial lesions underlie postinfarction subacute free wall rupture. Clinical presentation varied widely. The diagnosis was based, usually but not always, on the association of hemopericardium and signs of cardiac tamponade. An organized approach to management of this complication of acute myocardial infarction was suggested.

Successful management of a postinfarction left ventricular rupture using a sutureless technique with concomitant myocardial revascularization

We present a case of left ventricular (LV) rupture that occurred on the second day after inferolateral myocardial infarction (MI). An aggressive diagnostic approach with rapid coronary angiography prior to surgical repair provides a benefit characterized postoperatively by complete recovery of myocardial contractility in the akinetic infarcted area. We believe that coronary artery disease associated with subacute ventricular rupture may, in fact, be better investigated and simultaneously treated under a protocol of early surgical repair.

Management of the uncontrollable pulmonary air leak with cyanoacrylate glue

Massive pulmonary air leak from a ruptured bleb in a patient with emphysema may be uncontrollable by the usual methods. A technique is illustrated where fibrin glue, cyanoacrylate glue, and a bovine pericardial patch are used in combination to seal the leak.

Medical management of selected patients with left ventricular free wall rupture during acute myocardial infarction

OBJECTIVES

This study sought to evaluate the effects of prolonged rest and blood pressure control on survival of patients in whom left ventricular free wall rupture (LVFWR) was strongly suspected.

BACKGROUND

Left ventricular free wall rupture in myocardial infarction is often fatal, and only a few patients may undergo operation. However, survival without surgical repair has not yet been evaluated.

METHODS

Eighty-one consecutive patients with a first transmural acute myocardial infarction in Killip class I or II who presented with acute hypotension due to cardiac tamponade, with electromechanical dissociation (EMD) in 72, were prospectively evaluated. Patients with early recovery were managed with prolonged bed rest and blood pressure control with beta-blockade as tolerated.

RESULTS

Forty-seven patients died within 2 h of acute tamponade, and autopsy in 21 showed LVFWR in all. In 15 others, an emergency surgical repair resulted in 2 survivors. The remaining 19 patients, 10 with EMD, had early recovery with dobutamine and colloid solution, and 15 required pericardiocentesis. Shortly thereafter, these 19 patients still showed a paradoxic pulse > or = 20 mm Hg, relevant pericardial effusion (24 +/- 7 mm [mean +/- SD]) and comparable elevation of right and left ventricular filling pressures (15.8 +/- 3.9 and 15.9 +/- 3.8 mm Hg, respectively). Subsequent management included bed rest (8.2 +/- 4.8 days) and control of systolic blood pressure (< or = 120 mm Hg) with beta-adrenergic blocking agents as tolerated (n = 12). Four patients died, and autopsy in three revealed a rupture that was sealed in two. A sealed rupture was also seen at thoracotomy in 2 other patients who, like the remaining 13, survived for 52.5 +/- 35.2 months.

CONCLUSIONS

Long-term survival of selected patients with prompt hemodynamic recovery after LVFWR is possible without surgical repair. Prolonged bed rest and blood pressure control are likely to contribute favorably to their initial outcome.

Reoperative aortic root surgery late after use of histo-acryl

Cardiovascular reoperations after the use of histo-acryl are extremely rare. A patient is described, who underwent an aortic root replacement according to Bentall's technique, for a postdissectional aneurysm. At that time, to achieve hemostasis, histo-acryl adhesive was applied and a Cabrol's fistula was created. Fourteen years later, a recurrent 'false', aneurysm had developed and the fistula had a hemodynamically significant left-right shunt. At reoperation, the composite graft was replaced by a cryopreserved aortic root allograft with long coronary arteries. To our knowledge, this is the first report of a cardiovascular reoperation after previous use of histo-acryl. This patient also merits attention as to the fact that it illustrates a failure of a modified Cabrol's procedure.

Postinfarction ventricular free wall rupture: strategies for diagnosis and treatment

Ventricular free wall rupture is a recognized complication of myocardial infarction. In recent years, the widespread availability of echocardiography has enabled prompt antemortem diagnosis. Consequently, an avenue for lifesaving surgical intervention has emerged for this hitherto fatal condition. We review the pathology and discuss strategies for diagnosis, resuscitation, and definitive surgical intervention. We illustrate this review using our experience with a patient whose condition was diagnosed by transthoracic echocardiography and who successfully underwent emergency operation.

Peri-infarct pursestring for repair of subacute cardiac rupture

A 55-year-old woman presented with cardiac tamponade after an inferior myocardial infarction. At surgical exploration there was an extensive area of hematoma associated with cardiac rupture. Rather than infarctectomy and ventricular repair an alternative approach was taken. The patient was successfully managed by the placement of a peri-infarct pursestring together with a superficial stitch closing the exit point of the cardiac rupture.

Subacute rupture of the left ventricular free wall after acute myocardial infarction. Three cases of long-term survival without emergency surgical repair

Rupture of the left ventricular free wall after acute myocardial infarction (AMI) has been regarded as uniformly fatal unless emergency surgical repair is performed. Among 2,862 patients admitted with AMI to our ICU during the last 8 years, 107 patients developed rupture of the left ventricular free wall. Twenty-nine patients had a subacute course and three of them survived for prolonged periods without having to have emergency surgical repair. At the onset of rupture on day 1 through 7 after AMI, the three survivors developed sudden hypotension accompanied by a new pericardial effusion. They were initially managed with hemodynamic support. Two patients had elective open-heart surgery 2 to 3 months after AMI, whereas one patient did nt require surgery. All three survived 1 1/2 to 8 1/2 years after AMI. This report indicates that a small subset of patients with subacute ventricular free wall rupture has a benign course that may allow for prolonged survival without having to have emergency surgical repair.

Successful repair of a ruptured postinfarct pseudoaneurysm of the left ventricle

We report a case of a 60-year-old woman who underwent emergency surgical repair of a ruptured pseudoaneurysm of the left ventricle 10 days after acute myocardial infarction. The repair consisted of oversewing the rupture (2 cm long) on the posterior wall under cardiopulmonary bypass. The patient made a satisfactory recovery.

"Concealed" rupture of the left ventricle: successful surgical repair

A 70-year-old woman with a history of angina and hypertension presented with a large anterior infarct complicated by rupture and tamponade. Angiography showed triple-vessel disease and a large anteroapical aneurysm. Operative findings included extensive dissection of the septum and rupture of the right ventricular free wall. The patient survived the operation, which included replacement of the left ventricular free wall, extensive patching of the septum, and plication of the infarcted right ventricle.

The use of cyanoacrylate adhesive (Krazy Glue) in cardiac surgery

The authors report four cases of patients in desperate clinical situations where cyanoacrylate adhesive (Krazy Glue) was successfully used to control hemorrhage. Clinical observations were supplemented with bacteriological studies which showed that commercially available cyanoacrylate adhesive showed lack of bacteriological contamination.

Intramyocardial dissecting hematoma: an unusual form of subacute cardiac rupture

Intramyocardial dissecting hematoma following myocardial infarction is an unusual form of subacute cardiac rupture that tends to develop along naturally occurring dissection planes between the spiral muscles of the ventricle. The diagnosis has commonly been made at surgery, postmortem examination, or by echocardiography. Most are associated with acute transmural inferior infarction. Few patients survive without surgical intervention. Fourteen cases have appeared in the literature. One additional case is described. Ten cases were treated medically with one survivor (10%). Five cases were treated surgically with five survivors. Surgical treatment of intramyocardial dissecting hematoma is preferable to medical treatment. Proper and timely diagnosis and prompt surgical treatment are necessary before complete myocardial rupture ensues. Diagnosis is facilitated through the use of two-dimensional echocardiography. Successful surgical management of this condition requires an appreciation of commonly associated pathoanatomical conditions, and the utilization of appropriate methods of repair in the presence of potential ventricular septal and ventricular free wall rupture.