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

Ventricular free wall Rupture after Myocardial Infarction

Patients with their first myocardial infarction (MI), who present to the emergency department many hours after the onset of chest pain, who appear to be improving but suddenly develop new chest pain and unexpected hypotension (with or without signs of cardiac tamponade), should be suspected of having ventricular free wall rupture (VFWR). The mainstay of treatment is surgery. These patients may be managed with the administration of fluids, cautious use of inotropes and echocardiographic scanning, which should be performed on an emergent basis, while being prepared to be moved to the emergency surgical suite. However, at no cost should surgery be delayed. This paper reviews the current literature of VFWR after MI, a condition which remains difficult to diagnose, in many aspects, to this day. The review examines the historical background, incidence, postulated risk factors, clinical presentation, investigations and management.

A systematic review and pooled analysis of CPR-associated cardiovascular and thoracic injuries

OBJECTIVE

The incidence of thoracic injuries resulting from cardiopulmonary resuscitation (CPR) is not well characterized. We describe a case in which a CPR-associated atrial rupture was identified with ultrasound and successfully managed in the intensive care unit with a bedside thoracotomy and atrial repair. We then describe a systematic review with pooled data analysis of CPR-associated cardiovascular, pulmonary, pleural, and thoracic wall injuries.

DATA SOURCES

PubMed, Scopus, EMBASE, and Web of Science were searched to identify relevant published studies. Unpublished studies were identified by searching the Australian and New Zealand Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform, Cochrane Library, ClinicalTrials.gov, Current Controlled Trials, and Google.

STUDY SELECTION

Inclusion criteria for the pooled analysis were any clinical or autopsy study in which (a) patients underwent cardiopulmonary resuscitation, (b) chest compressions were administered either manually or with the assistance of active compression-decompression devices, and (c) autopsy or dedicated imaging assessments were conducted to identify complications. Exclusion criteria for the pooled analysis were pre-clinical studies, case reports and abstracts.

DATA EXTRACTION

Nine-hundred twenty-eight potentially relevant references were identified. Twenty-seven references met inclusion criteria.

DATA SYNTHESIS

A systematic review of the literature is provided with pooled data analysis.

CONCLUSIONS

The incidence of reported CPR-associated cardiovascular and thoracic wall injuries varies widely. CPR with active compression-decompression devices has a higher reported incidence of cardiopulmonary injuries. Bedside ultrasound may be a useful adjunct to assess and risk-stratify patients to identify serious or life-threatening CPR-associated injuries.

Repair of ventricle free wall rupture after acute myocardial infarction: a case report

Introduction

Acute myocardial infarction (AMI) may culminate in sudden death by ventricular fibrillation, cardiogenic shock, and cardiac rupture. We present a case of postinfarction rupture treated by direct closure and coronary artery bypass grafting after thrombolytic therapy.

Case report

A 67-year-old woman with cardiac risk factors of hypertension, diabetes mellitus, and being post-menopausal was admitted complaining of chest pain and sweating. Thrombolytic therapy with streptokinase was started due to acute myocardial infarction. But, reperfusion criteria were not achieved. Echocardiography revealed a moderate pericardial effusion with mild right chamber collapse and pericardial thrombus. Cardiac catheterization revealed totally occluded left anterior descending (LAD) and circumflex coronary arteries. She was taken to the operating-room immediately. The pericardium was opened and a large amount of blood with thrombus was removed. Her hemodynamic indices improved immediately. There was active bleeding from multiple sites with a 4 mm rupture. Cardiopulmonary bypass was established. Direct closure of rupture was carried out. Reversed autogenous saphenous vein bypass grafts were placed to the LAD and second obtuse margin coronary arteries. Postoperative recovery was uneventful and she was discharged from hospital in good condition. She remained asymptomatic during first year following the surgery.

Conclusion

This case demonstrates that left ventricular free wall rupture is not always fatal and that early diagnosis and emergency surgical therapy may be successful. The combination of surgical repair with revascularization should be considered, because 80% of patients who experience LVFWR have multivessel coronary artery disease.

Acute heart failure: is there a role for surgery?

Many of the disorders and lesions leading to acute heart failure can be treated surgically. Modern surgical techniques like the off pump coronary surgery, newer techniques for the surgical treatment of the mechanical complications of acute MI and valvular reparative techniques have been added to the surgical armamentarium in recent years. Modern ventricular assist devices have started their career in the clinical arena promising to be less invasive. At the same time the spectrum of indications for mechanical circulatory support continues to witness a rapid expansion. Technical advances have led to an evolution of surgical strategies. Heart failure surgery is now in a position to offer improved outcomes, avoidance of recurrence of acute heart failure or the development of advanced chronic heart failure.

Surgical treatment of postinfarction left ventricular pseudoaneurysm

BACKGROUND

Left ventricular pseudoaneurysm from myocardial infarction is rare and is associated with a high risk of rapid enlargement and rupture. The purposes of this study were to describe its clinical presentation, assess the accuracy of diagnostic imaging modalities, and determine operative and late surgical results.

METHODS

From January 1986 through December 2001, 30 patients aged 50 to 85 years (mean, 68; 70% male) underwent left ventricular pseudoaneurysm repair. Two surgical approaches were used: primary repair (n = 5, 17%) and patch closure (n = 25, 83%). Twenty-one patients (70%) had concomitant procedures, including coronary revascularization (n = 17, 57%) and mitral valve surgery (n = 9, 30%); 8 patients (29%) underwent emergent surgery. Clinical presentation, preoperative imaging data, and surgical outcomes were abstracted from medical records or obtained by patient follow-up.

RESULTS

The most common clinical presentations were heart failure (n = 22, 73%) and angina (n = 11, 41%). Pseudoaneurysm was rarely suspected at clinical presentation. Contrast ventriculography was diagnostic in 54% of patients in whom it was performed, as opposed to 97% for two-dimensional echocardiography (p = 0.2). Postoperative intra-aortic balloon pump was required in 7 patients (23%). Hospital mortality was 20%, and late survival was 73%, 59%, and 45% at 1, 5, and 8 years, respectively.

CONCLUSIONS

Left ventricular pseudoaneurysm should be suspected in postinfarction patients with unexplained heart failure. Echocardiography is usually diagnostic and is superior to ventriculography. The surgical mortality rate is elevated in this complex patient population. Long-term survival is also poor, mainly because of underlying ischemic cardiomyopathy.

Postinfarction cardiac rupture despite immediate reperfusion therapy in a patient with severe aortic valve stenosis

A 74-year-old woman with severe aortic valve stenosis (AS) was admitted to our hospital because of dyspnea on exertion. On day 2, she developed acute anterior wall myocardial infarction (MI) with ST elevation. Tissue plasminogen activator (tPA) was administered 10 min after the onset of chest pain, and emergency percutaneous coronary intervention was performed to induce coronary reperfusion after another 50 min. Five hours after MI onset, however, she suddenly went into electromechanical dissociation and died from cardiac rupture. This is the first case report of postinfarct cardiac rupture with severe AS occurring in spite of instituting immediate reperfusion therapy. High intraventricular pressure may be a critical risk factor for cardiac rupture in patients with AS complicated with acute MI. Further studies are required to clarify the risk and benefit of tPA administration before percutaneous coronary intervention and the necessity of the emergency correction of AS to prevent cardiac rupture.

Thrombolysis Increases the Risk of Free Wall Rupture in Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention

In spite of the progress made in acute angiographic evaluation and obtaining durable reperfusion of acute myocardial infarction (AMI) in the past two decades, cardiac free wall rupture (FWR) is still one of the causes of mortality following AMI. In this study, we evaluated the role of thrombolysis in the risk of FWR in AMI patients treated with acute percutaneous coronary intervention (PCI). Among 3,786 consecutive AMI patients seen between 1985 and 2003, 3,066 patients were treated by primary PCI or rescue PCI, with or without additional thrombolysis. FWR occurred in 24 of 3,066 patients (0.8%) treated by PCI; female gender (1.4% vs 0.6%, P=0.001), age >75 years, (1.4% vs 0.6%, P=0.001) left main coronary artery (LMCA)-related infarction, (4.5% vs all other arteries, P=0.015), and thrombolytic use (3.1% vs 0.4%, P<0.001) were all associated with higher rates of FWR by univariate analysis. In patients treated with PCI and thrombolysis, FWR occurred in 2.7% with optimal PCI results but in only 4.9% if PCI was unsuccessful (P=NS). The incidence of FWR in patients with optimal PCI without thrombolysis was 0.4% (P<0.001). Multivariable analysis identified thrombolytic use (odds ratio [OR]: 8.49, 95% confidence interval [CI]: 3.66-19.7, P<0.001), LMCA-related infarction (OR: 7.06, 95% CI: 1.89-26.4, P=0.004), and female gender (OR: 3.02, 95% CI: 1.27-7.21, P=0.013) as independent predictors of FWR. Thrombolysis is one of the contributing causes of FWR in AMI patients undergoing PCI, even when PCI is successful.

Left ventricular free wall rupture after reperfusion therapy for acute myocardial infarction

We evaluated the clinical significance of angiographic indexes and pericardial involvement in predicting increased risk of free wall rupture after reperfusion therapy and found that Thrombolysis In Myocardial Infarction (TIMI) <3 flow grade after reperfusion therapy was a significant variable related to the free wall rupture. Moreover, pericardial rub was found to be a significant variable related to TIMI <3 grade flow after reperfusion, which indicates that detection of pericardial rub is one of the clinical signs that predicts inadequate anterograde flow of the infarct-related artery after reperfusion and hence, higher risk for free wall rupture.

Myocardial laser coagulation for free wall rupture following acute infarction

A 73-year-old woman was diagnosed with ventricular free wall rupture following acute myocardial infarction. The lesion was repaired with laser coagulation, fibrinogen-thrombin glue application, and patch reinforcement. Five years after surgery, the patient was in New York Heart Association class I.

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.

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.

Revascularization during acute myocardial infarction: risks and benefits revisited

BACKGROUND

Indication for immediate revascularization during acute myocardial infarction (MI) is debated. Drug-resistant crescendo angina, as well as hemodynamic compromise, however, often requires acute operation. In this study the differential risks of acute coronary artery bypass grafting with and without MI were stratified.

METHODS

Five hundred eighteen patients undergoing isolated coronary artery bypass grafting were investigated. Thirty-nine patients underwent acute revascularization because of enzyme-proven or electrocardiogram-proven MI accompanied by crescendo angina, hemodynamic compromise, or both. They were compared with 33 emergent, 63 urgent, and 383 elective patients without MI. Preoperative risk factors for early mortality and necessity of continuous venovenous hemofiltration were analyzed by means of logistical regression analysis. Perioperative data were compared.

RESULTS

Early mortality of the MI cohort was 15.4%, in contrast to 15.2% in emergent, none in urgent, and 2.1% in elective patients. Left internal thoracic artery was used in 87% of MI, 97% of emergent, 94% of urgent, and 97% of elective patients. Intraaortic balloon pump was necessary in 50% of MI patients, 27% of emergent, 6.3% of urgent, and 3.1% of elective cases. Continuous venovenous hemofiltration was performed in 29% of MI patients, 15% of emergent, 4.9% of urgent, and 3.4% of elective patients. Hemodynamic instability significantly increased the odds ratio for early mortality and continuous venovenous hemofiltration.

CONCLUSIONS

Patients undergoing acute revascularization carried an elevated risk to die early notwithstanding the presence or absence of acute MI. Liberal use of left internal thoracic artery grafts was not detrimental in acute patients whereas liberal use of intraaortic balloon pump was beneficial. In almost 30% of MI patients, continuous venovenous hemofiltration was not necessary, implying a severely impaired perioperative hemodynamic condition. Immediate revascularization in the presence of acute MI is therefore indicated although it may be addressed as a separate high-risk group.