Long-term usefulness of percutaneous intrapericardial fibrin-glue fixation therapy for oozing type of left ventricular free wall rupture: a case report

Ventricular Pseudoaneurysm and Free Wall Rupture After Acute Myocardial Infarction: JACC Focus Seminar 4/5

Postinfarction ventricular free-wall rupture is a rare mechanical complication, accounting for <0.01% to 0.02% of cases. As an often-catastrophic event, death typically ensues within minutes due to sudden massive hemopericardium resulting in cardiac tamponade. Early recognition is pivotal, and may allow for pericardial drainage and open surgical repair as the only emergent life-saving procedure. In cases of contained rupture with pseudo-aneurysm (PSA) formation, hospitalization with subsequent early surgical intervention is warranted. Not uncommonly, PSA may go unrecognized in asymptomatic patients and diagnosed late during subsequent cardiac imaging. In these patients, the unsettling risk of complete rupture demands early surgical repair. Novel developments, in the field of transcatheter-based therapies and multimodality imaging, have enabled percutaneous PSA repair as a feasible alternate strategy for patients at high or prohibitive surgical risk. Contemporary advancements in the diagnosis and treatment of postmyocardial infarction ventricular free-wall rupture and PSA are provided in this review.

Intra-pericardial thrombin injection as bailout strategy in iatrogenic pericardial tamponade

BACKGROUND

Cardiac tamponade is a rare but life-threatening complication of cardiac interventions. Despite prompt pericardiocentesis, clinical management can be challenging and sometimes haemodynamic stabilisation is difficult to achieve. Intra-pericardial thrombin injection after pericardiocentesis promotes haemostasis and acts as a sealing agent, as previously described for left ventricular free-wall rupture. We aimed to evaluate intra-pericardial thrombin injection as a bailout strategy for pericardial tamponade following percutaneous cardiac interventions.

METHODS

In a 5-year single-centre retrospective analysis we identified 31 patients with cardiac tamponade due to percutaneous intracardiac procedures. Intra-pericardial thrombin injection as a bailout strategy was administered in 5 of 31 patients (16.1%).

RESULTS

Patients receiving intra-pericardial thrombin were in a more critical state when thrombin was applied, as demonstrated by a higher rate of resuscitation (40% versus 26.9%) and a trend toward a prolonged stay in the intensive care unit (177.6 ± 84.0 vs 98.0 ± 31.4 h). None of the patients with pericardial tamponades treated with intra-pericardial thrombin needed cardiothoracic surgery. Mortality after 30 days was lower with intra-pericardial thrombin injection than with standard treatment (0% vs 15.4%). We observed no complications using intra-pericardial thrombin.

CONCLUSION

Intra-pericardial thrombin injection could be considered as a bailout strategy for patients with iatrogenic pericardial tamponade due to percutaneous procedures. We recommend further evaluation of this technique in the clinical management of refractory pericardial tamponade.

Systematic review and meta-analysis of the mechanical complications of ischemic heart disease: papillary muscle rupture, left ventricle rupture and post-infarct ventricular septal defect

BACKGROUND

Improvements in revascularisation, including pharmacological, catheter-based and surgical, have resulted in improved outcomes for patients with acute myocardial infarction (AMI), leading to decreased frequency of mechanical complications. Improvements in both techniques and technology have permitted select patients to be managed with a purely percutaneous, transcatheter strategy. Through systematic review, this study aims to synthesise the collective experience of percutaneous treatment of the mechanical complications of ischaemic heart disease.

METHODS

The search strategy queried the electronic databases PubMed, Embase and the Cochrane Central Register of Controlled Trials, from 1 January 2000 to 31 December 2020. Studies highlighting the outcomes of patients receiving percutaneous treatment of post-myocardial infarction papillary muscle rupture (PMR), ventricular septal defect (VSD), left ventricular free wall rupture (FWR) and pseudoaneurysm (PA) were included. A qualitative review of studies was conducted for PMR, FWR and PA. A quantitative analysis was conducted for VSD.

RESULTS

Fifteen studies were included in the qualitative synthesis of the percutaneous management of PMR, 4 were included in the qualitative analysis of the percutaneous management of left ventricular FWR, 7 studies defined the outcomes of the percutaneous management of PA and 25 were included in the quantitative meta-analysis of the primary percutaneous management of post-MI VSD. For VSD, there were 43 failed procedures in 314 patients. The proportion of failed procedures was 15.9% and there were 174 deaths in 428 patients. 37.5% of patients experienced early mortality.

CONCLUSIONS

Although surgical techniques remain the gold standard, we have shown that percutaneous management may be a viable option in certain cases.

Technologies for intrapericardial delivery of therapeutics and cells

The pericardium, which surrounds the heart, provides a unique enclosed volume and a site for the delivery of agents to the heart and coronary arteries. While strategies for targeting the delivery of therapeutics to the heart are lacking, various technologies and nanodelivery approaches are emerging as promising methods for site specific delivery to increase therapeutic myocardial retention, efficacy, and bioactivity, while decreasing undesired systemic effects. Here, we provide a literature review of various approaches for intrapericardial delivery of agents. Emphasis is given to sustained delivery approaches (pumps and catheters) and localized release (patches, drug eluting stents, and support devices and meshes). Further, minimally invasive access techniques, pericardial access devices, pericardial washout and fluid analysis, as well as therapeutic and cell delivery vehicles are presented. Finally, several promising new therapeutic targets to treat heart diseases are highlighted.

Inadvertent ascending aortic perforation after transseptal puncture: Successful treatment with an Amplatzer Duct Occluder II device

Transseptal puncture is a routine technique to access the left atrium during catheter ablation, but carries a small risk of perforation into the pericardium or aorta. When conservative management fails, surgical repair is usually needed. We report an 81-year-old male in whom aortic root perforation occurred after transseptal puncture and was treated successfully by percutaneous deployment of an Amplatzer Duct Occluder II device.

Treatment strategies for post-infarction left ventricular free-wall rupture

Left ventricular free-wall rupture is one of the most fatal complications after acute myocardial infarction. Surgical treatment of post-infarction left ventricular free-wall rupture has evolved over time. Direct closure of the ventricular wall defect (linear closure) and resection of the infarcted myocardium (infarctectomy), with subsequent closure of the created defect with a prosthetic patch, represented the original techniques. Recently, less aggressive approaches, either with the use of surgical glues or the application of collagen sponge patches on the infarct area to cover the tear and achieve haemostasis, have been proposed. Despite such modifications in the therapeutic strategy and surgical treatment, however, postoperative in-hospital mortality may be as high as 35%. In extremely high-risk or inoperable patients, a non-surgical approach has been reported.

Haemostasis with fibrin glue injection into the pericardial space for right ventricular perforation caused by an iatrogenic procedural complication

An 89-year-old woman with severe aortic valve stenosis and bradycardia presented with circulatory shock due to cardiac tamponade. We performed pericardiocentesis, and then diagnosed right ventricular perforation by echocardiography with microcavitation contrast medium just before inserting a drainage tube. We then inserted the drainage tube in the appropriate position and withdrew blood-filled fluid. The patient was haemodynamically stabilised, but haemorrhage from the perforation site continued for a few days. We injected fibrin glue into the pericardial space through the drainage tube and achieved haemostasis. Thus, we avoided surgery to close the perforation in this high-risk patient. There was no recurrence of haemorrhage. She subsequently had elective aortic valve replacement at another hospital. No adhesions in the pericardial space were seen during surgery.

Transcatheter device closure of pseudoaneurysms of the left ventricular wall: An emerging therapeutic option

Left ventricular pseudoaneurysm is a rare but serious complication of acute myocardial infarction and cardiac surgery. While surgical intervention is the conventional therapeutic option, transcatheter closure can be considered in selected patients with suitable morphology of the pseudoaneurysm. We report a case of successful transcatheter closure of a left ventricular pseudoaneurysm orifice and isolation of the sac using an Amplatzer septal occluder.

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

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

Successful therapy of ventricular rupture by percutaneous intrapericardial instillation of fibrin glue: a case report

Rupture of the ventricular myocardium is an often lethal complication after myocardial infarction. Due to the dramatic hemodynamics and the short time frame between ventricular rupture and surgical closure of the defect, additional therapeutic strategies are needed. Here we report the successful therapy of ventricular rupture by percutaneous intrapericardial instillation of fibrin glue in a 72-year-old male patient with postinfarct angina secondary to anterior myocardial infarction.

Preoperative and perioperative management of patients with pericardial diseases

Hemodynamic instability is the major concern in surgical patients with pericardial diseases, since general anesthesia and positive pressure ventilation may precipitate cardiac tamponade. In advanced constriction diastolic impairment and myocardial fibrosis/atrophy may cause low cardiac output during and after surgery. Elective surgery should be postponed in unstable patients with pericardial comorbidities. Pericardial effusion should be drained percutaneously (in local anesthesia) and pericardiectomy performed for constrictive pericarditis before any major surgical procedure. In emergencies, volume expansion, catecholamines, and anesthetics keeping cardiac output and systemic resistance should be applied. Etiology of pericardial diseases is an important issue is the preoperative management. Patients with neoplastic pericardial involvement have generally poor prognosis and any elective surgical procedure should be avoided. For patients with acute viral or bacterial infection or exacerbated metabolic, uremic, or autoimmune diseases causing significant pericardial effusion, surgery should be postponed until the causative disorder is stabilized and signs of pericarditis have resolved.

Injectable cardiac tissue engineering for the treatment of myocardial infarction

Heart disease is a leading cause of morbidity and mortality worldwide. Myocardial infarction leads to permanent loss of cardiac tissue and ultimately heart failure. However, current therapies could only stall the progression of the disease. Thus, new therapies are needed to regenerate damaged hearts to overcome poor prognosis of patients with heart failure. The shortage of heart donors is also a factor for innovating new therapies. Although the cardiac performance by cell-based therapy has improved, unsatisfactory cell retention and transplant survival still plague this technique. Because biomaterials can improve the cell retention, survival and differentiation, cardiac tissue engineering is now being explored as an approach to support cell-based therapies and enhance their efficacy for cardiac disease. In the last decade, cardiac tissue engineering has made considerable progress. Among different kinds of approaches in the cardiac tissue engineering, the approach of injectable cardiac tissue engineering is more minimally invasive than that of in vitro engineered tissue or epicardial patch implantation. It is therefore clinically appealing. In this review, we strive to describe the major progress in the flied of injectable cardiac tissue engineering, including seeding cell sources, biomaterials and novel findings in preclinical studies and clinical applications. The remaining problems will also be discussed.

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.

Outcome of percutaneous intrapericardial fibrin-glue injection therapy for left ventricular free wall rupture secondary to acute myocardial infarction

Left ventricular free wall rupture (LVFWR) is a fetal complication of acute myocardial infarction. This study was conducted to test the feasibility of percutaneous intrapericardial fibrin-glue injection therapy (PIFIT) for LVFWR after acute myocardial infarction and to assess its clinical outcome. From January 2000 to December 2004, LVFWR was confirmed by echocardiography in 22 patients. Thirteen patients showing abrupt hemodynamic collapse failed to recover from resuscitation maneuvers and died <2 hours after LVFWR. The remaining 9 patients (5 women, mean age 73 +/- 10 years) underwent PIFIT. Pericardiocentesis was performed from the subxiphoid process, and a 6Fr pigtail catheter was introduced into the pericardial space. After bloody fluid was drained from the catheter, the fibrin glue was injected into the pericardial space. There were no complications relating to pericardiocentesis and PIFIT. One patient underwent surgical repair on the day of PIFIT because of uncontrollable bleeding from pericardial drainage. In-hospital death as a result of rerupture occurred in 2 patients on days 4 and 7 after PIFIT. Echocardiography during follow-up revealed no evidence of pseudoaneurysm or left ventricular restriction. On follow-up at a median of 4.0 years (interquartile range 3.1 to 4.8), 1 noncardiac death occurred at 3.3 months. The other 5 patients were free of cardiovascular events and in New York Heart Association functional class I. In conclusion, PIFIT is a simple, effective, and less invasive technique for the management of LVFWR and thus can be an alternative to surgical repair for LVFWR after acute myocardial infarction.

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.

Effect of Reperfusion Therapy on Cardiac Rupture After Myocardial Infarction in Japanese

BACKGROUND

Cardiac rupture after acute myocardial infarction (AMI) is unpredictable and almost always fatal, so the present study reviewed all the clinical characteristics of patients with cardiac rupture to determine if its occurrence can be predicted.

METHODS AND RESULTS

The clinical characteristics of 1,296 consecutive AMI patients from January 1992 to February 2002 were retrospectively evaluated using multi-logistic analysis. Cardiac rupture occurred in 45 patients (3.5%), comprising left ventricular free wall rupture (n=23), ventricular septal perforation (n=20) and papillary muscle rupture (n=2). Early-phase rupture (within 72 h after AMI onset) was associated with anterior infarction. Of the 45 patients who experienced ruptures, 24 (53.3%) survived to discharge; 21 (46.6%) of the 45 ruptures occurred after admission. Successful reperfusion therapy was performed within 24 h for 840 patients. The incidence of rupture was significantly lower for reperfused patients than for non-reperfused patients (0.6% vs 3.5%, respectively; p<0.01). Peak C-reactive protein concentration was a reliable predictor of late-phase rupture (p=0.01), but not of early-phase rupture.

CONCLUSIONS

Reperfusion therapy appears to aid in the prevention of cardiac rupture, especially late-phase rupture.