Left ventricular unloading therapy using Impella 5.5 after emergency surgery for acute myocardial infarction mechanical complication: a case report.

BACKGROUND: Following an acute myocardial infarction (AMI), surgery for left ventricular free wall rupture (LVFWR) and ventricular septal rupture (VSR) has a high in-hospital mortality rate, which has not improved significantly over time. Unloading the LV is critical to preventing excessive stress on the repair site and avoiding problems such as bleeding, leaks, patch dehiscence, and recurrence of LVFWR and VSR because the tissue is so fragile. We present two cases of patients who used Impella 5.5 for LV unloading following emergency surgery for AMI mechanical complications. CASE PRESENTATION: A 76-year-old male STEMI patient underwent fibrinolysis of the distal right coronary artery. Three days later, he passed out and went into shock. Echocardiography revealed a cardiac tamponade. We found an oozing-type LVFWR on the posterolateral wall and treated it with a non-suture technique using TachoSil. Before the patient was taken off CPB, Impella 5.5 was inserted into the LV via a 10 mm synthetic graft connected to the right axillary artery. We kept the flow rate above 4.0 to 4.5 L/min until POD 3 to reduce LV wall tension while minimizing pulsatility. On POD 6, we weaned the patient from Impella 5.5. A postoperative cardiac CT scan showed no contrast leakage from the LV. However, a cerebral hemorrhage on POD 4 during heparin administration complicated his hospitalization. Case 2: A diagnosis of cardiogenic shock caused by STEMI occurred in an 84-year-old male patient, who underwent PCI of the LAD with IABP support. Three days after PCI, echocardiography revealed VSR, and the patient underwent emergency VSR repair with two separate patches and BioGlue applied to the suture line between them. Before weaning from CPB, we implanted Impella 5.5 in the LV and added venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for right heart failure. The postoperative echocardiography revealed no residual shunt. CONCLUSIONS: Patients undergoing emergency surgery for mechanical complications of AMI may find Impella 5.5 to be an effective tool for LV unloading. The use of VA-ECMO in conjunction with Impella may be an effective strategy for managing VSR associated with concurrent right-sided heart failure.

Post-infarction Left Ventricular Free Wall Rupture Diagnosed by Contrast-Enhanced Computed Tomography: A Case Report.

A 70-year-old Japanese woman with hypertension, dyslipidemia, and diabetes mellitus complained of abdominal discomfort and vomiting and was brought to our emergency department by ambulance two days later with impaired consciousness. Her vital signs suggested shock with a heart rate of 120 bpm. Electrocardiogram and initial transthoracic echocardiography suggested an inferior wall ST-elevation myocardial infarction, but the altered consciousness was inconsistent. Contrast-enhanced computed tomography was urgently performed to further clarify the cause. It revealed pericardial effusion and apparent extravasation from the left ventricular wall, confirming the early definitive diagnosis of left ventricular free wall rupture. The patient underwent successful emergent surgical repair without sequelae. Differential diagnosis of left ventricular free wall rupture is important in patients with ST-elevation myocardial infarction and impaired consciousness. Contrast-enhanced computed tomography allows early diagnosis and treatment of this life-threatening complication.

Successful surgical treatment of left ventricular free wall rupture.

Left ventricular free wall rupture (LVFWR) is a rare mechanical complication of acute myocardial infarction. The clinical course of LVFWR is very poor. Direct or patch closure of the rupture area and sutureless procedures constitute the treatment for LVFWR. We present the surgical treatment of a patient who developed LVFWR after high lateral myocardial infarction, and its successful outcome. Successful salvage of LVFWR remains relatively rare. Transthoracic echocardiography, myocardial contrast echocardiography and thoracic computed tomography are important diagnostic tools for LVFWR. These patients usually present with acute cardiac tamponade symptoms requiring immediate treatment.

Up against the wall - emergency double myocardial rupture repair.

BACKGROUND: Left ventricular free wall rupture (LVFWR) and interventricular septal rupture (VSR) are potentially catastrophic mechanical complications after acute myocardial infarction (AMI). When they occur together, "double myocardial rupture" (DMR), survival is unlikely. DMR is seen in only 0.3% of all AMIs. With or without surgical intervention, the odds are against the patient. CASE PRESENTATION: A 57-year-old male self-referred to the emergency department of a remote hospital 5 days after first experiencing chest pain. Investigations in ED confirmed an inferior ST-segment elevation myocardial infarction (STEMI) complicated by DMR. Coronary angiography revealed a mid-course total occlusion of the right coronary artery (RCA). He was rapidly transferred to our regional cardiac surgical unit, arriving straight into the operating theatre, in cardiogenic shock. He was briefly conscious, before arresting prior to intubation and being massaged onto bypass. Not only did he survive the all-night operation, requiring a mitral valve replacement in the process, but he survived multiple postoperative complications to be eventually transferred on postoperative day 66, neurologically intact, to a peripheral unit to complete his rehabilitation. He was subsequently discharged home 88 days after the operation and was able to ambulate with a walking frame into his first postoperative follow-up clinic appointment. CONCLUSIONS: Our patient, against all odds, has survived DMR and multiple postoperative complications. We present the details of his case and the literature surrounding the condition. The patient's mental fortitude and his supportive family played a significant role, along with excellent multidisciplinary team work, in assuring his survival.

Successful conservative treatment for left ventricular free wall rupture after acute myocardial infarction.

Left ventricular free wall rupture (LVFWR) is a rare but fatal complication of acute myocardial infarction (AMI). An 81-year-old female patient with several cardiovascular risk factors presented to the emergency department with symptoms of developing a chronic stomachache and cold sweat. An echocardiograph showed wall motion abnormalities from the lateral to posterior wall, as well as pericardial effusion containing clots of up to 17 mm in the posterior wall that indicated LVFWR after AMI. Although she was conscious after being brought to the initial care unit, she suddenly lost consciousness and fell into electromechanical dissociation (EMD). Endotracheal intubation was immediately initiated and her pericardial drainage and intra aortic balloon pump (IABP) placement, and hemodynamics recovered. Although she had 100% obstruction in the left circumflex artery (LCX) #12 on coronary angiography (CAG), she was discharged to the Intensive Care Unit (ICU) without percutaneous coronary intervention (PCI). Conservative treatment such as intubation, sedation, pericardiocentesis and strict blood pressure management as well as treatment by IABP long-term support led to the patient being uneventfully discharged after 60 days.

Sutureless repair of left ventricular free wall rupture following acute myocardial infarction with cardiogenic shock.

We report a case of blow-out-type left ventricular free wall rupture (LVFWR) after acute myocardial infarction, who presented with unstable hemodynamic condition in New York Heart Association (NYHA) functional class IV. Immediately, we performed a successful LVFWR repair with sutureless technique using a glue and expanded polytetrafluoroethylene patch on cardio-pulmonary bypass support. Postoperative period and recovery was uneventful. Over a period of 2-year follow-up, the patient is in NYHA class I and cardiac magnetic resonance imaging showed adequate left ventricular (LV) function and no evidence of LV aneurysm.

Spontaneous Coronary Artery Dissection Complicated by Left Ventricular Free Wall Rupture in Turner Syndrome.

A 38-year-old with Turner syndrome presented with acute myocardial infarction due to multivessel spontaneous coronary artery dissection (SCAD) complicated by left ventricular free wall rupture. Conservative management for SCAD was pursued. She underwent sutureless repair for an oozing-type left ventricular free wall rupture. SCAD has not been previously reported in Turner syndrome. (Level of Difficulty: Advanced.).

Surgical repair of left ventricular free-wall rupture complicating acute myocardial infarction: a single-center 30 years of experience.

Background: Left ventricular free-wall rupture (LVFWR) is a catastrophic complication of acute myocardial infarction (AMI). Historically, cardiac surgery is considered the treatment of choice. However, because of the rarity of this entity, little is known regarding the efficacy and safety of surgical treatment for post-infarction LVFWR. The aim of this study was to report a single-center experience in this field over a period of 30 years. Methods: Patients who developed LVFWR following AMI and underwent surgical repair at our Institution from January 1990 to December 2019 were considered. The primary end-point was in-hospital morality rate; secondary outcomes were long-term survival and postoperative complications. Multivariate analysis was carried out by constructing a logistic regression model to identify risk factors for early mortality. Results: A total of 35 patients were enrolled in this study. The mean age was 68.9 years; 65.7% were male. The oozing type of LVFWR was encountered in 29 individuals, and the blowout type in 6 subjects. Sutured repair was used in 77.1% of patients, and sutureless repair in the remaining cases. The in-hospital mortality rate was 28.6%. Low cardiac output syndrome was the main cause of postoperative death. Multivariable analysis identified age >75 years at operation, preoperative cardiac arrest, concurrent ventricular septal rupture (VSR) as independent predictors of in-hospital death. Follow-up was complete in 100% of patients who survived surgery (mean follow-up: 9.3 ± 7.8 years); among the survivors, 16 patients died during the follow-up with a 3-year and 12-year overall survival rate of 82.5% and 55.2%, respectively. Conclusions: Surgical treatment of LVFWR following AMI is possible with acceptable in-hospital mortality and excellent long-term results. Advanced age, concurrent VSR and cardiac arrest at presentation are independent risk factors of poor early outcome.

Perioperative Management of a Patient With Left Ventricular Free Wall Rupture After Myocardial Infarction: A Rare Case Scenario.

Myocardial infarction (MI) is typically followed by numerous lethal complications. One such complication is left ventricular free wall rupture (LVFWR). We present the case of a middle-aged hypertensive patient who had a history of unstable angina for seven days. He presented to the emergency room with chest pain, dyspnea, and unstable vital parameters. Clinical signs, electrocardiography, and echocardiography raised the suspicion of left ventricular free wall rupture with ST-segment elevation inferior wall and lateral wall MI. As a result, the patient received aggressive resuscitative measures. Later, he underwent surgical repair for cardiac rupture via cardiopulmonary bypass. Finally, the patient was discharged from the hospital on the 10th postoperative day. The window period from the onset of cardiac wall rupture to patient admission to the operating room is crucial. This case report highlights that a high index of suspicion for left ventricle free wall rupture should be considered for a patient presenting with MI and cardiogenic shock. Timely diagnosis and quick surgical intervention can deter complications and save the patient.

Left Ventricular Free Wall Rupture After Acute Myocardial Reinfarction Due to In-Stent Thrombosis in COVID-19 Patient.

Background: Acute left ventricular free wall rupture (LVFWR) is a life-threatening complication of myocardial infarction that requires urgent intervention. Surgical repair has continued to be the treatment of choice. Studies suggest a posterolateral or inferior infarction is more likely to result in free wall rupture than an anterior infarction. LVFWR generally results in death within minutes of the onset of recurrent chest pain, and on average was associated with a median survival time of 8 hours. Prompt diagnosis and management can lead to successful treatment for LVFWR. Objective: The aim of this article was to present an emergency case with an LVFWR in a COVID-19 patient who suffers from AMI and was treated with PCI stents in the ramus intermedius and circumflex coronary artery. Case report: We present an emergency case with an LVFWR in a COVID-19 patient who suffers from AMI and was treated with PCI stents in the ramus intermedius and circumflex coronary artery. Although dual antiplatelet therapy introduction and good outcome of PCI were achieved, soon after instant thrombosis of both stents appear to result in transmural necrosis and LVFWR. Urgent catheterization was performed and diagnosed in-stent thrombosis where the ventriculography confirmed LVFWR of the posteroinferior wall. Urgent surgery was performed. Transmural necrosis was noticed alongside the incision line. The incision is sawn with 4 U-stitches (Prolen 2.0 with Teflon buttressed stitches). Another layer of fixation was made by Prolen 2.0 running stitches reinforced with Teflon felts from both sides. A large PTFE patch was fixed to epicardium over the suture line by Prolen 6.0 running stitch and BioGlue was injected in-between patch and LV (Figures 8 and 9). After aortic cross-clamp removal, the sinus rhythm was restored. Conclusion: Despite the high mortality, the urgency and the complexity of surgical treatment the early diagnosis plays a key role in the management of postinfarction LVFWR patients presenting a case of preserved postoperative left ventricular function and accomplished good functional status, as presented in our case.

Sutureless repair of subacute left ventricular free wall rupture.

Left ventricular free wall rupture (LVFWR) is one of the most lethal heart conditions where mortality rates reach 40% intraoperatively and 80% in hospital. A few days after the acute event, the rupture becomes subacute, and surgery is indicated to repair the frail myocardium. Despite the lack of strong evidence to support the efficacy of sutureless repair of subacute LVFWR in the literature, this technique has recently been gaining popularity with acceptable success rates. In this article, we present two techniques to repair the subacute LVFWR without using sutures: the direct glued-hemostatic patch technique and the glued pericardial patch technique. In both techniques, the healthy myocardium surrounding the infarcted zone is recruited, together with hemostatic materials, to seal the rupture. Moreover, we describe the clinical presentation of the acute and subacute LVFWR, peri-operative management, together with intra-operative tips and the advantages and disadvantages of each material used in these operations.

Surgical management for mechanical complications of acute myocardial infarction: a systematic review of long-term outcomes.

Background: Mechanical complications following acute myocardial infarction (AMI), though rare, are associated with significant morbidity and mortality. Surgical management remains a mainstay of therapy for these complications. The purpose of this review is to evaluate long-term outcomes data of surgical management for postinfarction free wall rupture, ventricular septal defect, papillary muscle rupture, and pseudoaneurysm. Methods: An electronic literature search was performed to identify original studies reporting long-term outcomes data of surgical management of one of the four mechanical complications following AMI. Studies were considered to have long-term outcomes if they at minimum included survival or mortality data up to one year. Results: A total of 285 studies were identified from the literature search. Of these, 29 studies with long-term survival data on surgically managed mechanical complications of AMI are included in the review. The majority of these are retrospective cohort studies or single-center case series. Five studies are included on free wall rupture, 18 on ventricular septal defect, 4 on papillary muscle rupture, and 2 on pseudoaneurysm. Detailed results are tabulated according to complication. Conclusions: Long-term surgical outcomes of postinfarction mechanical complications remain understudied. Outcomes for ventricular septal defect repair are better represented in the literature than are outcomes for other mechanical complications, though available studies are still limited by small sample sizes and retrospective design. Further research is warranted, particularly for outcomes of acute pseudoaneurysm repair.

Proposal of a new classification: "sealed type" postinfarction left ventricular free wall rupture.

OBJECTIVE: Postinfarction left ventricular free wall rupture (FWR) has been classified into blow-out type and oozing type. However, considering past papers, oozing type included the cases in which the bleeding had spontaneously stopped or sealed, and the distinction between blow-out type and oozing type was not always clear. We classified FWR into the BO type (combination of blow-out type and oozing type) with continuous bleeding and sealed type and clarified the pathophysiology of the sealed type. METHODS: Thirty-five patients who underwent surgical treatment for FWR during the past 21 years were retrospectively evaluated. RESULTS: Twenty-one patients (60%) were sealed. Comparing the sealed type with the BO type, the incidence of sudden collapse with acute onset was significantly lower (sealed type; 62%, BO type; 100%, P = 0.0118), and there were more cases of transport from outside the hospital (76%, 43%, P = 0.0453). Significantly few cases had electro-mechanical dissociation immediately before surgery (10%, 71%, P = 0.0001). In the sealed type, median sternotomy was performed in 9 patients (43%), and subxiphoid drainage was performed in 12 (57%). Fifteen patients (71%) were supported by IABP postoperatively, and re-rupture occurred in 3 patients without IABP. Long-term outcomes were significantly better in the sealed type than in the BO type. CONCLUSION: Sixty percent of postinfarction ventricular free wall rupture was the sealed type. Median sternotomy and sutureless repair with postoperative IABP support were reliable treatments. Subxiphoid drainage and strict blood pressure control with IABP may be acceptable surgical strategies in elderly, frail patients.

A Case of Left Ventricular Free Wall Rupture with Suspected Posterior Papillary Muscle Necrosis / 日本心臓血管外科学会雑誌

We report a case of arbitrary delayed surgical repair for left ventricular free wall rupture (LVFWR) after acute myocardial infarction with suspected posterior papillary muscle necrosis. The case was a 67-year-old woman who had chest and back pain in the morning, and relapsed in the evening, and was urgently transported. She had an acute lateral wall myocardial infarction on an electrocardiogram and pericardial effusion on transthoracic echocardiography (TTE). She was found to have an obstruction at the origin of the left circumflex branch on coronary angiography. TTE showed low-intensity findings on the head of the posterior papillary muscle, suggesting necrosis of the papillary muscle. For LVFWR, conservative treatment was prioritized and IABP (intra-aortic balloon pumping) management was performed for the purpose of reducing after load because there was concern about papillary muscle rupture (PMR) due to cardiac manipulation and because it was an oozing type and did not disrupt respiratory of circulatory dynamics. On the 7th day after the onset, TTE showed improvement in echo-luminance of the posterior papillary muscle head and gradual increase in pericardial fluid, and a non-suture procedure was performed. She withdrew from the IABP on the third day after surgery and was discharged home on the 12th day.

Can a Biohybrid Patch Salvage Ventricular Function at a Late Time Point in the Post-Infarction Remodeling Process?

A biohybrid patch without cellular components was implanted over large infarcted areas in severely dilated hearts. Nonpatched animals were assigned to control or losartan therapy. Patch-implanted animals responded with better morphological and functional echocardiographic endpoints, which were more evident in a subgroup of animals with very low pre-treatment ejection fraction (<35%). Patched animals also had smaller infarcts than both nonpatched groups. This simple approach could hold promise for clinical translation and be applied using minimally invasive procedures over the epicardium in a large set of patients to induce better ventricular remodeling, especially among those who are especially frail.

Left ventricular free wall rupture as a result of delayed presentation of an inferior ST-elevation myocardial infarction due to fear of COVID-19: case report.

BACKGROUND: Left ventricular free wall rupture (LVFWR) is a rare complication after myocardial infarction and usually occurs 1 to 4 days after the infarct. Over the past decade, the overall incidence of LVFWR has decreased given the advancements in reperfusion therapies. However, during the COVID-19 pandemic, there has been a significant delay in hospital presentation of patients suffering myocardial infarctions, leading to a higher incidence of mechanical complications from myocardial infarctions such as LVFWR. CASE PRESENTATION: We present a case in which a patient suffered a LVFWR as a mechanical complication from myocardial infarction due to delay in seeking care over fear of contracting COVID-19 from the medical setting. The patient had been having chest pain for a few days but refused to seek medical care due to fear of contracting COVID-19 from within the medical setting. He eventually suffered a cardiac arrest at home from a massive inferior myocardial infarction and found to be in cardiac tamponade from a left ventricular perforation. He was emergently taken to the operating room to attempt to repair the rupture but he ultimately expired on the operating table. CONCLUSIONS: The occurrence of LVFWR has been on a more significant rise over the course of the COVID-19 pandemic as patients delay seeking care over fear of contracting COVID-19 from within the medical setting. Clinicians should consider mechanical complications of MI when patients present as an out-of-hospital cardiac arrest, particularly during the COVID-19 pandemic, as delay in seeking care is often the exacerbating factor.

A case of cardiopulmonary arrest due to left ventricular free wall rupture successfully treated with sutureless repair supported by venoarterial extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation for cardiopulmonary arrest due to left ventricular free wall rupture is considered effective, because it enables rapid cardiopulmonary support and introduction of targeted temperature management.

Survival after left ventricular free wall rupture following acute myocardial infarction by conservative treatment.

Left ventricular free wall rupture (LVFWR) is a rare and fatal mechanical complication following an acute myocardial infarction (AMI). Cases of survival after LVFWR due to ST-segment elevation myocardial infarction (STEMI) treated with a conservative treatment strategy are extremely rare. In this case, a 55-year-old male patient with several cardiovascular risk factors presented to the emergency department with symptoms of ongoing chest pain and syncope. The patient's electrocardiogram was in sinus rhythm with ST-elevation on I, aVL, and V4-6 leads. His myoglobin and troponin I levels were elevated. Due to the unstable hemodynamic state of the patient, bedside echocardiography was performed. The echocardiography indicated LVFWR after AMI. Pericardiocentesis was used to restore a satisfactory hemodynamic state in the patient. Following the initial treatment, the patient opted for a conservative treatment strategy and was uneventfully discharged after 19 days.

Ventricular free wall rupture-a rare under-diagnosed fatal complication of myocardial infarction.

Ventricular free wall rupture is a rare complication of acute myocardial infarction (MI) i.e. <1.7% of cases, although it occurs more frequently than might be expected. Without imaging evidence or autopsy, sudden cardiac death in acute MI setting is commonly attributed to fatal dysrhythmias, high degree atrio-ventricular blocks or pulmonary embolism resulting in underdiagnosis of free wall rupture. Modern therapies have probably reduced the incidence but not eliminated the problem. We present a case of left ventricular free wall rupture in acute MI setting and syncopal presentation. The diagnosis was established during left heart catheterisation and further confirmed on transthoracic echocardiography. The patient deteriorated abruptly, pericardial window was made to bridge for surgical repair. Unfortunately, the patient died before surgical intervention.