doi: 10.1161/01.cir.0000089042.80722.7a
(Circulation. 2003;108:II-237.)
© 2003 American Heart Association, Inc.
Cardiac Transplantation and Surgery for Congestive Heart Failure |
Midterm Clinical and Echocardiographic Results With Patch Glue Repair of Left Ventricular Free Wall Rupture
From the Department of Cardiac Surgery, University General Hospital, Valencia, Spain (S.J.C., M.J.D., M.B., J.B., F.H., O.G., R.G., J.M.); the Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, United Kingdom (E.L.); and the Department of Cardiology, University General Hospital, Valencia, Spain (R.P., J.P., I.E.).
Correspondence to Sergio J. Cánovas, MD, Servicio Cirugia Cardiaca, Hospital General Universitario, Tres Cruces s/n, 46014- Valencia, Spain. Phone: + (34)96 3335740, Fax + (34) 96 3862982, E-mail sjcanovas{at}comv.es
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Abstract |
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 Top Abstract IntroductionPatients and MethodsResultsDiscussionConclusionReferences |
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Background— Left ventricular free wall rupture (LVFWR) is a dramatic complication after myocardial infarction. We present our mid-term clinical and echocardiographic results of LVFWR with an epicardial patch without cardiopulmonary bypass.
Methods— From February 1993 to May 2001, 17 patients underwent surgery for LVFWR. The mean age±SD of 12 males and 5 females was 68±10 years. All patients presented for emergency surgery with cardiac tamponade confirmed on echocardiography. After opening the chest and identification of the site of rupture, a Goretex patch was fashioned and applied with enbucrilate surgical glue.
Results— Effective control of bleeding was achieved in all cases. There were no on-table deaths. The operative (30 day) mortality was 23.5% (4/17). One death occurred because of patch failure, two because of cardiogenic shock, and one from pneumonia. On follow-up at a median of 2.2 years (interquartile range, 1.1 to 4.3 years), two further deaths occurred, one from myocardial infarction and another of undetermined etiology. Echocardiography did not reveal any evidence of restriction to left ventricular free wall motion.
Conclusions— Patch glue repair is expedient, simple and effective; with no adverse effects on mid-term ventricular dynamics. In view of superior published results to infarctectomy and repair with extra corporeal circulation, it should be considered to be the initial procedure of choice for the surgical repair of LVFWR.
Key Words: surgery • myocardial infarction • complications • echocardiography • coronary disease
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionConclusionReferences |
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Left ventricular free wall rupture (LVFWR) is one of the most dramatic complications of myocardial infarction, occurring with a frequency of 4% to 8%.1,2 It is the most common cause of death after pump failure,3 and accounts for 15% of the mortality from acute myocardial infarction.4,5
LVFWR is associated with transmural infarctions involving at least 20% of the ventricle,6 and usually occurs after 1 to 4 days. The clinical characteristics are variable depending on the location and size of the rupture.3 Although acute myocardial rupture is almost universally fatal,6 a proportion of patients with subacute rupture present with a window of opportunity for intervention. The widespread availability of echocardiography and prompt diagnosis in this subgroup has improved the prospect of operative repair.1,3
A number of surgical procedures have been advocated. Traditionally, closing the defect with Teflon® supported sutures or infarctectomy and prosthetic patch repair have been performed utilizing cardiopulmonary bypass.1,3,4,7–13 Recently, the use of epicardial patch repair without extracorporeal circulation is increasing in popularity,14–16 although little is known of the effects of glue and prosthetic patch on subsequent ventricular function. Therefore, we describe mid term clinical and echocardiographic outcome in our 8-year experience with this technique.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionConclusionReferences |
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This study is a follow-up of a series of patients referred for consideration of surgery for LVFWR from 1993 through 2001. The primary modality of confirmatory diagnosis was transthoracic echocardiography (Figure 1). Because of emergent status of the patients in this series, cardiac catheterization was not undertaken prior to surgical intervention.
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Surgical Technique
Surgical access was obtained via median sternotomy. Evacuation of blood and hematoma was undertaken. There was no evidence of active bleeding in the majority. One patient with active bleeding at the site of the rupture had hemostasis secured by 5/0 polypropylene sutures with two supporting Teflon pledgets prior to patch glue repair of LVFWR.
The site of rupture was carefully identified and a visual estimation of size undertaken (Figure 2). Subsequently, a Gore-Tex patch was fashioned of sufficient size to exceed the radius of the infarcted area by approximately 4 cm circumferentially. The shaped patch was applied to the epicardium, and enbucrilate surgical glue (Histoacryl blue, Braun, Germany) was instilled with gentle pressure against the beating heart (Figure 3). Secure bonding occurred within seconds (Figure 4). After careful attention to general hemostasis, routine sternal closure was performed.
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Follow-Up
Follow-up was undertaken telephone contact, and postmortem reports. In addition, survivors were invited for transthoracic echocardiography at clinics organized specifically for the purposes of this study.
Statistical Analysis
Continuous variables were presented as means with standard deviations (SD) or medians with interquartile ranges (IQR). Frequencies were expressed as percentages (%). Actuarial survival was calculated using Kaplan Meier product limit method using SPSS version 10.0 (Chicago, IL).
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Results |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionConclusionReferences |
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From February 10, 1993 through May 13, 2001, 17 patients were referred for surgery with subacute LVFWR after myocardial infarction. The mean age ± SD of 12 males and 5 females was 68±10 years. All patients in this series presented with cardiogenic shock due to tamponade following myocardial infarction. The median time to onset of tamponade was 1.5 days (ranging from 1 to 6 days).
The location of the site of rupture was the free wall of the left ventricle in all cases, occurring at the following sites: posterior 29.4% (5/17), apical 23.5% (4/17) lateral 23.5% (4/17), anterior 11.8% (2/17), and 11.8% (2/17) that extended to both anterior and lateral walls.
There were no on-table deaths. The operative (30-day) mortality associated with this procedure was 23.5% (4/17; 95% CI 9.6 to 47.3%). One death occurred as a result of re-rupture with massive cardiac tamponade 2 hours postoperatively. Emergency sternotomy was performed on the intensive care unit, and incomplete adherence of the patch to the ventricular wall was observed resulting in uncontrollable massive bleeding. The second death occurred on the first postoperative day from intractable cardiogenic shock. This was subsequent to preoperative myocardial infarction, and occurred despite support with intraaortic balloon conterpulsation. Transthoracic echocardiography confirmed that the patch was intact and there was no evidence of any significant pericardial effusion. The third death also occurred from intractable cardiogenic shock. Transthoracic echocardiography again confirmed that the patch was intact and again there was no evidence of any significant pericardial effusion. The fourth death occurred as a result of pneumonia on 19th postoperative day. The remainder of the patients had an uneventful postoperative course.
Follow-up was undertaken at a median of 2.2 years (interquartile range of 1.1 to 4.3 years). Two further deaths occurred, one as a result of myocardial infarction at 15 months after surgery and the other at 1.6 months was sudden death of unknown etiology. The one year survival (SE) was 68.8% (11.6) and 5-year survival was 61.1% (12.6). The hazard for death was highest within the first 30 days. On follow up, all patients were free from angina and in New York Heart Association functional class I.
Echocardiographic Results
Of 11 survivors, 8 attended for follow-up echocardiography. The mean left ventricular end-diastolic dimension (SD) was 52.8% (6.5) mm, the mean left ventricular end-systolic dimension (SD) was 36.3% (6.8) mm, and the mean ejection fraction (SD) was 49.3% (11.9). It was not possible to identify the patch on transthoracic echo, and visual estimation was used to screen for regional wall motion abnormalities. No restriction to left ventricular free wall motion was noted, and dynamic function was preserved in all patients. There was no evidence of mitral regurgitation in any of the patients.
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Discussion |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionConclusionReferences |
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Emergency surgical intervention in patients with LVFWR often yields poor results. Mortality from infarctectomy and patch repair ranges from 35% to 61%.15,17 A number of challenging problems have been reported with this operation. It is often difficult to assess viability to determine the extent of myocardial resection in the presence of acute infarction.9 Traditional LVFWR repair techniques, such as a series of interrupted plegeted sutures, reinforced linear Teflon strips, and circular patch repair, often involve tying sutures though friable necrotic muscle.9,10 Moreover, repair involving cardiopulmonary bypass is disadvantaged by systemic heparinization and continuous oozing of blood though necrotic areas of myocardium adjacent to the primary site of infarction.7
Distinct advantages of the patch glue technique are simplicity and speed. This sutureless epicardial patch technique effectively controlled hemorrhage for patients in this series, without requiring cardiopulmonary bypass or aortic cross clamping; while retaining the flexibility to approach all regions of the heart. Another theoretical advantage is preservation of ventricular geometry compared with distortion that can potentially result from linear plication.18,19 On the other hand, little is known of the effects (if any) of enbrucrilate surgical glue and a prosthetic patch on subsequent restriction to left ventricular free wall motion. Our study confirmed that the glue and patch did not lead to any impediment of left ventricular free wall dynamics in the mid term.
Prior to the popularization of the patch glue repair, there has been little improvement in survival with infarctectomy and repair utilizing cardiopulmonary bypass.10,20–24 Although no direct comparative studies have been performed, results with the patch glue technique are superior. Padro and associates, 14 for example, describe survival rates of 100%.
Potential Limitations
Although we used the patch glue technique successfully for all of our patients with subacute LVFWR, this technique is not suitable for patients with blowout rupture. Also, it may not be suitable for patients requiring surgical intervention for concomitant complications, such as postinfarction ventricular septal defect or mitral regurgitation. Excessive bleeding has been cited as a relative contraindication to patch glue repair.16 However, individualization of the approach with a hybrid technique by initial hemostasis using pledgeted sutures followed by patch application may overcome this problem. Although revascularization was not performed in any of our patients, off-pump surgery could be a consideration to avoid complete heparinization and cardiopulmonary bypass.
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Conclusion |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionConclusionReferences |
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Patch glue repair is a simple, effective, and versatile technique that can be used solely, or in combination with reinforced direct suture repair in patients with isolated LVFWR, without subsequent restriction to left ventricular free wall dynamics. Because current published results are superior to infarctectomy and repair with extra corporeal circulation, the patch glue technique should be considered to be the initial procedure of choice for surgical repair of subacute LVFWR.
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References |
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