Intraoperative left ventricular perforation with false aneurysm formation.

Abstract

regurgitant, severely stenosed, and heavily calcified mitral valve. There was minrimal aortic regurgitation and the left ventricular cavity was of normal size.At operation (22 November 1974) the calcification was found not to involve the mitral annulus and there was only moderate disease of the subvalvar mechanism. A 27 mm Bjork-Shiley prosthesis was inserted using multiple interrupted sutures. While attempting to come off bypass the pericardium was found to be filling with blood. Bypass was restarted and a tear was found in the posterior left ventricular wall where the papillary muscle had been removed. The left anterior descending artery and branches of the circumflex coronary artery on either side of the defect were intact. The tear was closed using 'teflon' reinforced mattress sutures and a second layer of continuous sutures. The closure appeared to be effective and bypass was terminated successfully. A haematoma was, however, noted in the atrioventricular groove.Recovery was uneventful and no murmurs were detected. The electrocardiogram, previously normal apart from mitral P waves, now showed right axis deviation and a broad prominent R wave in lead Vl ( Fig. 1A and B). This was thought to indicate a strictly posterior myocardial infarction. Progress, however, was uneventful and she was discharged well 14 days after the operation. Two weeks later she suddenly developed severe,

A Treatise on The Surgical Management and A Suggested Amendment of Surgical Classification of Left Ventricular Rupture Following Mitral Valve Replacement

“…Delayed rupture occurs within hours after leaving the operation room, usually in the ICU, and late is defined as occurring days to years after the operation [9,15,29]. Delayed rupture is the most dreaded complication because this occurs in the ICU, making it difficult to control the bleeding and to undertake timely surgical management [13,[29][30][31][32][33][34][35][36][37][38][39][40][41][42]. Late tears may present as left ventricular pseudoaneurysms [15].…”

“…These are: a) an underlying fragile myocardium, b) a primary tear, and c) dynamic forces that contribute to the formation of the primary tear or convert a partial-thickness injury into a transmural rupture. [13,23,41]. These features presumably reflect a weakened myocardium and enhanced vulnerability to injury [9].…”

“…The tear is closed using a woven Dacron fabric patch sutured with a 3-0 polypropylene continuous suture. The valve prosthesis is re-implanted and the left atriotomy is closed [40,41].…”

Left Ventricular Rupture Post Mitral Valve Replacement

“…True aneurysm is usually found at the site of the previously sutured ventricular perforation and the area was plicated using ‘teflon’ reinforced sutures. Sharratt G.P et al, recommend that all patients who have repair of a ventricular perforation, particularly if this was in the atrioventricular groove, should have left ventriculography performed before discharge 20. However with MRA and Echo, the need to ventriculography is decreasing.…”

“…left ventriculography is recommended when surgery is contemplated, even in the presence of an aortic valve prosthesis, and even though echocardiography indicates mitral regurgitation. 20…”