Repair of Left Ventricular Rupture Following Mitral Valve Replacement Concomitant With Left Atrial Reduction Procedure

Abstract

eft ventricular (LV) rupture is one of the most severe complications after mitral valve replacement (MVR). Although its occurrence is rare, it is potentially lethal. The present report describes successful repair of a type 1 LV rupture, which occurred after MVR concomitant with a left atrial (LA) reduction procedure, by combination of an intracardiac patch repair and an extracardiac buttress suture. Case ReportA 64-year-old woman, who was diagnosed with mitral stenosis with atrial fibrillation resulting from rheumatic fever, underwent percutaneous mitral comissurotomy. After this procedure, severe mitral regurgitation occurred. The patient subsequently underwent mitral replacement and LA reduction in May 1999.The operation was performed with a cardiopulmonary bypass and intermittent/continuous cold blood cardioplegia. The atrial incision was initiated from the right side of the LA, and an area of the pulmonary vein was circularly isolated. The middle third of the LA, including the LA appendage, was excised, as followed by a report by Sankar and Farnsworth. 1 The mitral valve was found to have developed fibrosis of the leaflet, and chordae shortening without calcification. There was a tear measuring 2 cm on the anterior leaflet, which was created by the percutaneous mitral comissurotomy. Both the anterior and the posterior leaflet were excised. The 27 mm ATS mitral prosthesis is fixed to the mitral annulas using interrupted mattress sutures. Japanese Circulation Journal Vol.65, June 2001After weaning from the cardiopulmonary bypass, a major bleeding was suddenly noted from the posterior area of the heart during the hemostasis of the LA suture line. Simultaneously, the ST level was elevated on the II and V5 leads of the electrocardiogram. Because LV rupture was suspected, cardiopulmonary bypass was re-established immediately. Epicardial oozing and myocardial hematoma were recognized at the posterior left ventricular wall, but the Rupture of the posterior wall of the left ventricle after mitral valve replacement is a dire complication associated with a very high mortality. This study reports a successful repair of type 1 left ventricular rupture, which occurred after mitral valve replacement concomitant with a left atrial reduction procedure, by combination of an intracardiac patch and an extracardiac buttress suture. In a case such as this, in which hemostasis is quite difficult to establish, this combination technique is particularly effective. ( Full-thickness buttressed suture was placed on the epicardium while making an effort to avoiding circumflex artery injury. Additionally, fibrin glue/sheet and GRF glue on the Teflon sheet were used to enhance hemostasis.

Repair of Delayed Left Ventricular Rupture After Mitral Valve Replacement: Report of a Case

“…Various etiological factors may contribute to this kind of rupture. [1][2][3][4][5][6] Although the precise cause of the rupture in our patient was unclear, we considered the contributing factors to be the excessive removal of a calcified mitral A B C D Fig. 1.…”

“…Both internal and external repair of LV ruptures have been reported. [1][2][3][4][5][6] Internal repair is performed by placing a pericardial patch from inside the LV after removal of the mitral prosthesis, whereas external repair is performed by placing a patch over the entire area of ecchymosis and hematoma on the epicardial surface. We think that a combination of these two methods may be more effective because epicardial hematomas are usually extensive and the point of bleeding, as seen from outside the heart, does not correspond with the area of the internal atrioventricular tear.…”

“…First, large quantities of GRF glue and collagen sheets, both very effective for ventricular free-wall rupture, were applied liberally over the heart surface. 3 Next, a piece of porcine pericardium was fastened to the epicardium superficially, excluding the atrioventricular groove, using a 4-0 monofilament suture. Finally, a lot more GRF glue and collagen sheets were compressed around the porcine pericardium to stabilize watertight pericardial exclusion.…”

“…1-6 However, intracardiac repair by itself is not sufficient to stop the bleeding completely. 3 We describe the successful repair of a delayed LV rupture, achieved by using both an intracardiac and extracardiac porcine pericardial patch with gelatin resorcinol formaldehyde (GRF) glue 3 and collagen sheets. …”

Left Ventricular Rupture Post Mitral Valve Replacement

“…Additionally, in response to continued bleeding, a fibrin sheet, fibrin glue, and GRF glue on the Teflon felt were attached to the repaired region with manual compression. In order to unload the LV afterload, an intra-aortic balloon pump (IABP) is initiated, and then CPB was weaned 23,33,34…”