Surgical treatment of postinfarction left ventricular free wall rupture

Abstract

Background: Left ventricular free wall rupture (LVFWR) is still one of the often fatal complications of acute myocardial infarction. Surgical repair is mandatory even with high operative mortality. The optimal surgical technique is controversial since the results depend on type of rupture. We present our mid-term surgical experience according to the status of the left ventricular tear and type of surgical repair.

Methods: From January 1997 to December 2007, 19 consecutive patients with LVFWR were treated at our institution. The mean age was 72 +/- 8 ranging from 53 to 81 years; there were eight males and 11 females. According to the intraoperative findings, patients were divided into two groups: group 1 (eight patients), where no macroscopic tear of the LVFW could be detected with blood oozing from infarcted zone (Oozing type LVFWR); and group 2 (11 patients), where a macroscopic defect of the epicardium, with free communication between left ventricular cavity and pericardial space, was identified (Blow-out type LVFWR). The patch covering and glue technique was applied for group 1 patients, while closure of the ventricular tear either by direct suture or by patch repair was used for group 2 patients.

Results: The interval between diagnosis of LVFWR and surgery was 2.9 +/- 1.1 hours. However, reevaluation of echocardiographic studies showed an early missed diagnosis of LVFWR in three patients of group 1 and in eight of group 2. Thus, the mean interval between initial signs of rupture and surgery was 9 +/- 8 hours and 21 +/- 15 hours, respectively, for oozing and blow-out type rupture. On arrival in the operating room, four patients were on cardiopulmonary resuscitation, while four were in cardiogenic shock. The hospital mortality was 12% (one death) in group 1 and 36% (four deaths) in group 2 mainly due to multiorgan failure. Fourteen patients were discharged with a mean follow-up of 3.8 +/- 3.5 years. During follow-up, one patient in group 1 died after 7.5 years. No recurrence of free wall rupture or aneurysm formation was demonstrated in all cases. At last follow-up, all survivors showed excellent clinical results with a preserved left ventricular function. Patients with oozing type LVFWR and patch covering technique repair showed an absence of left ventricular-restricted motion at the echocardiographic study.

Conclusion: In patients with LVFWR, early diagnosis and surgical treatment are crucial for successful outcome when excellent results can be achieved with a simple glued patch covering technique.