BEATING HEART REPAIR OF POST-INFARCTION VENTRICULAR PSEUDOANEURYSM: A CASE REPORT
Annarita IavazzoA. LongobardiPierpaolo ChivassoMario ColombinoA. MarinielloFlora PirozziMaria Giovanna VassalloA BonadiesEnrico Coscioni
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Background and Aim: Left Ventricular Pseudoaneurysm (LVPA) is a rare but disastrous complication of myocardial infarction. Urgent surgical repair is required to avoid catastrophic rupture and it’s is necessary in order to exclude the pseudoaneurysm to preserve the LV geometry and function. Beating heart repair can be successfully performed in specific patients. Methods: A 71-years old male patient with a history of systemic hypertension, cigarette smoking, hyoercholesterolemia, peripheral arterial disease, presented with a 48-hours progressive epigastric pain. The diagnosis of anterior STEMI was made and the patient was referred for early coronary angiography, which revealed an occlusion of the left anterior descending artery and a PTCA with a stent implantation was successfully performed. Two days later, the echocardiography showed an apical free wall defect, suspicious of a small LVPA. An MRI confirmed the diagnosis and the patient was admitted to cardiac surgery department. A beating heart repair of the LVPA was performed. A 2-0 Prolene purse-string suture was done at the apex of the left ventricle between the viable myocardium and the infarcted tissues. The exclusion of the pseudoaneurysm was performed using two suture lines (U-shaped single stitches and a continuous 2-0 Prolene suture reinforced by Teflon strips) with the apposition of a bovine pericardial patch. Results: Postoperative echocardiography showed the successful exclusion of the psudoaneurysm, confirmed by a one-month-post- intervention MRI. Conclusions: Beating heart repair of post-infarction left ventricular pseudoaneurysm is a new, feasible and simple approach and provides good short and middle-term results in selected patients.Keywords:
Pseudoaneurysm
Heart Rupture
Myocardial rupture complications after acute myocardial infarction are infrequent but lethal. They mainly involve rupture of the ventricular free wall, ventricular septum, papillary muscle, or combined. We compare features of different kinds of myocardial ruptures after acute myocardial infarction by reviewing the clinical insights. Tanzania Medical Journal Vol. 23 (1) 2008: pp. 30-33
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A clinicopathological study was made on a total of 6 cases of cardiac rupture following myocardial infarction, which was found among 50 cases of recent myocardial infarction with the incidence of 16%. Five out of 6 were women, age ranged from 68 to 88 with an average of 77 years old, and 5 cases showed a previous history of hypertension. In 3 cases both old and fresh myocardial infarctions were documented by electrocardiograms. Pathological examination showed the mixture of old scar or fibrosis and fresh myocardial infarction in all cases. Cardiac rupture occurred at the border of the old and fresh myocardial lesions presumed by increased strain at the junction area. Bizarre electrocardiogram at the time of cardiac rupture was shown in one of the cases, which was thought as extraordinarily rare.
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Summary Although myocardial rupture occurs in only 2% to 4% of cases of acute myocardial infarction (AMI), there is a high mortality rate due to acute cardiogenic shock. We present the anatomopathological findings of three cases of myocardial rupture in autopsied hearts in the last 30 years, with a diagnosis of cardiac rupture in acute myocardial infarction. In these 30 years the percentage of AMI with myocardial rupture was 0.2%. Risk factors for post-AMI myocardial rupture include older age, atherosclerosis, diabetes mellitus and systemic arterial hypertension.
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The medical histories of those who died from heart rupture (PC) were analyzed. Of the 1499 patients with myocardial infarction (MI) who were admitted to the specialized department for patients with myocardial infarction from 1972 to 1978, 221 died; PC was the direct cause of death in 56 of them (25.3%). MS was mainly observed in the elderly, more often in women than in men. In the 51-60 age group, PC occurred in 5 out of 284 men (1.8%) and in 3 out of 70 women (4.3%), in the 61-70 age group - in 8 out of 270, respectively (2.9 %) and 18 out of 191 (9.4%); in the group of MI patients over 70 years old - in 5 out of 107 (4.7%) and in 17 out of 155 (10.9%). In all patients, MS occurred against the background of transmural MI in the anterior wall region. More often MS was observed in primary MI (76.7%), in 2 cases with repeated MI (3.3%), in 12 with recurrent MI (20.0%). On the first day of myocardial infarction, cardiac rupture occurred in 30 patients, on days 2-3 - in 10, on 4-7 - in 2, on 19-23 - in 8. All cases of late ruptures (after 7 day) were associated with recurrent myocardial infarction.
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Out of 3673 patients with myocardial infarction treated between 1989 and 1998, 128 (54 males and 74 females) deceased due to left ventricle wall rupture (death rate: 18.5%). Thrombolytic therapy started to be used in 1992. It was administered in 36.0% patients with myocardial infarction in the years 1992-1998. Out of the patients deceased due to left ventricle wall rupture thrombolytic was carried out in 24.2%, predominantly in males (31.5%) as compared to females (18.8%). Left ventricle wall rupture during acute myocardial infarction occurred mainly in females (57.7%), in patients with first infarction (89.8%), in the case of anterior wall infarction (66.4%), hypertension (80.5%), in patients aged 61-80 and more (86.7%). Majority of the patients (83.6%) deceased because of this condition between 1 and 7 hospitalisation day, mainly during the first 48 hours (48.4%).
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In 18 patients with myocardial infarction. who had died due to the rupture of the heart muscle the activity of lactate-dehydrogenase (LDG) and of its isoenzymes in the blood serum and cardiac tissue was studied. Comparisons were made with the results of investigations in donors, in persons dead as a result of accidents, in patients with uncomplicated transmural myocardial infarction, with aneurysm of the heart, severe cardiogenic shock and with other lethal complications of myocardial infarction. The highest levels of the blood LDG activity were registered in cases involving rupture of the heart. The determination of the LDG and its isoenzymes activity mat be used in assessing the degree of the resorption-necrotic syndrome intensity and of factors indicating the risk of a developing aneurysm and rupture of the heart in patients with myocardial infarction.
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In two patient series including 809 and 327 patients, respectively, with acute myocardial infarction we have compared those who died in myocardial rupture (verified at autopsy, Group A) with those who died without rupture (autopsied, Group B), and those who survived hospitalization (Group C) with regard to previous history and clinical course in hospital. Rupture among autopsied patients was observed in 45% and 40% of the cases in the respective studies. Previous infarction was observed in each study as 0% and 0% in Group A compared with 25% and 31% in Group B, and 20% and 34% in Group C. Previous angina pectoris was observed in 26% and 22% in Group A compared with 50% and 54% in Group B and 52% and 54% in Group C. Maximum serum enzyme activity in Group A did not differ from Group B, but was higher than in Group C (p less than 0.001). Group A patients tended to have a higher initial pain score and a higher requirement of analgesics compared with other groups, whereas initial heart rate or systolic blood pressure did not differ in these patients compared to others. We thus conclude that patients with myocardial rupture have a very low occurrence of previous myocardial infarction and angina pectoris, and that their pain course appears to be particularly severe in the acute phase.
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