Case Study
Repair of right ventricle rupture caused by left coronary artery occlusion
Asian Cardiovascular & Thoracic Annals 21(4) 447–449 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312454745 aan.sagepub.com
Tatsuya Tarui and Masahiro Ikeda
Abstract A 67-year-old man was admitted with right ventricular free wall rupture secondary to occlusion of the left anterior descending artery. Emergency coronary angiography showed total occlusion of the proximal left anterior descending artery and severe stenosis of the proximal right coronary artery. Echocardiography revealed acute cardiac tamponade, and free wall rupture of the heart was suspected. At surgery under cardiopulmonary bypass, closure was achieved using mattress sutures with pledgets.
Keywords Cardiac tamponade, heart rupture, post-infarction, heart ventricles, myocardial infarction
Case report A 67-year-old man who experienced severe chest pain for a day, was admitted to the emergency room in a state of cardiogenic shock. On arrival, he was pale with a systolic blood pressure of 70 mm Hg and heart rate of 80 beatsmin 1. Electrocardiography showed normal sinus rhythm and ST elevation in leads V1–V6, II, III, and aVf. Assuming acute myocardial infarction, emergency coronary angiography was performed, which showed total occlusion of the left anterior descending artery (LAD) and severe stenosis of the proximal right coronary artery (RCA). A percutaneous coronary intervention was undertaken to revascularize the LAD (Figure 1). Although it was successful, the patient’s hemodynamics remained unstable. Echocardiography revealed an echo-free space in the pericardial cavity. Therefore, percutaneous pericardial drainage was carried out. Continuous bleeding occurred, and dark blood was drained. Free wall rupture secondary to myocardial infarction was suspected, and the patient was immediately taken to the operating room. A median sternotomy was performed, and when the pericardium was incised, 300 mL of blood burst out from the pericardial cavity. Cardiac wall motion of the apex was dyskinetic, and that of the anterior wall was hypokinetic. After cardiopulmonary bypass was established, further exploration of the heart revealed a 3 4-mm area of free wall rupture in the right side of the LAD
(Figure 2). Direct closure of the rupture was achieved by placing 2 mattress sutures with pledgets (Figure 3). To manage the severe stenosis of the proximal RCA, a reversed autogenous saphenous vein graft was placed on the distal RCA. The patient was weaned from cardiopulmonary bypass uneventfully. He recovered well, and was discharged on the 17th postoperative day.
Discussion Free wall rupture of the left ventricle after an episode of acute myocardial infarction occurs at a frequency of 2% to 4%.1 Free wall rupture limited to the right ventricle is rare. The difference in occurrence rates of free wall rupture in the left and right ventricles is attributable to the lower pressure in the right ventricle. Even in cases of severe ischemia of the right ventricular wall, perforation or rupture rarely occurs. The right ventricle receives its blood supply through both the RCA and LAD, although much of the blood supply is through the RCA. In this case, the right ventricular rupture was Department of Cardiovascular Surgery, Toyama Red Cross Hospital, Toyama City, Japan Corresponding author: Tatsuya Tarui, Department of Cardiovascular Surgery, Toyama Red Cross Hospital, 2-1-58 Ushijima Honnmachi, Toyama City, Toyama 930-0859, Japan. Email: [email protected]
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Asian Cardiovascular & Thoracic Annals 21(4)
Figure 1. Coronary angiography showing (a) total occlusion of the left anterior descending artery. (b) A percutaneous intervention was performed to achieve revascularization of the left anterior descending coronary artery (arrow). (c) Coronary angiography also showed severe stenosis of the proximal right coronary artery.
Figure 2. Surgical findings of a right ventricular rupture, after establishment of cardiopulmonary bypass.
adjacent to the occluded LAD, and the proximal RCA was not completely occluded. We believe that severe proximal lesions in both the RCA and LAD may have exacerbated the ischemia of the right ventricle and caused the RVFWR. However, RVFWR is mostly caused by occlusion of the RCA.2,3 According
to Furukawa and colleagues,4 all RVFWR caused by LAD occlusion are associated with ventricular septal rupture. Therefore, ours is an interesting case of isolated RVFWR caused by occlusion of the LAD. Sherer and colleagues5 reported the case of a patient who survived without surgical repair of RVFWR. However, surgical treatment is strongly recommended in when patients show unstable hemodynamics, as observed in our patient. Several techniques of surgical repair have been proposed for the treatment of free wall rupture in the heart, including direct compression, suturing with pledgets, and sutureless patch-glue techniques. Recent reports suggest a likely shift toward the use of sutureless techniques for managing oozing-type of free wall ruptures, because of the simplicity and effectiveness, without the risk of myocardial friability. However, despite the risk of myocardial friability, suturing with pledgets is the preferred technique for treating RVFWR in cases of non-oozing rupture, as in our patient, because of the low pressure in the right ventricle.
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Figure 3. (a) Right ventricular free wall rupture in the right side of the left anterior descending coronary artery. (b) Two mattress sutures with pledgets.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Haddadin S, Milano AD, Faggian G, Morjan M, Patelli F, Golia G, et al. Surgical treatment of postinfarction left ventricular free wall rupture. J Card Surg 2009; 24: 624–631. 2. Woldow AB, Mattleman SJ, Ablaza SG and Nakhjavan FK. Isolated rupture of the right ventricle in a patient with acute inferior wall MI. Chest 1990; 98: 484–485.
3. Ventura F, Landolfa MC, Bonsignore A, Gentile R and De Stefano F. Sudden death due to isolated right ventricular infarction: a case report. Cardiovasc Pathol 2011; 20: 58–62. 4. Furukawa T, Kohata S, Hayashi S. Two cases of acute myocardial infarction complicated by ventricular septal perforation and right ventricular free wall rupture. Jpn J Cardiovasc Surg 2005; 34: 29–32. Abstract available at: http://jscvs.umin.ac.jp/eng/journal/vol34-1/29.html. Accessed June 23, 2012. 5. Sherer Y, Levy Y, Shahar A, Leibovich L, Konen E and Shoenfeld Y. Survival without surgical repair of acute rupture of the right ventricular free wall. Clin Cardiol 1999; 22: 319–320.
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Repair of right ventricle rupture caused by left coronary artery occlusion
Asian Cardiovascular & Thoracic Annals 21(4) 447–449 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312454745 aan.sagepub.com
Tatsuya Tarui and Masahiro Ikeda
Abstract A 67-year-old man was admitted with right ventricular free wall rupture secondary to occlusion of the left anterior descending artery. Emergency coronary angiography showed total occlusion of the proximal left anterior descending artery and severe stenosis of the proximal right coronary artery. Echocardiography revealed acute cardiac tamponade, and free wall rupture of the heart was suspected. At surgery under cardiopulmonary bypass, closure was achieved using mattress sutures with pledgets.
Keywords Cardiac tamponade, heart rupture, post-infarction, heart ventricles, myocardial infarction
Case report A 67-year-old man who experienced severe chest pain for a day, was admitted to the emergency room in a state of cardiogenic shock. On arrival, he was pale with a systolic blood pressure of 70 mm Hg and heart rate of 80 beatsmin 1. Electrocardiography showed normal sinus rhythm and ST elevation in leads V1–V6, II, III, and aVf. Assuming acute myocardial infarction, emergency coronary angiography was performed, which showed total occlusion of the left anterior descending artery (LAD) and severe stenosis of the proximal right coronary artery (RCA). A percutaneous coronary intervention was undertaken to revascularize the LAD (Figure 1). Although it was successful, the patient’s hemodynamics remained unstable. Echocardiography revealed an echo-free space in the pericardial cavity. Therefore, percutaneous pericardial drainage was carried out. Continuous bleeding occurred, and dark blood was drained. Free wall rupture secondary to myocardial infarction was suspected, and the patient was immediately taken to the operating room. A median sternotomy was performed, and when the pericardium was incised, 300 mL of blood burst out from the pericardial cavity. Cardiac wall motion of the apex was dyskinetic, and that of the anterior wall was hypokinetic. After cardiopulmonary bypass was established, further exploration of the heart revealed a 3 4-mm area of free wall rupture in the right side of the LAD
(Figure 2). Direct closure of the rupture was achieved by placing 2 mattress sutures with pledgets (Figure 3). To manage the severe stenosis of the proximal RCA, a reversed autogenous saphenous vein graft was placed on the distal RCA. The patient was weaned from cardiopulmonary bypass uneventfully. He recovered well, and was discharged on the 17th postoperative day.
Discussion Free wall rupture of the left ventricle after an episode of acute myocardial infarction occurs at a frequency of 2% to 4%.1 Free wall rupture limited to the right ventricle is rare. The difference in occurrence rates of free wall rupture in the left and right ventricles is attributable to the lower pressure in the right ventricle. Even in cases of severe ischemia of the right ventricular wall, perforation or rupture rarely occurs. The right ventricle receives its blood supply through both the RCA and LAD, although much of the blood supply is through the RCA. In this case, the right ventricular rupture was Department of Cardiovascular Surgery, Toyama Red Cross Hospital, Toyama City, Japan Corresponding author: Tatsuya Tarui, Department of Cardiovascular Surgery, Toyama Red Cross Hospital, 2-1-58 Ushijima Honnmachi, Toyama City, Toyama 930-0859, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at NORTH CAROLINA STATE UNIV on March 18, 2015
448
Asian Cardiovascular & Thoracic Annals 21(4)
Figure 1. Coronary angiography showing (a) total occlusion of the left anterior descending artery. (b) A percutaneous intervention was performed to achieve revascularization of the left anterior descending coronary artery (arrow). (c) Coronary angiography also showed severe stenosis of the proximal right coronary artery.
Figure 2. Surgical findings of a right ventricular rupture, after establishment of cardiopulmonary bypass.
adjacent to the occluded LAD, and the proximal RCA was not completely occluded. We believe that severe proximal lesions in both the RCA and LAD may have exacerbated the ischemia of the right ventricle and caused the RVFWR. However, RVFWR is mostly caused by occlusion of the RCA.2,3 According
to Furukawa and colleagues,4 all RVFWR caused by LAD occlusion are associated with ventricular septal rupture. Therefore, ours is an interesting case of isolated RVFWR caused by occlusion of the LAD. Sherer and colleagues5 reported the case of a patient who survived without surgical repair of RVFWR. However, surgical treatment is strongly recommended in when patients show unstable hemodynamics, as observed in our patient. Several techniques of surgical repair have been proposed for the treatment of free wall rupture in the heart, including direct compression, suturing with pledgets, and sutureless patch-glue techniques. Recent reports suggest a likely shift toward the use of sutureless techniques for managing oozing-type of free wall ruptures, because of the simplicity and effectiveness, without the risk of myocardial friability. However, despite the risk of myocardial friability, suturing with pledgets is the preferred technique for treating RVFWR in cases of non-oozing rupture, as in our patient, because of the low pressure in the right ventricle.
Downloaded from aan.sagepub.com at NORTH CAROLINA STATE UNIV on March 18, 2015
Tarui and Ikeda
449
Figure 3. (a) Right ventricular free wall rupture in the right side of the left anterior descending coronary artery. (b) Two mattress sutures with pledgets.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Haddadin S, Milano AD, Faggian G, Morjan M, Patelli F, Golia G, et al. Surgical treatment of postinfarction left ventricular free wall rupture. J Card Surg 2009; 24: 624–631. 2. Woldow AB, Mattleman SJ, Ablaza SG and Nakhjavan FK. Isolated rupture of the right ventricle in a patient with acute inferior wall MI. Chest 1990; 98: 484–485.
3. Ventura F, Landolfa MC, Bonsignore A, Gentile R and De Stefano F. Sudden death due to isolated right ventricular infarction: a case report. Cardiovasc Pathol 2011; 20: 58–62. 4. Furukawa T, Kohata S, Hayashi S. Two cases of acute myocardial infarction complicated by ventricular septal perforation and right ventricular free wall rupture. Jpn J Cardiovasc Surg 2005; 34: 29–32. Abstract available at: http://jscvs.umin.ac.jp/eng/journal/vol34-1/29.html. Accessed June 23, 2012. 5. Sherer Y, Levy Y, Shahar A, Leibovich L, Konen E and Shoenfeld Y. Survival without surgical repair of acute rupture of the right ventricular free wall. Clin Cardiol 1999; 22: 319–320.
Downloaded from aan.sagepub.com at NORTH CAROLINA STATE UNIV on March 18, 2015
