Successful Cardiorrhexis Repair with Off-Pump Technique

6342 

Cardiothoracic Resident Case Report Competition 

Ameen Basha (1), Teresa Kieser (2)

(1) N/A, United States, (2) University of Calgary, Calgary, NA

Ameen Basha    -  Contact Me
N/A

Teresa Kieser    -  Contact Me
University of Calgary

Ameen Basha    -  Contact Me
N/A

We report a case of post-acute coronary syndrome (ACS) cardiorrhexis repaired off-pump with deep Trendelenburg positioning using felt strips and multiple pledgeted sutures. The patient was an 84-year-old female diagnosed with anterior ST-segment elevation myocardial infarction complicated by cardiorrhexis following percutaneous coronary intervention. Repeated cardiocentesis resulted in transient blood pressure rises and falls necessitating emergent surgery. Upon entry into the thorax, multiple jets of bright red blood from the anterior, apical, and inferior left ventricular wall were apparent. As the patient had received fibrinolytic therapy 6 hours prior to the rupture event resulting in massive coagulopathy, the repair was undertaken off-pump. The operative time (skin-to-skin) was 2 hours 53 minutes. The next day the patient was returned to the operating room for tamponade. Removal of clot in the anterior mediastinum revealed a longitudinal 7-8 cm partial-thickness laceration of the right ventricle directly beneath the sternal halves. A pericardial patch was tacked over the right ventricular erosion with biological adhesives. The chest was easily closed. Postoperatively, the patient remained intubated in the cardiovascular intensive care unit for 7 days. Her postoperative course was complicated by a left pleural effusion resolved with extended chest drainage, postoperative atrial fibrillation cardioverted with amiodarone, and delirium which resolved with orientation and time. She was discharged to her home in stable condition after a postoperative hospital stay of 23 days. Today, she is alive and fully functional 3 years post-op with echocardiographic left ventricle ejection fraction of 55-60%.

Cardiorrhexis is a rare but well-described mechanical complication of ACS affecting between 0.01% and 0.5% of patients in the post-thrombolytic era. Among the most lethal mechanical complications following ACS, risk factors for cardiorrhexis reported from retrospective analyses by Yamaguchi et al. included increased age and first ACS event. Suchil Bernal et al. additionally reported that female patients, hypertension, and those with anterior wall infarcts were at a greater risk for ruptured heart. Furthermore, patients were most likely to experience left ventricular rupture within the first four days after ACS. In a meta-analysis of 11 observational studies, Matteucci et al. reported a summary operative mortality rate of 32%. Described repair techniques include patch and non-patch techniques. In patch-based techniques, a biological (pericardial) or synthetic patch is applied to the rupture site. In non-patch techniques a plication-type repair with felt approximates the two sides of the rupture site and excludes the site of rupture. Moreover, patch repairs can be applied with or without sutures; preference for non-suture techniques are based on poor quality tissue which would prevent effective suture anchoring. Importantly, on-pump and off-pump techniques have been described with the latter being applied for cases with profound coagulopathy.

In summary, because of hemodynamic instability associated with cardiac rupture, the off-pump technique is rarely performed. This report emphasizes the importance of considering stabilization with deep Trendelenburg positioning and off-pump repair for this high mortality complication of ACS.

*References provided separately.

Adult Cardiac