CASE REPORTS
Left Ventricular Wall Rupture after Mtral Valve Replacement: Report of Successful Repair in 2 Patients Seong Chi, M.D., Richard Beshore, D.O., and Lorenzo Gonzalez-Lavin, M.D. ABSTRACT Left ventricular wall rupture after mitral valve replacement, though uncommon, is a disastrous complication when it does occur. We have experienced this problem in 2 separate instances. Successful treatment was accomplished by suturing a large prosthetic patch over the entire area of laceration and hematoma.
Following right anterolateral thoracotomy, cardiopulmonary bypass was instituted with high flow and moderate systemic hypothermia to 28°C. Utilizing myocardial perfusion and electrical fibrillation, the diseased mitral valve was easily replaced with a large Beall valve inserted with interrupted sutures of 2-0 Tevdek. Excessive bleeding was apparent when bypass was Mitral valve replacement can now be carried out terminated, and complete cardiopulmonary with low operative mortality and good long- bypass was reinstituted. term results [l-31. Problems inherent in the surInspection of the external surface of the left gical procedure remain, however, the most dras- ventricle revealed a laceration in the posterior tic of which is left ventricular wall rupture. In a wall. To achieve better exposure, the sternum recent review Zacharias and co-workers [41 was transected, the aorta was cross-clamped, found a 100% mortality in 6 patients with this and a left ventricular sump was placed at the complication among 1,154 operations for mitral apex. Massive bleeding was found to originate valve replacement in one institution and 13 from a laceration 4 cm in length involving the deaths among 19 cases reported in the literature. entire thickness of the left ventricular wall. This We have experienced this disastrous compli- tear was located very close to the atrioventricular cation twice. In both instances successful treat- groove, near the left circumflex coronary artery, ment was accomplished by suturing a large and was surrounded by hematoma (Fig 1).Sevprosthetic patch over the entire area of laceration eral attempts to suture the laceration were unand hematoma. The case histories and surgical successful. A large Dacron patch was placed over technique employed are described. the entire area of laceration and hematoma and sutured to healthy myocardium with multiple Patient 1 interrupted sutures of 4-0 Prolene, taking care A 54-year-old white woman with a long history to avoid the left circumflex coronary artery (Fig of rheumatic heart disease and increasing disa- 2). After the aorta was undamped, the heart bility due to mitral regurgitation was admitted vented, and the ventricular sump removed, the to Ingham Medical Center for elective mitral heart began to contract forcefully. Cardiopulvalve replacement. She was found to be in monary bypass was discontinued once hemoFunctional Class I11 by New York Heart Associa- stasis was secured, and the heart maintained tion criteria. Operation was performed on April adequate output. Postoperative chest drainage was 1,500 ml per 24 hours (83 ml per square 23, 1974. meter of body surface area) for the first postoperative day and subsequently tapered off. From the Division of CardiothoracicSurgery, Michigan State The patient’s course was complicated by a University, East Lansing, and Ingham Medical Center, Lansing, MI. short episode of tubular renal failure that was We thank Mrs. Beverly Zell for her help in the preparation of managed successfully by the usual medical this manuscript. means. She was discharged on May 11, 1974. Accepted for publication Nov 26, 1975. When last seen in the cardiac follow-up clinic Address reprint requests to Dr. Gonzalez-Lavin, Department of Surgery, Michigan State University, 111 Giltner two years after operation she was asymptomatic, and the prosthetic valve was functioning well. Hall, East Lansing, MI 48824. 380
381
Case Report: Chi, Beshore, and Gonzalez-Lavin: Left Ventricular Wall Rupture
Fig 1 . Thesitesoflacerationin t h e 2 patientsare indicated b y their respective patient number.
Patient 2 A 62-year-old white woman with a long history of rheumatic heart disease and severe mitral stenosis was admitted to Ingham Medical Center for elective valve replacement. She was found to be in Functional Class IV, and an operation was performed on July 25, 1974. Through a midline sternal-splitting incision, cardiopulmonary bypass was instituted with high flow and moderate systemic hypothermia to 28°C. The diseased mitral valve was replaced with a 33 mm Hancock porcine xenograft valve* inserted with multiple interrupted sutures of 2-0 Tevdek during 30 minutes of anoxic arrest. She was able to sustain good cardiac output at the conclusion of bypass. After decannulation, however, profuse bleeding was encountered coming from the posterior surface of the heart. Following urgent recannulation and return to cardiopulmonary bypass, the aorta was crossclamped and sump was placed in the apex of the left ventri le. On inspection of the posterior wall of the left ventricle, a laceration 4 cm in length was found 1 cm below the atrioventricular groove and surrounded by a large hematoma (see Fig 1).When the heart was'retracted to the right, the sewing ring of the xenograft valve protruded slightly
t:
Fig2. Thefirst step in the repairconsistedofplacing multiple interrupted mattress sutures reinforced w i t h Teflon felt pledgets. Due to persisfenf bleeding, a large, two-way-stretch Dacron graft w a s then sutured to healthy myocardial tissue at a distance from the laceration w i t h a running suture.
II
*Hancock Laboratories, Anaheim, CA.
382 The Annals of Thoracic Surgery Vol 22 No 4 October 1976
through the laceration. A strip of Teflon felt was placed on each side of the laceration and incorporated into multiple interrupted mattress sutures in an attempt to control the excessive hemorrhage. Due to continuing bleeding, a large, two-way-stretch Dacron patch was then fashioned so as to cover the entire area of laceration and hematoma; it was sutured to healthy myocardium with a running stitch of 3-0 Prolene (see Fig 2). Hemostasis was readily obtained, and after cardiopulmonary bypass was discontinued the heart was able to cope with the circulatory load. Inotropic drugs were given for the first 48 hours. Chest drainage postoperatively was 675 ml per 24 hours (42 ml per square meter). The patient’s postoperative course was complicated by transient tubular renal failure and postperfusion psychosis. Mechanical ventilation was required for five days. She was discharged from the hospital on August 26. When last seen in the cardiac follow-up clinic twenty months after the operation, she was asymptomatic and the xenograft valve was functioning well. Comment The apparent mechanism of posterior left ventricular wall rupture following mitral valve replacement has been clearly outlined by Zacharias and associates [41. Traction on the mitral valve leaflets and papillary muscles during their excision may invaginate some of the left ventricular wall at the base of the papillary muscles. Blood infiltrating this denuded and weak area produces a large hematoma that dissects the entire thickness of the myocardium and perforates the ventricle when forceful ventricular contractions are resumed. The valve prosthesis itself appears to have no direct bearing in this complication, although in some instances the prosthesis may be seen pro-
truding through the laceration when the heart is retracted to visualize the posterior wall of the left ventricle. Control of bleeding by direct suture of the perforation is obviously unsuccessful due to surrounding hematoma with friable myocardium. Interrupted sutures between two Dacron strips also fail because bleeding into and between individual muscle bundles reduces their holding strength. Stitches taken wide enough to be effective would compromise potentially friable myocardium and, in some cases, deprive a major portion of the heart of its blood supply. The patch technique involves tailoring a Dacron patch large enough to cover the entire affected area so that it can be sutured to good holding tissue. A patch that is large relative to the lesion must be used. The size factor probably distributes the pressure beneath the patch over a greater area, reducing the tension on individual sutures and thus the possibility of suture tearing. The patch itself provides a firm backing for clot formation. This technique has been used with success in 2 patients. We attribute the favorable outcome to early diagnosis and prompt treatment as well as to the use of a large Dacron patch.
References 1. Beall AC Jr, Morris GC Jr, Howell JF Jr, et al: Clini-
cal experience with an improved mitralvalve prosthesis. Ann Thorac Surg 15:601, 1973 2. Bonchek LI, Anderson RP, Starr A: Mitral valve replacement with cloth-covered composite-seat prostheses: the case for early operation. J Thorac Cardiovasc Surg 67:93, 1974 3. Gonzalez-Lavin L, O’Connell TX: Mitral valve replacement with viable aortic homograft valves. Ann Thorac Surg 15:592, 1973 4. Zacharias A, Groves LK, Cheanvechai C, et al: Rupture of the posterior wall of the left ventricle after mitral valve replacement. J Thorac Cardiovasc Surg 69959, 1975
Left Ventricular Wall Rupture after Mtral Valve Replacement: Report of Successful Repair in 2 Patients Seong Chi, M.D., Richard Beshore, D.O., and Lorenzo Gonzalez-Lavin, M.D. ABSTRACT Left ventricular wall rupture after mitral valve replacement, though uncommon, is a disastrous complication when it does occur. We have experienced this problem in 2 separate instances. Successful treatment was accomplished by suturing a large prosthetic patch over the entire area of laceration and hematoma.
Following right anterolateral thoracotomy, cardiopulmonary bypass was instituted with high flow and moderate systemic hypothermia to 28°C. Utilizing myocardial perfusion and electrical fibrillation, the diseased mitral valve was easily replaced with a large Beall valve inserted with interrupted sutures of 2-0 Tevdek. Excessive bleeding was apparent when bypass was Mitral valve replacement can now be carried out terminated, and complete cardiopulmonary with low operative mortality and good long- bypass was reinstituted. term results [l-31. Problems inherent in the surInspection of the external surface of the left gical procedure remain, however, the most dras- ventricle revealed a laceration in the posterior tic of which is left ventricular wall rupture. In a wall. To achieve better exposure, the sternum recent review Zacharias and co-workers [41 was transected, the aorta was cross-clamped, found a 100% mortality in 6 patients with this and a left ventricular sump was placed at the complication among 1,154 operations for mitral apex. Massive bleeding was found to originate valve replacement in one institution and 13 from a laceration 4 cm in length involving the deaths among 19 cases reported in the literature. entire thickness of the left ventricular wall. This We have experienced this disastrous compli- tear was located very close to the atrioventricular cation twice. In both instances successful treat- groove, near the left circumflex coronary artery, ment was accomplished by suturing a large and was surrounded by hematoma (Fig 1).Sevprosthetic patch over the entire area of laceration eral attempts to suture the laceration were unand hematoma. The case histories and surgical successful. A large Dacron patch was placed over technique employed are described. the entire area of laceration and hematoma and sutured to healthy myocardium with multiple Patient 1 interrupted sutures of 4-0 Prolene, taking care A 54-year-old white woman with a long history to avoid the left circumflex coronary artery (Fig of rheumatic heart disease and increasing disa- 2). After the aorta was undamped, the heart bility due to mitral regurgitation was admitted vented, and the ventricular sump removed, the to Ingham Medical Center for elective mitral heart began to contract forcefully. Cardiopulvalve replacement. She was found to be in monary bypass was discontinued once hemoFunctional Class I11 by New York Heart Associa- stasis was secured, and the heart maintained tion criteria. Operation was performed on April adequate output. Postoperative chest drainage was 1,500 ml per 24 hours (83 ml per square 23, 1974. meter of body surface area) for the first postoperative day and subsequently tapered off. From the Division of CardiothoracicSurgery, Michigan State The patient’s course was complicated by a University, East Lansing, and Ingham Medical Center, Lansing, MI. short episode of tubular renal failure that was We thank Mrs. Beverly Zell for her help in the preparation of managed successfully by the usual medical this manuscript. means. She was discharged on May 11, 1974. Accepted for publication Nov 26, 1975. When last seen in the cardiac follow-up clinic Address reprint requests to Dr. Gonzalez-Lavin, Department of Surgery, Michigan State University, 111 Giltner two years after operation she was asymptomatic, and the prosthetic valve was functioning well. Hall, East Lansing, MI 48824. 380
381
Case Report: Chi, Beshore, and Gonzalez-Lavin: Left Ventricular Wall Rupture
Fig 1 . Thesitesoflacerationin t h e 2 patientsare indicated b y their respective patient number.
Patient 2 A 62-year-old white woman with a long history of rheumatic heart disease and severe mitral stenosis was admitted to Ingham Medical Center for elective valve replacement. She was found to be in Functional Class IV, and an operation was performed on July 25, 1974. Through a midline sternal-splitting incision, cardiopulmonary bypass was instituted with high flow and moderate systemic hypothermia to 28°C. The diseased mitral valve was replaced with a 33 mm Hancock porcine xenograft valve* inserted with multiple interrupted sutures of 2-0 Tevdek during 30 minutes of anoxic arrest. She was able to sustain good cardiac output at the conclusion of bypass. After decannulation, however, profuse bleeding was encountered coming from the posterior surface of the heart. Following urgent recannulation and return to cardiopulmonary bypass, the aorta was crossclamped and sump was placed in the apex of the left ventri le. On inspection of the posterior wall of the left ventricle, a laceration 4 cm in length was found 1 cm below the atrioventricular groove and surrounded by a large hematoma (see Fig 1).When the heart was'retracted to the right, the sewing ring of the xenograft valve protruded slightly
t:
Fig2. Thefirst step in the repairconsistedofplacing multiple interrupted mattress sutures reinforced w i t h Teflon felt pledgets. Due to persisfenf bleeding, a large, two-way-stretch Dacron graft w a s then sutured to healthy myocardial tissue at a distance from the laceration w i t h a running suture.
II
*Hancock Laboratories, Anaheim, CA.
382 The Annals of Thoracic Surgery Vol 22 No 4 October 1976
through the laceration. A strip of Teflon felt was placed on each side of the laceration and incorporated into multiple interrupted mattress sutures in an attempt to control the excessive hemorrhage. Due to continuing bleeding, a large, two-way-stretch Dacron patch was then fashioned so as to cover the entire area of laceration and hematoma; it was sutured to healthy myocardium with a running stitch of 3-0 Prolene (see Fig 2). Hemostasis was readily obtained, and after cardiopulmonary bypass was discontinued the heart was able to cope with the circulatory load. Inotropic drugs were given for the first 48 hours. Chest drainage postoperatively was 675 ml per 24 hours (42 ml per square meter). The patient’s postoperative course was complicated by transient tubular renal failure and postperfusion psychosis. Mechanical ventilation was required for five days. She was discharged from the hospital on August 26. When last seen in the cardiac follow-up clinic twenty months after the operation, she was asymptomatic and the xenograft valve was functioning well. Comment The apparent mechanism of posterior left ventricular wall rupture following mitral valve replacement has been clearly outlined by Zacharias and associates [41. Traction on the mitral valve leaflets and papillary muscles during their excision may invaginate some of the left ventricular wall at the base of the papillary muscles. Blood infiltrating this denuded and weak area produces a large hematoma that dissects the entire thickness of the myocardium and perforates the ventricle when forceful ventricular contractions are resumed. The valve prosthesis itself appears to have no direct bearing in this complication, although in some instances the prosthesis may be seen pro-
truding through the laceration when the heart is retracted to visualize the posterior wall of the left ventricle. Control of bleeding by direct suture of the perforation is obviously unsuccessful due to surrounding hematoma with friable myocardium. Interrupted sutures between two Dacron strips also fail because bleeding into and between individual muscle bundles reduces their holding strength. Stitches taken wide enough to be effective would compromise potentially friable myocardium and, in some cases, deprive a major portion of the heart of its blood supply. The patch technique involves tailoring a Dacron patch large enough to cover the entire affected area so that it can be sutured to good holding tissue. A patch that is large relative to the lesion must be used. The size factor probably distributes the pressure beneath the patch over a greater area, reducing the tension on individual sutures and thus the possibility of suture tearing. The patch itself provides a firm backing for clot formation. This technique has been used with success in 2 patients. We attribute the favorable outcome to early diagnosis and prompt treatment as well as to the use of a large Dacron patch.
References 1. Beall AC Jr, Morris GC Jr, Howell JF Jr, et al: Clini-
cal experience with an improved mitralvalve prosthesis. Ann Thorac Surg 15:601, 1973 2. Bonchek LI, Anderson RP, Starr A: Mitral valve replacement with cloth-covered composite-seat prostheses: the case for early operation. J Thorac Cardiovasc Surg 67:93, 1974 3. Gonzalez-Lavin L, O’Connell TX: Mitral valve replacement with viable aortic homograft valves. Ann Thorac Surg 15:592, 1973 4. Zacharias A, Groves LK, Cheanvechai C, et al: Rupture of the posterior wall of the left ventricle after mitral valve replacement. J Thorac Cardiovasc Surg 69959, 1975
