Left ventricular wall ruptures occur in the posterior
and posterolateral wall and, classically, there are
three different types according to the location of the
rupture. Reports of posterior wall ruptures caused by strut positioning and their high incidence in the
small left ventricular cavities[
14] lead the companies to
reduce the strut profiles and lead the surgeons to pay
attention, while positioning bioprosthesis struts with
good results.[
4] The concept of “untethered loop” was
introduced by Cobbs et al.[
15] The suture technique
applied to the posterior annulus is crucial. Sutures
from both the annulus and prosthetic valve should be
positioned equally spaced, and the sutures should be
reciprocal. Asymmetrical and uneven spaced suture
positioning may cause either leakage or rupture in the
later period.[
4]
In the injured area, first dissection and hematoma
develop in the myocardium and, then, rupture.[9,12] In
redo cases, the main reason is the deep cut of tissue
through the annulus during the removal of the valve.[12]
However, in redo cases, this area is very adherent, and
the attached posterior wall may be partially protective.
Although acute left ventricular ruptures are not seen in
these cases, pseudoaneurysms may develop in the late
period. The repair of late pseudoaneurysms is easier,
and the results are more satisfactory.
In the publication of Cabrol in 1984, Lillehei
reported that none of the 2,100 cases had ventricular
wall rupture for 20 years due to the protection of the
posterior leaflet.[16] In the series of Deniz et al.,[13] no
ventricular wall rupture was observed in patients with
preserved posterior leaflet. Karlson et al.[14] also agreed
with this opinion. In our practice, we also preserve the
posterior leaflet in primary cases and bioprostheses. If
cardiopulmonary resuscitation is needed in a patient
with mitral valve prosthesis, we recommend a soft
cardiac massage to avoid the rupture of left ventricle.
It is not possible to preserve the posterior leaflet in all
cases. However, it should be preserved in all eligible
patients. Deep excision of the posterior annulus and
deep hard decalcification should be avoided. The
appropriate size of valves should be selected, sutures
from both annulus and prosthetic valve should be
equally spaced and reciprocal.
Treatment of left ventricular rupture is
challenging in many ways. The left ventricular muscle
tissue easily splits and does not support the sutures.[6]
Regardless of the type of rupture, it is difficult to
access and vision is limited.[6] Surgical suturing
and positioning of the heart is also very difficult,
when repair under a beating heart is chosen. Repair
techniques on the beating heart can lead to elongation
of the tear widening the ruptured area. Repairing the ventricle by decompressing the heart under CPB and
cross-clamping the aorta is the most reliable way.[5]
The reasons that make the situation more difficult
are sutures extending to the ventricle's endocardium
that may damage the mitral bioprosthesis and the
circumflex artery and its branches, inducing acute
myocardial infarction (MI).[17] Sutures may occlude
the coronary sinus or cause stenosis. Malignant
arrhythmias may develop in the following period. The
surgical technique aims to cover the ruptured area
with patches and pass the sutures through the intact
myocardial tissue by a wide external patch covering
the laceration and hematoma area.[10] Also, the major
branches of the circumflex artery must be protected.[6]
In type 1 tears, the great vein of the coronary sinus
should not be damaged. In the double-patch repair
or sandwich technique, sutures must pass through
non-damaged tissue. If there is a doubt about the
coronary arteries injury, revascularization of the
suspected vessel is needed. Successful cases have been
described in the literature using the posterior leaflet as
support in type 1 ruptures.[6]
Repair with a buttressed suture technique using a
felt strip is recommended in type 1 ventricular rupture.
Both internal and extracardiac patching techniques
are suggested for type 2, 3, and mixed ruptures.[6]
Another method is to support the surgical repair of
the torn region with adhesives such as bio-glue.[7,9] To
create a bloodless environment in the 2-min period in
which adhesives are used, the total circulatory arrest
may be needed. Adhesives alone do not form the basis
of repair, but support the surgical technique.[9] The
chance of encountering left ventricular wall rupture
varies between clinics and even between surgeons in
a single clinic.
If the rupture occurs in the operating room, it is
easier to re-start CPB, and the problem is easier to
manage. However, if it occurs during the postoperative
period, the diagnosis is complex and there may not be
enough time for stabilization.
Two main routes of repair the left ventricular
rupture have been defined as internal and external.[5,14]
The method we describe has an external approach,
and it differs from the sandwich method 2 in terms
of suture technique and placement of the pericardial
patches.
In the internal repair, the lesion is exposed
through atriotomy. However, if mitral valve repair is applied, it is impossible to perform the internal
repair without removing the valve. The results of
the external technique with CPB are better than the
internal technique.[5,14] The results of repair without
CPB are even worse.[5,12] We do not recommend
autotransplantation, which is the last step of the
algorithm created by Sersar and Jamjoom[6]
In the present case, the patient underwent
bioprosthetic valve implantation, and injury of the left
ventricle due to the bioprosthesis struts occurred. The
ventricle was repaired with the double-patch repair
technique. Eventually, the patient was discharged on
postoperative Day 11 after ICU stay for four days. We
also used this technique in two more patients previously.
Both of them were left ventricular free wall rupture due
to ischemic MI. After the operation, bleeding stopped
and both patients were discharged. All three patients
weaned from the CPB with inotropic support. Two
patients needed intra-aortic balloon support.
We also suggest the double-patch repair with a
similar technique in patients with post-MI ventricular
septal defect.[18]
In conclusion, preventive measures should be
taken to avoid the occurrence of left ventricular
rupture after mitral valve replacement, particularly
in patients with predisposing factors. In case of left
ventricular rupture, repair of the defect on CPB with
cross-clamping the aorta protects the left ventricular
functions, thereby avoiding excessive blood loss. The
double-patch repair technique secures the suture
lines and strengthens the jeopardized area with
better results in this difficult situation to handle
complication.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.