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Intraventricular Patch Repair Through an Extended Aortotomy for Repeated Left Ventricular Rupture After Mitral Valve Replacement

2008; Elsevier BV; Volume: 86; Issue: 3 Linguagem: Inglês

10.1016/j.athoracsur.2008.01.082

1552-6259

Choung Kyu Park, Pyo Won Park, Ji‐Hyuk Yang, Young Tak Lee, Kiick Sung, Wook Sung Kim,

Mechanical Circulatory Support Devices

Posterior wall rupture of the left ventricle is a rare but lethal complication after mitral valve replacement. We treated a patient with repeated left ventricular rupture. Initially, type 1 left ventricular rupture was repaired in the intensive care unit, but persistent bleeding occurred after the repair. We treated the bleeding through an extended aortotomy and successfully repaired the repeated type 3 left ventricular rupture with bovine pericardium (Synovis Surgical Innovations Inc, St. Paul, MN). Posterior wall rupture of the left ventricle is a rare but lethal complication after mitral valve replacement. We treated a patient with repeated left ventricular rupture. Initially, type 1 left ventricular rupture was repaired in the intensive care unit, but persistent bleeding occurred after the repair. We treated the bleeding through an extended aortotomy and successfully repaired the repeated type 3 left ventricular rupture with bovine pericardium (Synovis Surgical Innovations Inc, St. Paul, MN). Rupture of the left ventricle is a serious complication of mitral valve replacement (MVR). This complication has a reported incidence of 1.2% and a mortality rate of up to 75% [1Kalson K.J. Ashraf M.M. Berger R.L. Rupture of left ventricle following mitral valve replacement.Ann Thorac Surg. 1988; 46: 590-597Abstract Full Text PDF PubMed Scopus (106) Google Scholar]. Several methods of repair have been reported for left ventricular ruptures, including an internal patch repair [2Celemin D. Nunez L. Gil-Aguado M. Larrea J.L. Intraventricular patch repair of left ventricular rupture following mitral valve replacement: new technique.Ann Thorac Surg. 1982; 33: 638-641Abstract Full Text PDF PubMed Scopus (26) Google Scholar, 3David T.E. Left ventricular rupture after mitral valve replacement: endocardial repair with pericardial patch.J Thorac Cardiovasc Surg. 1987; 93: 935-936PubMed Google Scholar]. Here we report the case of a 66-year-old woman with a repeated type 1 and type 3 left ventricular rupture after MVR. We obtained an effective operative exposure through an extended aortotomy between the noncoronary cusp (NCC) and the left coronary cusp (LCC) of the aortic valve in the type 3 left midventricular rupture. We repaired both ruptures with bovine pericardium by the internal approach. A 66-year-old woman had been diagnosed with valvular heart disease 10 years previously. The patient complained recently of aggravated symptoms, including facial and peripheral edema and exertional dyspnea. Echocardiography revealed severe mitral stenosis, moderate mitral regurgitation, mild aortic regurgitation, severe tricuspid regurgitation, and atrial fibrillation. An elective MVR with a Perimount 27-mm porcine mitral bioprosthesis (Carpentier-Edwards, Irvine, CA), tricuspid annuloplasty (modified DeVega type), and modified Cox-Maze procedure with cryoablation was performed. The mitral valve was exposed with a Waterston's groove incision. The anterior leaflet of the mitral valve was thickened, calcified, and retracted. The posterior leaflet was relatively pliable and clear. The mitral annular calcification was not present. The commissure of the mitral valve was fused. When we excised the mitral valve, we preserved the posterior leaflet partially. No complications occurred during the operation, and the patient was in good condition, with normal sinus rhythm and acceptable blood pressure. Shortly after she arrived in the intensive care unit (ICU), her blood pressure dropped to 60 mm Hg. The patient sustained massive bleeding (900 mL in 25 minutes) from the chest drainage tubes and hypotension. We urgently reopened the sternotomy in the ICU and found a large epicardial hematoma and continuous bleeding from the posterior side of the left ventricle. After immediate reinstitution of cardiopulmonary bypass (CPB), the mitral bioprosthesis was removed so we could locate the exact site of the rupture. A 2-cm long tear was found on the ventricular side, under the posterior annulus near the atrioventricular groove. The chordae and the posterior leaflet preserved previously were excised during the second operation. We repaired this type 1 left ventricular rupture with a bovine pericardium (Synovis Surgical Innovations Inc, St. Paul, MN) with 5-0 Prolene (Ethicon, Somerville, NJ) continuous running sutures and 17 interrupted, pledgeted mattress sutures for reinforcement. Repeat MVR with a 25-mm mechanical prosthetic valve (St. Jude Medical, St. Paul, MN) was performed. After termination of the CPB, bleeding continued from the posterior wall of the left ventricle through the pericardial cavity; therefore, the patient was taken to the operating room to reevaluate the internal disruption site. CPB was resumed, and the mitral valve prosthesis was explanted. The previously placed bovine pericardium was well located, but there was a repeated type 3 semicircular rupture at the midventricle that had newly occurred. The operative surgical field was too deep to be approached through a standard left atriotomy. We therefore decided to approach the midventricular rupture through an extended aortotomy and transection of the superior vena cava. The aortotomy incision was extended to the aortic valve annulus between the NCC and the LCC of the aortic valve, similar to the Manouguian incision. This incision was extended to the standard left atriotomy (Fig 1). The previously placed bovine pericardium was removed. Then a repeat intraventricular patch repair, with a large single bovine pericardium covering the first type 1 and the second type 3 left ventricular ruptures, was simultaneously performed through an extended aortotomy (Fig 2). For reinforcement, 19 interrupted, pledgeted mattress sutures were placed around the bovine pericardium. A second repeat MVR with a 25-mm St. Jude mechanical prosthetic valve was performed. The aortic annulus and intervalvular aortomitral fibrous continuity was approximated with Prolene 6-0 continuous running sutures at the commissure between the NCC and the LCC. In addition, another plication stitch with 4-0 pledget-buttressed horizontal mattress sutures were placed at the commissure between the NCC and the LCC for good coaptation because the patient had mild aortic regurgitation. During weaning from the CPB, the patient's vital signs were stable, and she was supported with a temporary left ventricular assist device for 150 minutes. Hemofiltration, thought to improve cardiac performance, was performed during each operation; the amount of fluid removed during the first operation was 3800 mL, during the second, 4700 mL; and during the third, 2100 mL. The durations of CPB for each of the three runs were 106 minutes, 186 minutes, and 239 minutes. After termination of the CPB, the sternotomy was not closed. We sutured a silicone elastomer membrane dressing over it and closed the wound in the operating room 3 days later. The patient's postoperative course was uneventful, and she was moved to a general ward in good condition 12 days later. The patient was discharged to home 33 days later. In addition, on postoperative day 38, the ventricular function was relatively good, except for a moderate tricuspid regurgitation by echocardiography. Mild aortic regurgitation that existed preoperatively did not progress to a more advanced state on follow-up echocardiogram 2 years later. Left ventricular rupture after MVR should be diagnosed immediately and repaired without hesitation. This complication can be classified into three types according to the location: Type 1 is a tear in the atrioventricular groove, type 2 is a tear around the base of the papillary muscle, and type 3 is a tear between the atrioventricular groove and the base of the papillary muscle [4Treasure R.L. Rainer W.G. Sadler T.R. Intraoperative left ventricular rupture associated with mitral valve replacement.Chest. 1974; 66: 511-514Crossref PubMed Scopus (89) Google Scholar]. In a review reported by Karlson in 1988, early rupture has an incidence of 55% and a survival rate of 40% [1Kalson K.J. Ashraf M.M. Berger R.L. Rupture of left ventricle following mitral valve replacement.Ann Thorac Surg. 1988; 46: 590-597Abstract Full Text PDF PubMed Scopus (106) Google Scholar]. We treated a patient with a repeated type 1 and type 3 left ventricular ruptures after MVR, an extremely rare situation. We used the internal approach for both ruptures because the internal approach to type 1 and type 3 left ventricular rupture, after MVR, is considered the safest and most successful method [2Celemin D. Nunez L. Gil-Aguado M. Larrea J.L. Intraventricular patch repair of left ventricular rupture following mitral valve replacement: new technique.Ann Thorac Surg. 1982; 33: 638-641Abstract Full Text PDF PubMed Scopus (26) Google Scholar, 5David T.E. Left ventricular rupture after mitral valve replacement: endocardial repair with pericardial patch.J Thorac Cardiovasc Surg. 1987; 93: 935-936PubMed Google Scholar]. In addition, intraventricular repair permits accurate evaluation of the lesion, permits perfect visualization, eliminates tension on the tissue, and allows accurate repair [2Celemin D. Nunez L. Gil-Aguado M. Larrea J.L. Intraventricular patch repair of left ventricular rupture following mitral valve replacement: new technique.Ann Thorac Surg. 1982; 33: 638-641Abstract Full Text PDF PubMed Scopus (26) Google Scholar]. In this case, the second ventricular rupture site was too deep to be approached through the mitral valve annulus alone. We therefore obtained exposure of the midventricle through an extended aortotomy and temporary transection of the superior vena cava. The aortotomy incision was taken down onto the intervalvular fibrous trigone through the aortomitral continuity through the aortic annulus between the NCC and the LCC anteriorly similar to a Manouguian incision [6Eghtesady P. Hanley F. Posterior aortic annular enlargement for mechanical aortic valve replacement.Oper Techn Thorac Cardiovasc Surg. 2002; 7: 181-187Abstract Full Text Full Text PDF Scopus (11) Google Scholar]. The standard left atriotomy incision was extended to the left atrial roof posteriorly. We did not consider a superior septal incision because we think it is hard to obtain exposure of the midventricle through this approach. Furthermore, temporary transection of the superior vena cava was effective for reducing the time required for the mitral valve and midventricle treatment. These maneuvers vastly improved the operative exposure, and we could repair the type 1 and type 3 left ventricular ruptures simultaneously with a single bovine pericardium [2Celemin D. Nunez L. Gil-Aguado M. Larrea J.L. Intraventricular patch repair of left ventricular rupture following mitral valve replacement: new technique.Ann Thorac Surg. 1982; 33: 638-641Abstract Full Text PDF PubMed Scopus (26) Google Scholar, 3David T.E. Left ventricular rupture after mitral valve replacement: endocardial repair with pericardial patch.J Thorac Cardiovasc Surg. 1987; 93: 935-936PubMed Google Scholar]. The proximal part of the pericardial patch crossing the posterior mitral annulus was sutured to the wall of the left atrium. Everting pledgeted horizontal mattress sutures including the left atrial wall and the bovine pericardium were made meticulously during the third operation [7Arena V. Alamanni F. Repossini A. Matteo S.D. Antona C. Biglioli P. Straddling endoventricular pericardial patch in prevention of type 1 myocardial rupture.Ann Thorac Surg. 1993; 56: 163-165Abstract Full Text PDF PubMed Scopus (7) Google Scholar]. We thought it also could help to protect the circumflex coronary artery in the atrioventricular groove. Finally, when we closed the extended aortotomy, approximation of the aortic annulus was performed with a 6-0 Prolene continuous running suture, and additional commissural plication with a 4-0 pledget buttressed the horizontal mattress suture and was performed at the commissure between the NCC and the LCC [8Minakata K. Schaff Zehr K.J. Dearani J.A. Daly R.C. Orszulak T.A. Puga F.J. Danielson G.K. Is repair of aortic valve regurgitation a safe alternative to valve replacement?.J Thorac Cardiovasc Surg. 2004; 127 (hv): 645-653Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar]. In conclusion, intraventricular patch repair with bovine pericardium in combination with an extended aortotomy, through the aortic annulus between the NCC and the LCC, was a safe and effective surgical treatment for repeated type 1 or type 3 left ventricular rupture after MVR.