Sutured Patch Repair of Ischemic Left Ventricular Free Wall Rupture

A fifty-three-year-old man was transferred for emergent surgical repair of a left ventricular free wall rupture (LVFWR). An expedited preoperative workup including an electrocardiogram and echocardiography revealed an old inferior infarct, reduced left ventricular ejection fraction of 25 percent, akinesis of the lateral and inferolateral walls, and a moderate-sized pericardial hematoma compressing the right ventricle. Importantly, there was minimal mitral regurgitation, suggesting no involvement of the papillary muscles. The patient was taken to the catheterization lab emergently for intra-aortic balloon pump placement and coronary angiogram, which identified total occlusion of the proximal left circumflex artery. He was then taken directly to the operating room for LVFWR repair.

Intraoperatively, the pericardium was noted to be thickened with dense adhesions. A large amount of clot was evacuated from the pericardial space which allowed for the identification of a five centimeter defect near the left ventricular apex extending up to but not involving the papillary muscles. The left ventricular musculature was subsequently debrided back to healthy tissue, after which individual pledgeted Ethibond sutures were placed in a circumferential manner from inside the ventricular cavity to outside through healthy myocardium. 

At this point, the patch was created from two sheets of bovine pericardium sandwiched around a strip of felt and parachuted down onto the defect. The patch was further secured to the surrounding healthy myocardium with a running polypropylene suture and, after ensuring hemostasis, Bioglue was applied to the edges of the patch. The patient was then weaned off bypass successfully and discharged home on postoperative day nine with an uneventful postoperative course.
 

References

1. Matteucci, M., et al., Sutured and sutureless repair of postinfarction left ventricular free-wall rupture: a systematic review. Eur J Cardiothorac Surg, 2019. 56(5): p. 840-848.
2. Matteucci, M., et al., Treatment strategies for post-infarction left ventricular free-wall rupture. Eur Heart J Acute Cardiovasc Care, 2019. 8(4): p. 379-387.
3. Matteucci, M., et al., Surgical Treatment of Post-Infarction Left Ventricular Free-Wall Rupture: A Multicenter Study. Ann Thorac Surg, 2021. 112(4): p. 1186-1192.

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