Drain, Patch, Unload: Post-Infarction Myocardial Rupture Treated With Surgical Repair and Graded Mechanical Support

This video is part of CTSNet’s 2024 Resident Video Competition. Watch all entries into the competition, including the winning videos.  

Left ventricular free wall rupture (LVFWR) following acute myocardial infarction is a lethal complication that necessitates emergent surgical intervention due to the sequelae of cardiac tamponade and cardiogenic shock. Achieving durable surgical repair is technically challenging because of evolving myocardial destruction and the hemodynamic stress from elevated ventricular pressures. Mechanical circulatory support may be employed to support systemic perfusion and prevent hemodynamic collapse. Given the relative rarity of this condition, no consensus exists regarding the optimal support strategy. Transvalvular microaxial flow pumps, such as the Impella 5.5, offer several advantages in this setting, including left ventricle (LV) unloading to prevent cavity distension and facilitate patient mobility. However, LVFWR has been listed as a relative contraindication due to concerns about potential thrombus embolization and/or disruption of LV repair. There is insufficient literature to guide clinicians in weighing the clinical benefits against theoretical concerns. The authors report a case of LVFWR treated with emergent venoarterial extracorporeal membrane oxygenation (VA-ECMO), patch repair, and staged Impella 5.5, resulting in survival for four months post-discharge. 
 
A 55-year-old female smoker presented with 12 hours of chest pain and ST-segment elevation on the electrocardiogram. Coronary angiography showed 100 percent thrombotic occlusion of the proximal left anterior descending artery. Revascularization attempts were unsuccessful, including intracoronary alteplase infusion. A postoperative echocardiogram demonstrated adherent clot and a large pericardial effusion with impending tamponade. The patient was brought to the operating room and femorally cannulated for cardiopulmonary bypass. Intraoperative transesophageal echocardiogram demonstrated active blood flow within the pericardium and ejection fraction of less than 20 percent. A large bloody pericardial effusion was noted during chest exploration. The anterior LV showed a 3 cm longitudinal perforation, adherent clot, and 2-3 cm of circumferential endocardial necrosis. Limited debridement was performed to prevent embolization and define the extent of necrosis. A 10x8 cm Dacron patch was sutured to the surrounding viable myocardium with mattress-style 2-0 Prolene sutures with Teflon pledgets, reinforced with continuous Prolene suture and Bioglue. Due to biventricular dysfunction, the patient was transitioned to femoral-femoral VA-ECMO at the conclusion of the case. 
 
On postoperative day two, the patient returned to the operating room, where the patch repair was found to be intact. An Impella 5.5 was inserted via a right axillary conduit under echocardiographic and fluoroscopic guidance, followed by chest closure. After right ventricular recovery, the patient was decannulated from VA-ECMO on postoperative day five. Impella flows were maintained at 3.3-4.2L /min for six days, then weaned over the next 21 days before removal. The patient was neurologically intact and ambulating, with mildly recovered heart function (ejection fraction 25-30 percent) at discharge to inpatient rehabilitation on day 42. 
 
Successful operative management of mechanical complications following acute myocardial infraction (AMI) requires timely and technically proficient repair, followed by the management of ventricular failure to protect the repair from undue LV wall stress. Mechanical circulatory support is frequently required, but no consensus exists on the optimal strategy. This report describes the successful management of LVWFR using a strategy of initial LV patch repair and VA-ECMO, followed by staged Impella deployment for intermediate-term mechanical support. This approach demonstrated the potential utility of Impella support as a postoperative adjunct in post-ischemic LVFWR, facilitating successful patch repair with survival to hospital discharge with acceptable functional capacity. 

References

1. Matteucci M, Fina D, Jiritano F, et al. The use of extracorporeal membrane oxygenation in the setting of postinfarction mechanical complications: outcome analysis of the Extracorporeal Life Support Organization Registry. Interact Cardiovasc Thorac Surg. 2020;31:369-374.
2. Gong FF, Vaitenas I, Malaisrie SC, Maganti K. Mechanical Complications of Acute Myocardial Infarction: A Review. JAMA cardiology. 2021;6:341-349.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.