Surgical Treatment of Right Ventricular Rupture Caused by Total Occlusion of the Right Coronary Artery.

The rupture of the right ventricular anterior wall after myocardial infarction is a rare and life-threatening complication associated with high mortality. Early diagnosis by echocardiographic examination and successful treatment is discussed in this case report.

INTRODUCTION

Ventricular free-wall rupture, ventricular septal rupture, and papillary muscle rupture are complications following acute myocardial infarction (MI) with rates of 0.8%, 0.2%, 0.7%, respectively, after revascularization.[1] Moreover, for the treatment of these complications emergent surgery must be performed with mortality rates of 20%–40%.[2]

The surgical repair includes direct closure, infarctectomy, and endoventricular patch technics.[2] Hemodynamic instability and necrotic tissue that is too weak for sutures are the major causes of bad outcomes. Hence, sutureless technique using glue and patch material is favored by surgeons.[3]

Herein, we report a surgical treatment of rupture with pericardial tamponade without using cardiopulmonary bypass.

CASE PRESENTATION

A 56-year-old male was admitted to the emergency department with chest pain of 6 h duration and syncope. On arrival his systolic blood pressure was 110/70 mm Hg and heart rate was 110 beats/min, respiratory rate was 12. Electrocardiography showed ST segment elevation in leads II, III, and arteriovenous fistula alterations of 2 mm. Serum cardiac enzymes (creatinine phosphokinase [CPK], CPK-MB, and troponin I) levels were elevated. Transthoracic echocardiography showed echo-dense mass on the anterior wall of the right ventricle and pericardial effusion. The diagnosis of the right ventricular rupture was entertained. [Figure 1] Dissection of the ascending aorta was ruled out with computed tomography angiography. The patient was admitted for cardiology care.

Figure 1

Echocardiography image that showed the right ventricle rupture

Further coronary angiography showed total occlusion of the right coronary artery (RCA) and muscular bridging on the mid portion of the left anterior descending coronary artery (LAD). A percutaneous attempt to revascularize the RCA was unsuccessful. The patient's hemodynamics remained stable throughout. He was admitted to intensive care unit. In the ensuing period deteriorating hemodynamics with signs of poor peripheral perfusion which required initiation of inotropic support. He had developed progressive signs of impending tamponade with increasing jugular venous distention, pulsus paradoxus, and orthopnea. A repeat transthoracic echocardiogram showed that the pericardial effusion had increased with signs of pericardial tamponade and the patient was immediately referred for surgical treatment.

The chest was opened through a median sternotomy. Significant amount of clotted blood was removed from the pericardium and the anterior wall of the right ventricle adherent to epicardium.

Hemodynamics immediately improved. There were no free bleeding sites.

The infarcted anterior wall of the right ventricle was observed and the rupture site with adherent thrombus was seen. Repair of the right ventricle was accomplished on the beating heart with 3 cm × 2 cm autologous pericardial patch which was sutured to healthy appearing epicardium beyond the infarct area with 6–0 polypropylene running sutures. Fibrin Bioglue (Cryolife Europa Ltd, Hampshire, United Kingdom) was injected between the autologous pericardial patch and the epicardium to reinforce the repair and enhance hemostasis [Figure 2]. We did not attempt to revascularize the RCA since most of the territory appeared to be infarcted. The postoperative course was uneventful, and the patient was discharged home on the 6th postoperative day. He is symptom-free on postoperative 6-month follow-up.

Figure 2

Intraoperative image of the right ventricle repair

DISCUSSION

Rupture of the heart occurs in approximately 5% of patients with acute MI and carries a high mortality. Free-wall rupture of the left ventricle occurs at a frequency of 2%–4%.[3] Free-wall rupture limited to the right ventricle is rare. The difference in occurrence rates of free-wall rupture in the left and right ventricles is attributable to the lower pressure in the right ventricle. The right ventricle free-wall rupture is an uncommon finding during transthoracic echocardiographic examination. One of the reasons could be the limited evaluation of the right ventricle due to its crescent shape, substernal location, and the presence of a large amount of artifact. In the presented case, echocardiography showed a suspected rupture.

In 1973, Cobbs et al.reported three cases with cardiac rupture, one involving the right ventricle.[4] Their patients developed cardiac tamponade necessitating pericardiosentesis and subsequently emergency surgical repair with closure of the large defect at the right ventricular apex.

Mechanical complications should be thought when rapid deterioration of patient's clinical situation occurs during the follow-up after myocardial infarction. Factors causing rupture are thinned wall, less collateral circulation, disfiguration of elastic tissue after transmural MI.[3]

Køber et al. reported that even small amount of pericardial effusion post MI should raise the alarm of free wall rupture.[5] Asirdizer et al. reported 10 cases with free-wall rupture in autopsies of 946 patients who died because of heart disease.[6] Many patients with free-wall rupture of the heart following MI die suddenly, often without an ante mortem diagnosis. Abrue Filho et al. reported 98 patients with free-wall rupture of which only 5 (5.1%) had a correct ante mortem diagnosis and underwent surgery with only 1 (20%) survival.[7] According to Furukawa et al., all right ventricular free-wall ruptures caused by LAD occlusion are associated with ventricular septal rupture.[8] Therefore, our case is an interesting case of isolated right ventricular free-wall rupture caused by occlusion of RCA. The reported patient had an isolated rupture of the right ventricle secondary to an inferior wall MI causing tamponade and necessitating emergency surgery.

There are only a few reports of survival without surgical repair in the literature.[910] Surgical treatment is strongly recommended once the diagnosis is established. Immediate surgery with aspiration of the hemopericardium results in rapid improvement in hemodynamic parameters and recovery. Several surgical maneuvers including direct compression, suturing with pledgets, and sutureless patch-glue techniques have been described for the repair of the rupture. We performed the repair by suturing autologous pericardial patch with 6–0 polyprolene sutures on the epicardium surrounding the infarcted area reinforced with Fibrin Bioglue (Cryolife Europa Ltd., Hampshire, United Kingdom) application.

CONCLUSION

Rupture of ventricular free wall after MI is a fatal complication. Rupture of right ventricular free wall is rare. Massive hemopericardium and tamponade are associated withsudden death. Early surgical intervention is required. Repair with autologous pericardial patch using Fibrin Bioglue may be a way of surgical treatment. This case highlights the need to keep in mind the possibility of right ventricle free-wall rupture as a mechanical complication of inferior MI.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.