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\begin{document}

\title{Sutureless repair and deep sedation for a blow-out type post-infarction
left ventricular free wall rupture}



\author[1]{Sho Kusadokoro}%
\author[1]{Manabu Shiraishi}%
\author[1]{Daijiro Hori}%
\author[1]{Atsushi Yamaguchi}%
\affil[1]{Saitama Medical Center, Jichi Medical University}%


\vspace{-1em}



  
  \date{March 14, 2025}


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\selectlanguage{english}
\begin{abstract}
A 71-year-old woman who was resuscitated from cardiac arrest after
pericardial drainage, was admitted to our hospital. Enhanced computed
tomography demonstrated pericardial effusion due to rupture of posterior
ventricular myocardium. She underwent emergent surgical repair. A 20-mm
tear in the extensively necrotic left ventricular posterior wall and
active hemorrhage were identified. Sutureless repair using three sheets
of TachoSil (CSL Behring, Tokyo, Japan) and fibrin glue was performed.
To reduce ventricular pressure to avoid re-rupture and formation of
ventricular aneurysm, deep sedation was followed in the intensive care
unit for 2 weeks. The patient returned to her normal daily life and is
progressing well for more than 5 months after the surgery.%
\end{abstract}%



\sloppy


\textbf{Sutureless repair and deep sedation for a blow-out type
post-infarction left ventricular free wall rupture}

\textbf{Running Head: Sutureless repair of ventricle}

Sho Kusadokoro, MD, Manabu Shiraishi, MD, PhD, Daijiro Hori, MD, PhD,
Atsushi Yamaguchi, MD, PhD

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi
Medical University, Saitama, Japan

\textbf{Data availability statement:} not applicable for this case
report.

\textbf{Funding:} none

\textbf{Conflict of interest:} none

\textbf{IRB approval:} waived for this case report.

\textbf{Patient consent:} Informed consent was obtained from the
patient.

\textbf{Clinical trial registration:} not applicable for this case
report.

\textbf{Address for correspondence} : Manabu Shiraishi MD, PhD.

ORCiD ID: https://orcid.org/0000-0002-4491-7473

1-847 Amanumacho, Omiya-ku, Saitama, 330-0834, Japan.

Tel: +81-48-647-2111, Fax: +81-48-645-0621, E-mail:
manabu@omiya.jichi.ac.jp

\textbf{Abstract}

A 71-year-old woman who was resuscitated from cardiac arrest after
pericardial drainage, was admitted to our hospital. Enhanced computed
tomography demonstrated pericardial effusion due to rupture of posterior
ventricular myocardium. She underwent emergent surgical repair. A 20-mm
tear in the extensively necrotic left ventricular posterior wall and
active hemorrhage were identified. Sutureless repair using three sheets
of TachoSil (CSL Behring, Tokyo, Japan) and fibrin glue was performed.
To reduce ventricular pressure to avoid re-rupture and formation of
ventricular aneurysm, deep sedation was followed in the intensive care
unit for 2 weeks. The patient returned to her normal daily life and is
progressing well for more than 5 months after the surgery.

\textbf{Key Words} : Left ventricular free wall rupture; Sutureless
repair; Myocardial infarction



\textbf{Introduction}

Post-infarction left ventricular free wall rupture (LVFWR) is a
life-threatening disease, for which the reported mortality is 42.9\%.
(1) In particular, the blow-out type is catastrophic, and immediate
surgery is necessary for the patient to survive. Although several
surgical methods have been reported, including suture repair and
sutureless repair, the relative success rates of these surgeries are
uncertain. Recently, the sutureless repair of LVFWR has been gaining in
popularity, but this approach may not be sufficient for hemostasis in
patients with blow-out type. (1) Furthermore, sutureless repair may be
followed by re-rupture and formation of ventricular aneurysm.

Here, we report a successful treatment of blow-out LVFWR via sutureless
repair and deep sedation for 2 weeks after the surgery.

\textbf{Case report}

A 71-year-old woman who had a history of hypertension and dyslipidemia
was admitted to a hospital due to acute onset of chest and back pain.
She suddenly went into cardiac arrest and cardiopulmonary resuscitation
was started. Echocardiography revealed a pericardial effusion, and she
underwent pericardial drainage and was successfully resuscitated. She
was suspected of having a type A aortic dissection and was transferred
to our hospital. Enhanced computed tomography (CT) demonstrated
pericardial effusion and a lack of enhancement in the lateral to
posterior ventricular wall with a suspected tear in the unenhanced
myocardium. (Fig 1 and Supplemental movie) Electrocardiography
demonstrated ST-T depression on the II, III, aVf, and V3--V6 leads. She
was diagnosed with post-infarction LVFWR and was transferred to the
operating room immediately.

During the induction of general anesthesia, the patient's blood pressure
(BP) dropped to 40/30 mmHg. Median sternotomy and pericardiotomy were
performed promptly, and a 1,000-ml of hematoma was drainaged. Extensive
necrosis and a 20-mm tear, accompanied by active hemorrhage, were
identified in the posterior wall. The rupture site was manually reduced
using TachoSil (CSL Behring, Tokyo, Japan) and fibrin glue from the
epicardial surface. To reduce the likelihood of further hemorrhage from
the left ventricle, three sheets of TachoSil were applied over a wide
area, not only at the rupture site, but also over the entire necrotic
area. Hemostasis was achieved and the patient's vital signs stabilized.

After admission to the intensive care unit (ICU), the patient was deeply
sedated and maintained in this state using propofol and midazolam. For 2
weeks, her systolic BP and heart rate were maintained at \textless{}100
mmHg and \textless{}60 beats/min to reduce ventricular pressure load.
Serum lactate level was also monitored for evaluation of systemic
perfusion. The maximum lactate level was 4.06 mmol/L on ICU admission,
which recovered to a normal level without re-elevation. The average
lactate during the 2 weeks period was 1.05\selectlanguage{ngerman}±0.42 mmol/L. The patient
experienced transient acute kidney injury due to post cardiac arrest
syndrome and was treated by continuous renal replacement therapy from
postoperative day (POD) 7 to 20. Echocardiography was frequently
performed to identify signs of re-rupture and left ventricular aneurysm,
and CT was performed on PODs 6 and 13 for the same reason. Fortunately,
these complications did not occur. The patient's sedation was reduced
gradually from POD 14, and her state of consciousness gradually improved
with full recovery after 1 month. Coronary CT demonstrated stenosis in
her peripheral right coronary artery, but no sign of ventricular
aneurysm (Fig 2). The patient was transferred to another hospital for
rehabilitation on POD 78, and was discharged after 2 months. She is now
following her normal daily routine for more than 5 months after the
surgery, without experiencing ventricular aneurysm or pseudoaneurysm.

\textbf{Discussion}

LVFWR is a catastrophic complication of acute myocardial infarction
(AMI) that has become rare due to advancement of prompt coronary
reperfusion strategies, with a reported incidence of 2\% following AMI.
(2) 87.5\% of LVFWR is reported to occurs in the first week of AMI and
55.6\% of LVFWR occurs in the first 48 hours. (3)

Matteucci \emph{et al.} published a systemic review of the use of suture
or sutureless repair for LVFWR, (4) in which they found that in-hospital
mortality (13.8\% \emph{vs} . 14\%, respectively) was comparable. The
fragility of the myocardium following infarction renders suturing
difficult, especially if extensive myocardial necrosis is present.
Sutureless repair has gained popularity because of its simplicity and
the lack of requirement for cardiopulmonary bypass. The use of several
hemostasis patches has been reported in sutureless repair, including
autologous pericardium and xenopericardium. Several articles reported
the use of TachoSil for LVFWR. (1, 5) TachoSil is a ready-to-use
collagen fleece that is coated with fibrin glue, containing fibrinogen,
thrombin, and aprotinin, which has been used for hemostasis in cardiac
surgeries. (1) To avoid re-rupture, we used three sheets of TachoSil in
the present patient, to cover not only the necrotic area, but also an
area of normal myocardium. This technique, to also cover healthy
myocardium, has also been proposed by Raffa \emph{et al} . previously.
(5)

Okamura \emph{et al} . reported 35 cases of sutureless repair for LVFWR.
Re-rupture occurred in six patients within 1 week of the initial
surgery, due to fragile myocardium at the time of surgery. (1) Left
ventricular pressure overload should be avoided during this period, and
there is a greater risk of hypertension if the patient is awake due to
postoperative pain and delirium. Previous reports have suggested strict
BP and heart rate control, bed rest, and the avoidance of agitation
during the postoperative care of patients with LVFWR. (2) Although deep
sedation has some disadvantages, including potential complications of
ventilator-associated pneumonia and weakening of the skeletal muscles,
we considered that deep sedation for 2 weeks was acceptable to minimize
the likelihood of re-rupture and ventricular aneurysm. Use of
intra-aortic balloon pumping (IABP) is also recommended after surgery
for circulatory support and reducing ventricular load. However, we did
not use IABP in the present patient, because her hemodynamics was stable
and the use of heparin may have predisposed this patient to a higher
risk of bleeding from the necrotic myocardium.

Sutureless repair with TachoSil may be an effective method of treating
blow-out type LVFWR. Deep sedation after surgery may improve the
surgical outcomes by reducing ventricular load, thus preventing from
re-rupture and formation of ventricular aneurysm .

\textbf{Author contributions}

Drafting of the manuscript: SK.

Critical revision of the manuscript: MS, DH, and AY.

Management of the manuscript writing: MS

\textbf{References}

1. Okamura H, Kimura N, Mieno M, Matsumoto H, Yuri K, Yamaguchi A.
Sutureless repair for postinfarction left ventricular free wall rupture.
The Journal of thoracic and cardiovascular surgery. 2019;158(3):771-7.

2. Matteucci M, Fina D, Jiritano F, Meani P, Blankesteijn WM, Raffa GM,
et al. Treatment strategies for post-infarction left ventricular
free-wall rupture. European heart journal Acute cardiovascular care.
2019;8(4):379-87.

3. Gong W, Shi H, Yan M, Yan Y, Wang X, Li S, et al. Clinical
Manifestation, Timing Course, Precipitating Factors, and Protective
Factors of Ventricular Free Wall Rupture Following ST-Segment Elevation
Myocardial Infarction. International heart journal. 2020;61(4):651-7.

4. Matteucci M, Fina D, Jiritano F, Blankesteijn WM, Raffa GM,
Kowalewski M, et al. Sutured and sutureless repair of postinfarction
left ventricular free-wall rupture: a systematic review. European
journal of cardio-thoracic surgery : official journal of the European
Association for Cardio-thoracic Surgery. 2019;56(5):840-8.

5. Raffa GM, Tarelli G, Patrini D, Settepani F. Sutureless repair for
postinfarction cardiac rupture: a simple approach with a tissue-adhering
patch. The Journal of thoracic and cardiovascular surgery.
2013;145(2):598-9.

\textbf{Figure legends}

\textbf{Fig 1. Preoperative enhanced computed tomography image}

The tear in the unenhanced myocardium in the posterior ventricular wall
is visible.

\textbf{Fig 2. Postoperative coronary computed tomography images}

(A) Stenosis in the peripheral right coronary artery and hypoplasia of
the circumflex coronary artery. (B) No ventricular aneurysm is present
on 3D computed tomography.\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Fig(2)/Fig(2)}

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