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 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% 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 et al . previously.
(5)
Okamura 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 .