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 <100
mmHg and <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±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.