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 .