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.