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A Technique to Repair Type I Left Ventricular Rupture Following Mitral Valve Replacement
A Technique to Repair Type I Left Ventricular Rupture Following Mitral Valve Replacement Robert E. Applebaum, M.D., Aleiandro Sequeira, M.D., and Joseph S: McLaughlin, M.D.' ABSTRACT Rupture of the posterior left ventricle is a serious complication following mitral valve replacement. A successful method of repair is illustrated. The causes, other methods of repair, and means to prevent this complication are discussed.
Her postoperative course was complicated by the need for prolonged ventilator support and mental confusion, but she recovered fully and was discharged on the 23rd hospital day. She complained of mild dyspnea on exertion and had an unremarkable chest roentgenogram when seen at a six-month follow-up visit.
Left ventricular rupture is a dreaded, often fatal complication of mitral valve replacement that was described by Roberts and Morrow [l]in 1967. Incidence has ranged from 0.5 to 2%, and mortality averages 65% [2]. These ruptures have been classified into three types based on location [3, 41. Type I is a tear of the thin attachment of the atrium to the ventricle in the posterior atrioventricular groove. It is caused by excessive traction of the posterior leaflet, by excessive debridement of a calcified annulus, or by inserting too large a prosthetic valve (Fig 1). Type I1 is in the midportion of the left ventricle overlying a papillary muscle. It is caused by too extensive a resection of the papillary muscle (Fig 2). Type I11 is located between the annulus and the insertion of a papillary muscle. It is secondary to laceration from a sucker or valve strut or to overdistention of a weakened, unsupported ventricular wall following excision of the posterior leaflet and chordae (Fig 3) [5]. In the present report, we present a technique for repairing an acute Type I rupture. We also discuss other methods of repair and methods to prevent this serious complication.
Technique
A 75-year-old woman with rheumatic heart disease underwent mitral valve replacement with a 25-mm Carpentier-Edwards bioprosthesis. At operation the valve and annulus were heavily calcified, with thickened and foreshortened chordae tendineae. The valve and its chordae were excised, and the prosthesis inserted. After successful weaning from cardiopulmonary bypass, bleeding and hematoma formation were noted in the posterior atrioventricular groove. Bypass was reinstituted, the aorta cross-clamped, and cardioplegia administered. The atriotomy was reopened, and the valve left in place. The disruption of the atrium from the ventricle was repaired by the technique described in the following section. The patient was successfully weaned from bypass with the aid of an intraaortic balloon pump. From the Division of Thoracic and Cardiovascular Surgery, University of Maryland Hospital, Baltimore, MD. Accepted for publication June 22, 1987. Address reprint requests to Dr. Applebaum, Cardiovascular and Renal Consultants, 2310 York St, Blue Island, IL 60406.
216
Following mitral valve replacement, a Type I rupture manifests as a hematoma or hemorrhage in the posterior atrioventricular groove (see Fig 1).Once diagnosed, cardiopulmonary bypass is reinstituted, the aorta crossclamped, cardioplegia administered, and the atriotomy reopened. The valve is left in situ. Several double-armed 3-0 polypropylene sutures on a slightly curved Keith needle are passed through the valve sewing ring and brought out the posterior left ventricular wall inferior to the atrioventricular groove, avoiding the circumflex artery (Fig 4). The sutures are tied over a Teflon felt bolster. This technique resuspends the ventricle to the atrium and seals the perforation while avoiding removal of the valve and injury to the circumflex artery.
Comment Methods to repair Type I ruptures have included the use of Teflon-reinforced sutures and the left atrial appendage as external bolsters. Repair from within the left atrium after the reinstitution of bypass has been somewhat more successful. Such techniques have involved removing the prosthesis and sealing the perforation and surrounding hematoma with a pericardial patch [6] or using left atrial tissue and the prosthetic valve ring to obliterate the perforation [7]. The technique presented herein was modified from a brief description by Treasure and colleagues [3]. It avoids removing the prosthetic valve and injuring the circumflex artery while resuspending the ventricle to the atrium and sealing the perforation (see Fig 4). Type I1 and I11 ruptures have been repaired on cardiopulmonary bypass by deeply placed Teflon-reinforced mattress sutures oriented transversely to the ventricular long axis. The circumflex artery is bypassed if necessary. If unsuccessful, a Dacron patch sutured in a running manner to include healthy myocardium may be placed over the laceration and hematoma to tamponade the area [8]. Methods to avoid left ventricular rupture following mitral valve replacement include (1)avoiding excessive debridement and excision of the posterior mitral valve annulus; (2) avoiding excessive traction on the posterior valve leaflet; (3) leaving the posterior leaflet intact, or if
Ann Thorac Surg 45:216-219, Feb 1988. Copyright 0 1988 by The Society of Thoracic Surgeons
217 Case Report: Applebaum et al: Repair of Type I LV Rupture
Fig 1 . Dehiscence of atrium from ventricle (Type 1 left ventricular rupture) and its causes.
Fig 2 . Type I1 left ventricular rupture and its causes.
218 The Annals of Thoracic Surgery Vol 45 No 2 February 1988
Fig 3 . Type 111left ventricular rupture and its causes.
Fig 4 . A technique to repair Type I left ventricular rupture.
219 Case Report: Applebaum et al: Repair of Type I LV Rupture
possible, leaving a fused posterior subvalvular mechanism intact [4]; (4) choosing a smaller valve when in doubt; (5) avoiding excessive traction and transection of papillary muscles; (6) carefully lifting and applying gentle traction on the heart to eliminate pressing of myocardium against the valve or strut; (7) avoiding surgical iatrogenic injury to the endomyocardium with cardiotomy suckers or vents; and (8) avoiding hypertension and ventricular distention, which can lead to abnormal myocardial stretching and tearing.
References 1. Roberts WC, Morrow AG: Causes of early postoperative death following cardiac valve replacement. J Thorac Cardiovasc Surg 54:422, 1967 2. Katske G, Golding LR, Tubbs DO, Loop FD: Posterior midventricular rupture after mitral valve replacement. Ann Thorac Surg 27130, 1979
3. Treasure RL, Rainer WG, Strevey TE, Sadler TR Intraoperative left ventricular rupture associated with mitral valve replacement. Chest 66:511, 1974 4. Miller DW, Johnson DD, Ivey TD: Does preservation of the posterior chordae tendineae enhance survival during mitral valve replacement? Ann Thorac Surg 28:22, 1979 5. Cobbs BW, Hatcher CR, Craver JM, Jones EL: Transverse midventricular disruption after mitral valve replacement. Am Heart J 99:33, 1980 6. Celemin D, Nunez L, Gil-Aguado M, Larrea JL: Intraventricular patch repair of left ventricular rupture following mitral valve replacement: new technique. Ann Thorac Surg 33:638, 1982 7. Bjork VO, Henze A, Rodriquez L: Left ventricular rupture as a complication of mitral valve replacement. J Thorac Cardiovasc Surg 73:14, 1977 8. Chi L, Beshore R, Gonzalez-Lavin L: Left ventricular wall rupture after mitral valve replacement: report of successful repair in 2 patients. Ann Thorac Surg 22:380, 1976
Her postoperative course was complicated by the need for prolonged ventilator support and mental confusion, but she recovered fully and was discharged on the 23rd hospital day. She complained of mild dyspnea on exertion and had an unremarkable chest roentgenogram when seen at a six-month follow-up visit.
Left ventricular rupture is a dreaded, often fatal complication of mitral valve replacement that was described by Roberts and Morrow [l]in 1967. Incidence has ranged from 0.5 to 2%, and mortality averages 65% [2]. These ruptures have been classified into three types based on location [3, 41. Type I is a tear of the thin attachment of the atrium to the ventricle in the posterior atrioventricular groove. It is caused by excessive traction of the posterior leaflet, by excessive debridement of a calcified annulus, or by inserting too large a prosthetic valve (Fig 1). Type I1 is in the midportion of the left ventricle overlying a papillary muscle. It is caused by too extensive a resection of the papillary muscle (Fig 2). Type I11 is located between the annulus and the insertion of a papillary muscle. It is secondary to laceration from a sucker or valve strut or to overdistention of a weakened, unsupported ventricular wall following excision of the posterior leaflet and chordae (Fig 3) [5]. In the present report, we present a technique for repairing an acute Type I rupture. We also discuss other methods of repair and methods to prevent this serious complication.
Technique
A 75-year-old woman with rheumatic heart disease underwent mitral valve replacement with a 25-mm Carpentier-Edwards bioprosthesis. At operation the valve and annulus were heavily calcified, with thickened and foreshortened chordae tendineae. The valve and its chordae were excised, and the prosthesis inserted. After successful weaning from cardiopulmonary bypass, bleeding and hematoma formation were noted in the posterior atrioventricular groove. Bypass was reinstituted, the aorta cross-clamped, and cardioplegia administered. The atriotomy was reopened, and the valve left in place. The disruption of the atrium from the ventricle was repaired by the technique described in the following section. The patient was successfully weaned from bypass with the aid of an intraaortic balloon pump. From the Division of Thoracic and Cardiovascular Surgery, University of Maryland Hospital, Baltimore, MD. Accepted for publication June 22, 1987. Address reprint requests to Dr. Applebaum, Cardiovascular and Renal Consultants, 2310 York St, Blue Island, IL 60406.
216
Following mitral valve replacement, a Type I rupture manifests as a hematoma or hemorrhage in the posterior atrioventricular groove (see Fig 1).Once diagnosed, cardiopulmonary bypass is reinstituted, the aorta crossclamped, cardioplegia administered, and the atriotomy reopened. The valve is left in situ. Several double-armed 3-0 polypropylene sutures on a slightly curved Keith needle are passed through the valve sewing ring and brought out the posterior left ventricular wall inferior to the atrioventricular groove, avoiding the circumflex artery (Fig 4). The sutures are tied over a Teflon felt bolster. This technique resuspends the ventricle to the atrium and seals the perforation while avoiding removal of the valve and injury to the circumflex artery.
Comment Methods to repair Type I ruptures have included the use of Teflon-reinforced sutures and the left atrial appendage as external bolsters. Repair from within the left atrium after the reinstitution of bypass has been somewhat more successful. Such techniques have involved removing the prosthesis and sealing the perforation and surrounding hematoma with a pericardial patch [6] or using left atrial tissue and the prosthetic valve ring to obliterate the perforation [7]. The technique presented herein was modified from a brief description by Treasure and colleagues [3]. It avoids removing the prosthetic valve and injuring the circumflex artery while resuspending the ventricle to the atrium and sealing the perforation (see Fig 4). Type I1 and I11 ruptures have been repaired on cardiopulmonary bypass by deeply placed Teflon-reinforced mattress sutures oriented transversely to the ventricular long axis. The circumflex artery is bypassed if necessary. If unsuccessful, a Dacron patch sutured in a running manner to include healthy myocardium may be placed over the laceration and hematoma to tamponade the area [8]. Methods to avoid left ventricular rupture following mitral valve replacement include (1)avoiding excessive debridement and excision of the posterior mitral valve annulus; (2) avoiding excessive traction on the posterior valve leaflet; (3) leaving the posterior leaflet intact, or if
Ann Thorac Surg 45:216-219, Feb 1988. Copyright 0 1988 by The Society of Thoracic Surgeons
217 Case Report: Applebaum et al: Repair of Type I LV Rupture
Fig 1 . Dehiscence of atrium from ventricle (Type 1 left ventricular rupture) and its causes.
Fig 2 . Type I1 left ventricular rupture and its causes.
218 The Annals of Thoracic Surgery Vol 45 No 2 February 1988
Fig 3 . Type 111left ventricular rupture and its causes.
Fig 4 . A technique to repair Type I left ventricular rupture.
219 Case Report: Applebaum et al: Repair of Type I LV Rupture
possible, leaving a fused posterior subvalvular mechanism intact [4]; (4) choosing a smaller valve when in doubt; (5) avoiding excessive traction and transection of papillary muscles; (6) carefully lifting and applying gentle traction on the heart to eliminate pressing of myocardium against the valve or strut; (7) avoiding surgical iatrogenic injury to the endomyocardium with cardiotomy suckers or vents; and (8) avoiding hypertension and ventricular distention, which can lead to abnormal myocardial stretching and tearing.
References 1. Roberts WC, Morrow AG: Causes of early postoperative death following cardiac valve replacement. J Thorac Cardiovasc Surg 54:422, 1967 2. Katske G, Golding LR, Tubbs DO, Loop FD: Posterior midventricular rupture after mitral valve replacement. Ann Thorac Surg 27130, 1979
3. Treasure RL, Rainer WG, Strevey TE, Sadler TR Intraoperative left ventricular rupture associated with mitral valve replacement. Chest 66:511, 1974 4. Miller DW, Johnson DD, Ivey TD: Does preservation of the posterior chordae tendineae enhance survival during mitral valve replacement? Ann Thorac Surg 28:22, 1979 5. Cobbs BW, Hatcher CR, Craver JM, Jones EL: Transverse midventricular disruption after mitral valve replacement. Am Heart J 99:33, 1980 6. Celemin D, Nunez L, Gil-Aguado M, Larrea JL: Intraventricular patch repair of left ventricular rupture following mitral valve replacement: new technique. Ann Thorac Surg 33:638, 1982 7. Bjork VO, Henze A, Rodriquez L: Left ventricular rupture as a complication of mitral valve replacement. J Thorac Cardiovasc Surg 73:14, 1977 8. Chi L, Beshore R, Gonzalez-Lavin L: Left ventricular wall rupture after mitral valve replacement: report of successful repair in 2 patients. Ann Thorac Surg 22:380, 1976