A 79-year-old, hypertensive, diabetic, male patient with a thoracic aortic aneurysm and aortic valve stenosis was scheduled for total aortic arch replacement and simultaneous aortic valve replacement. Following sternal entry, CPB was established by right axillary and femoral arterial cannulation with bicaval cannulation. After aortic cross-clamping, myocardial protection was achieved with antegrade, retrograde, and selective cold blood cardioplegia without any technical problem. The aortic valve was replaced with a 21-mm bioprosthesis (Inspiris Resilia, Edwards Life Sciences, Irvine, CA). Subsequent total aortic arch replacement was performed under antegrade selective cerebral perfusion with moderate hypothermic circulatory arrest. After aortic declamping, a small point of oozing hemorrhage was identified on the epicardial surface of the right ventricular outflow tract. The oozing was controlled by hemostatic agent application, followed by the reconstruction of the arch vessels. The surgical maneuver was completed without any technical difficulty; however, we noticed the progressively expanding hematoma at the right ventricular surface to the size of a Japanese rice ball measuring 50 × 50 mm (Fig. ). The hematoma was hard, and the epicardial surface was dark red and notably swollen with multiple oozing ruptures. There was no evidence of ST-T changes on electrocardiogram. No cardiac wall motion abnormalities were observed on transesophageal echocardiography. Because of the rapid growth of the hematoma, we decided that early discontinuation of CPB and protamine administration should be mandatory. After termination of CPB, followed by the administration of protamine and fresh frozen plasma/platelet transfusion, manual compression with hemostatic agents such as Surgicel (Ethicon, Somerville, NJ, USA) and Tachosil (CSL Behring, Tokyo, Japan) were applied for 15 min. Thereafter, hemostasis was achieved on the epicardial surface, and the hematoma did not expand further without hemodynamic deterioration. The patient showed uneventful postoperative course. Postoperative computed tomography showed hematoma absorption, and transthoracic echocardiography revealed normal ventricular function of both the right and left ventricles. He is doing well 1 year after surgery.
We describe 60-year-old man with acute left ventricular free wall rupture due to AMI. He was admitted in emergency department with severe retrosternal chest pain, dyspnea, and sweating. A presumed diagnosis of anterior wall AMI with ST segment elevation was made. Treatment with streptokinase was started. Retrosternal chest pain was relieved, but the ST segment elevations did not resolve. The patient was transferred to a cardiac care unit.\nThe coronary angiography demonstrated a three-vessel disease with proximal significant stenosis of the left anterior descending (LAD) and right coronary (RCA) arteries and totally occluded left circumflex artery (LCX) filling via collaterals ().\nThe patient was discharged after 7 days and candidate for elective coronary artery bypass graft (CABG). Six hours after discharge, he was brought back to emergency department in a state of hemodynamic collapse. His blood pressure was 60/45 mmHg; his heart rate was 130 beats/minute; and an electrocardiogram showed sinus tachycardia. Signs of systemic hypoperfusion and cardiogenic shock were noted, and intra-aortic balloon pump (IABP) support was started immediately. Further electrocardiography revealed sinus tachycardia, low-voltage QRS complexes with diffuse ST segment elevation, and no electrical changes. Echocardiography revealed a moderate pericardial effusion and manifestations of early cardiac tamponade [right atrium (RA) and right ventricle (RV) diastolic collapse] but no signs of myocardial tear, mitral regurgitation, or ventricular septal defect.\nThe patient was transported to the operating room, and midsternotomy was done. Later, 300 ml of blood and clot was drained from the pericardium, and cardiopulmonary bypass (CPB) was established. Rupture of anterolateral wall of LV was repaired via Gore-Tex and Dacron patch, and CABG was done (-).\nThe patient recovered quickly and after 12 days, he was discharged from the hospital.\nAt the 18-month follow-up, the patient was taking statins, diuretics, β-blockers, angiotensin-converting enzyme (ACE) inhibitors, and warfarin. Follow-up echocardiography revealed a left ventricular ejection fraction of 35% to 40%, mild enlargement of the left ventricle, and mild mitral valve regurgitation.