left ventricular free wall rupture ( lfwr ) is rare but one of the most serious complications of myocardial infarction , and is associated with high mortality . early diagnosis and prompt surgical management
a 66-year - old her patient was admitted to the emergency department with chest pain and dyspnea .
his initial vital signs were a blood pressure of 94/63 mmhg with a pulse rate of 111 beats / min .
electrocardiographic ( ecg ) findings showed st elevation in leads ii and iii and st depression in lead v2 .
echocardiography showed regional wall motion abnormalities of the lateral wall , and the left ventricular ( lv ) ejection fraction was less than 30% .
emergency cardiac catheterization showed total occlusion of the mid - portion of the left anterior descending artery ( lad ) and 75% focal stenosis of the diagonal branch ostium .
there was also total occlusion of the distal left circumflex artery ( lcx ) . up to 50% diffuse luminal irregularity
an intra - aortic balloon pump ( iabp ) was inserted due to the patient developing cardiogenic shock during cardiac catheterization .
the operation was performed with a median sternotomy with a cardiopulmonary bypass ( cpb ) after the heartbeat stopped .
the rupture site was directly repaired with two pledgeted 4 - 0 polypropylene interrupted sutures .
bioglue was applied over the sutured rupture site and bovine pericardium was used to cover the site .
coronary artery bypass grafting was performed with the saphenous vein graft to the lad , diagonal branch , obtuse marginal ( om ) branch , and proximal rca .
the patient was successfully weaned from the cpb and transferred to the intensive care unit .
on the first postoperative day , bleeding control was performed . on the third postoperative day , ecmo was removed . on the fourth postoperative day , the iabp was removed . however , a brain computed tomography ( ct ) was performed due to weakness of the left side .
the brain ct showed an acute infarction involving the right mid - cerebral artery territory .
continuous renal replacement therapy was applied from the fifth to seventh postoperative days due to acute renal failure .
the patient was transferred to the department of rehabilitation on the 41st postoperative day and discharged on the 105th postoperative day .
the patient has been followed up for 5 years and has not developed any other complications .
an 88-year - old female patient was admitted to the emergency department with loss of consciousness .
her initial vital signs were stable except that her body temperature had decreased to 32.8. her blood pressure dropped suddenly to 67/23 mmhg .
septic shock was suspected and early goal - directed therapy was started . however , ecg findings showed t - wave inversion in leads v4 - 6 , ii , iii , and avf .
her serum troponin - i level was elevated , and echocardiography showed regional wall motion abnormalities of the lateral wall and pericardial effusion .
an emergency operation was decided upon , with the suspicion of a concealed lv rupture .
after an inverted y - shaped pericardiotomy , the hematoma was removed and irrigation was performed . under cpb ,
aseptic industrial glue was applied and a teflon patch was used to cover the rupture site .
furthermore , the bovine pericardium was sutured with 5 - 0 polypropylene running sutures with a 2-cm - long lateral margin .
tisseel ( baxter healthcare , deerfield , il , usa ) was injected between the bovine pericardial patch and the epicardium to enhance the compressing sutured tear point and to prevent blood leakage .
tachocomb ( nycomed pharma , linz , austria ) was placed over the suture site .
the patient was successfully weaned from cpb and transferred to the intensive care unit ( icu ) .
on the second postoperative day , the patient was extubated . on the third postoperative day ,
the patient was reintubated because of desaturation and dyspnea , and extubated again on the fourth postoperative day .
a 48-year - old male patient was admitted to the emergency department with loss of consciousness .
initial vital signs were a blood pressure of 74/52 mmhg with a pulse rate of 124 beats / min .
the patient had been treated for diabetes mellitus and htn without any history of angina pectoris or myocardial infarction .
his serum troponin - t level was elevated and echocardiography and chest ct showed hemopericardium and lfwr .
emergency cardiac catheterization showed total occlusion of the distal lcx with thrombolysis in myocardial infarction score 0 flow and a thrombus .
the pericardium was dilated , and old blood - colored fluid gushed out when the pericardium was opened .
a large amount of hematoma was observed behind the lv side . under cpb , after the heartbeat stopped , the hematoma was removed .
a section of lv free wall about 56 cm in size had developed a hematoma , and bloody oozing was observed in the central area of the hematoma .
tachocomb was applied to the hematoma , and caution was taken to ensure that any visible margins of the hematoma were covered .
the patient was transferred to the general ward on the sixth postoperative day . due to monoplegia of the right leg ,
a brain magnetic resonance imaging was performed , which showed multiple embolic infarctions in the bilateral cortical border zone .
follow - up echocardiography showed thinning of the basolateral lv to the mid - wall and a focal absence of middle portion of the lateral wall reinforced with tachocomb , as well as minimal pericardial effusion .
a 66-year - old her patient was admitted to the emergency department with chest pain and dyspnea .
his initial vital signs were a blood pressure of 94/63 mmhg with a pulse rate of 111 beats / min .
electrocardiographic ( ecg ) findings showed st elevation in leads ii and iii and st depression in lead v2 .
echocardiography showed regional wall motion abnormalities of the lateral wall , and the left ventricular ( lv ) ejection fraction was less than 30% .
emergency cardiac catheterization showed total occlusion of the mid - portion of the left anterior descending artery ( lad ) and 75% focal stenosis of the diagonal branch ostium .
up to 50% diffuse luminal irregularity was observed from the proximal to the distal right coronary artery ( rca ) . an intra - aortic balloon pump ( iabp )
the operation was performed with a median sternotomy with a cardiopulmonary bypass ( cpb ) after the heartbeat stopped .
the rupture site was directly repaired with two pledgeted 4 - 0 polypropylene interrupted sutures .
bioglue was applied over the sutured rupture site and bovine pericardium was used to cover the site .
coronary artery bypass grafting was performed with the saphenous vein graft to the lad , diagonal branch , obtuse marginal ( om ) branch , and proximal rca .
the patient was successfully weaned from the cpb and transferred to the intensive care unit .
on the first postoperative day , bleeding control was performed . on the third postoperative day
, ecmo was removed . on the fourth postoperative day , the iabp was removed . however , a brain computed tomography ( ct ) was performed due to weakness of the left side .
the brain ct showed an acute infarction involving the right mid - cerebral artery territory .
continuous renal replacement therapy was applied from the fifth to seventh postoperative days due to acute renal failure .
the patient was extubated on the 10th postoperative day . on the 16th postoperative day ,
the patient was transferred to the department of rehabilitation on the 41st postoperative day and discharged on the 105th postoperative day .
the patient has been followed up for 5 years and has not developed any other complications .
an 88-year - old female patient was admitted to the emergency department with loss of consciousness .
her initial vital signs were stable except that her body temperature had decreased to 32.8. her blood pressure dropped suddenly to 67/23 mmhg .
septic shock was suspected and early goal - directed therapy was started . however , ecg findings showed t - wave inversion in leads v4 - 6 , ii , iii , and avf .
her serum troponin - i level was elevated , and echocardiography showed regional wall motion abnormalities of the lateral wall and pericardial effusion .
an emergency operation was decided upon , with the suspicion of a concealed lv rupture .
after an inverted y - shaped pericardiotomy , the hematoma was removed and irrigation was performed . under cpb ,
aseptic industrial glue was applied and a teflon patch was used to cover the rupture site .
furthermore , the bovine pericardium was sutured with 5 - 0 polypropylene running sutures with a 2-cm - long lateral margin .
tisseel ( baxter healthcare , deerfield , il , usa ) was injected between the bovine pericardial patch and the epicardium to enhance the compressing sutured tear point and to prevent blood leakage .
tachocomb ( nycomed pharma , linz , austria ) was placed over the suture site .
the patient was successfully weaned from cpb and transferred to the intensive care unit ( icu ) .
on the second postoperative day , the patient was extubated . on the third postoperative day ,
the patient was reintubated because of desaturation and dyspnea , and extubated again on the fourth postoperative day .
a 48-year - old male patient was admitted to the emergency department with loss of consciousness .
initial vital signs were a blood pressure of 74/52 mmhg with a pulse rate of 124 beats / min .
the patient had been treated for diabetes mellitus and htn without any history of angina pectoris or myocardial infarction .
his serum troponin - t level was elevated and echocardiography and chest ct showed hemopericardium and lfwr .
emergency cardiac catheterization showed total occlusion of the distal lcx with thrombolysis in myocardial infarction score 0 flow and a thrombus .
the pericardium was dilated , and old blood - colored fluid gushed out when the pericardium was opened .
a large amount of hematoma was observed behind the lv side . under cpb , after the heartbeat stopped , the hematoma was removed .
a section of lv free wall about 56 cm in size had developed a hematoma , and bloody oozing was observed in the central area of the hematoma .
tachocomb was applied to the hematoma , and caution was taken to ensure that any visible margins of the hematoma were covered .
the patient was transferred to the general ward on the sixth postoperative day . due to monoplegia of the right leg ,
a brain magnetic resonance imaging was performed , which showed multiple embolic infarctions in the bilateral cortical border zone .
follow - up echocardiography showed thinning of the basolateral lv to the mid - wall and a focal absence of middle portion of the lateral wall reinforced with tachocomb , as well as minimal pericardial effusion .
the incidence is 2% to 4% after acute myocardial infarction , and mortality has been reported to range from 12% to 20% .
old age , being female , experiencing the first myocardial infarction or transmural infarction , a high systolic blood pressure , an absence of heart failure before rupture , prolonged angina , delay of hospitalization , excessive in - hospital physical activity , a lower body mass index , and a longer time to reperfusion are all reported to be risk factors of lfwr .
two types of rupture have been noted based on intraoperative findings . in blow - out type ruptures , a macroscopic tear or defect in the epicardium with free communication between the lv cavity and the pericardial space
can be seen ; in oozing type ruptures , no macroscopic tears can be detected .
patients can present with any of the following : chest pain , syncope , jugular vein distention , hypotension , arrhythmias , nausea , or pulsus paradoxus .
a sudden onset of shock , hemodynamic instability due to cardiac tamponade , or cardiac arrest can occur .
our patients also each showed a different presentation , specifically , delayed rupture 3 days after acute myocardial infarction presenting as cardiac arrest , concealed rupture resulting in pseudoaneurysm and misdiagnosis as septic shock , and an oozing type rupture accompanied by embolic stroke and altered mental state .
a localized pericardial effusion over the infarcted akinetic area is the most common echocardiographic finding in cases of lfwr .
echogenic ' specks ' within the effusion and visible wall defects are other signs of lfwr .
contrast echocardiography is helpful in the direct visualization of myocardial tears and in demonstrating the extent of a pseudoaneurysm .
various operative techniques have been applied , including pericardial patch placement with biological glue or epicardial sutures , infarctectomy with patch placement and ventricular wall reconstruction , pledgeted sutures without infarctectomy , and pericardial , dacron , goretex , or teflon patches adhered with biologic glue or sutures .
sutureless techniques include gelatin - resorcin - formalin ( grf glue : cardial , saint - etienne , france ) applied to a bovine pericardial patch ( impra , tempe , az , usa )   and collagen fleece with fibrinogen - based impregnation ( tachocomb ; nycomed pharma , linz , austria ) .
some authors have suggested that , under cpb , bypassing all major coronary arteries empirically prior to closing the defect is necessary because of the association of multivessel disease .
this paper reviewed two cases of direct closure with bovine pericardial patch reinforcement for blowout - type lfwr and one case of a sutureless technique with tachocomb for oozing - type lfwr at samsung medical center ( table 1 ) .
the first and third patient had early postoperative complications and the second patient had no early postoperative complications , even though she was of old age and a female patient who had been treated for htn .
the postoperative course of the first patient was the worst because the diagnosis was delayed to the third hospital day and cardiac arrest occurred after iabp removal . in conclusion , lfwr is rare , but one of the most serious complications of myocardial infarction , and is associated with high mortality . the surgical treatment of lfwr remains challenging .
 left ventricular free wall rupture ( lfwr ) is rare , but is one of the most serious complications of myocardial infarction and is associated with high mortality . 
 several operative techniques have been attempted , but early diagnosis and prompt surgical management are crucial for a positive patient outcome . 
 we report three cases of lfwr successfully treated with surgical methods . 
CASE REPORTS
1) Case 1
2) Case 2
3) Case 3
DISCUSSION