A Case of a Cardiac Re-Rupture Caused by the Removal of Pericardial Patches Late after a Sutureless Repair for a Cardiac Rupture.

INTRODUCTION: Surgical treatment is the only reliable therapeutic option for a left ventricular free wall rupture (LVFWR). There are 2 major surgical techniques, namely, sutureless repair and sutured repair; a ventricular pseudoaneurysm is a late postoperative complication. We herein report a case of a re-ruptured left ventricular pseudoaneurysm after a sutureless bovine pericardial patch repair.

CASE PRESENTATION: The patient was a 79-year-old woman who underwent a sutureless pericardial patch repair for a blow-out-type left ventricular rupture following an anterior myocardial infarction 10 months previously. She was referred to Fujita Health University Okazaki Medical Center with a diagnosis of thoracic empyema and a suspected pericardial patch infection. Pleural effusion was positive for a few Streptococcus agalactiae. Coronary CT revealed the occlusion of the proximal left anterior descending branch and aneurysmal dilatation of the anterolateral wall of the left ventricle covered with pericardial patches. The operation was performed via a left fifth intercostal thoracotomy without cardiopulmonary bypass. The covering bovine pericardial patches and felt strips were easily removed, and the omental flap was secured in place. However, an emergency reoperation was necessitated for a left hemothorax 3 hours after surgery. Active bleeding was observed from the aneurysmal area, which had been previously covered with pericardial patches. After inducing deep hypothermia of 20°C, the fragile tissue surrounding the bleeding site was debrided under ventricular fibrillation. A 3 × 3-cm myocardial tissue defect was observed and closed using a bovine pericardial patch (Model 4700; Edwards Lifesciences, Irvine, CA, USA) with ten 2-0 MH U sutures (ETHIBOND EXCEL polyester suture, 2-0, MH needle, X843H; Ethicon, Somerville, NJ, USA). All intraoperative cultures were negative, and the fragile tissue revealed an organizing hematoma lacking any myocardial tissue. She experienced prolonged respiratory failure, requiring tracheostomy and mechanical ventilation for 6 months, and was moved to the rehabilitation ward, but died 1 year after surgery due to pneumonia.

CONCLUSIONS: Left ventricular pseudoaneurysm formation is a notable late complication that should be carefully monitored during the postoperative follow-up after surgery for LVFWR. We encountered a case of a re-ruptured left ventricular pseudoaneurysm after a sutureless bovine pericardial patch repair. The possibility of re-rupture must be considered because the myocardial tissue beneath the pericardial patch might disappear and be replaced with an organizing hematoma.