[HSF] A case: cardiac rupture

[Dr. Roberto Battellini]

Dear Members,

 

Woman born  1952, was  studied In a foreign Hospital  because of
haemopericardium of unknown origin. CT: No dissection, haemopericardium.
There she was  punctured and send then  to HZL.   In Leipzig she got ECG ,
almost normal, CKMB normal, troponin was not done, and went directly to cath
lab: LAD 99% stenotic, RCA 2-3 stenosis 70%, CX 50%. She got another
punction for tamponade, unsuccessful. Then the interventionist, under
reanimation,   called me for inferior drainage. I did a  5 cm incision and
drained it ( lot of clots and 200 blood). With good pressure, I send her to
OR. During the transport, she was  again 2 times reanimated.  In OR, we put
her on pump. The aorta was ok. I closed 3 bleeding sites. One at the
marginal angle of RV,  and two bleeding strongly between Diagonal and obtuse
marginal branches. These were stitched with 4/0 Prolene with pledget. Also
there was a haematoma in the region of the sulcus, at the region  of  AV
groove. I thought as diagnosis   1. status after heart reanimation or 2.
acute infarction. I added   2 vein bypasses   to LAD and PD. (no mammary
because of reanimation and sternal fracture). If it was an infarction, why
there, the CX was only 50% stenosed!.  I added glue and tachosyl as for a
coronary sinus rupture. 

After going out off bypass, came blood from the sutured zone, where the
pledgets were stitched, now the muscle looked a little disrupted. . Again 20
minutes on bypass, I added 2 teflon felt strips sutured with 3/0 Prolene as
it were an aneurysma. It Bleeded diffuse, again Bioglue, etc. I added an
IABP as she was long reanimated and got That suture.  Quick time was 7%. I
left the chest open and with packing, she received everything to favour
coagulation, inclusive factor 7.  At night she was reoperated by Michael
Borger, he had to stitch again with Teflon, again packing. Bleeding stopped
12 hours after. The ventricle had good contractions on echo. No more
bleeding. One day after (may be a decision  error) ,she was again reoperated
with intention to close the chest. After taking out the gauzes she began to
bleed again. We poured 3 pistols of bioglue and tabotamp and so on. Bleeding
stopped and the chest was left open. At night the heart ruptured , she was
carried gain to OR, and there  died there at 3.00 AM. 

Questions: experience from the members, what would have done different those
with experience, etc.

Diagnosis: 1.
infarction->haemopericardium->puntions->tamponade->reanimation->cardiac
rupture, etc against    2. other cause of haemopericardium and the rest is
iatrogenic.

Roberto