[HSF] A case: cardiac rupture

[Rwmfglycar at aol.com]

Dear Roberto,
The problem with myocardial rupture through an infarct is twofold:
1) the dead tissue is considerably wider than the hole
2) the coronaries are epicardial which for fear of making things worse  stops 
you from taking the wide deep sutures in good tissue that you need to  
achieve a secure direct closure. 
Compare this with closing a ruptured septum due to myocardial infarction.  By 
placing a very wide pericardial patch against the septum on the left  
ventricular side and attaching it to good myocardium and allowing the  ventricular 
pressure to compress the patch against the hole you do not need to  rely on 
shallow sutures in necrotic tissue. While the mortality remains high  salvage is 
not uncommon.
The same applies to posterior left ventricular rupture after mitral valve  
replacement. In my experience the success is achieved by leaving the outside of  
the heart completely alone and going immediately to removing the prosthesis 
and  repairing the endocardial rupture site with a wide patch of pericardium on 
the  inside.
That said, I have seen one success (patient out of hospital and  walking 
around a few months after the event) achieved by arresting the  heart,  gluing a 
pericardial patch over  the site of the infarct  and a wide margin around it, 
with  small epicardial sutures at the edge of  the patch, waiting for the glue 
to set before allowing the ventricle to fill and  beat. IABP support, minimal 
inotropy and keeping the afterload low  postop.
Too bad Roberto; we have all had the nightmare of herculaean effort  rewarded 
ultimately by failure.
Yours
Bob