Left ventricular wall rupture: revisited and updated

We read with interest the article written by Deniz et al. [1]. We do agree with them that from the age of 60 and older, reoperation and resection of the posterior leaflet are significant risk factors for wall rupture. We wonder if calcified annulus, infective endocarditis and emergency of the operation are not [1]. ‘Prevention is better than cure’ best applies here. As per authors, posterior leaflet should be preserved. We advise not to over preserve at the expense of the position or size of the prosthesis and/or LVOT. The chordae are more important to preserve than the leaflet. We had operated a 40-year-old female with severe mitral regurge 5 years post MVR (bio-prosthesis). Chest X-ray and echo retrospectively showed abnormal position of strut with narrowing of the LVOT mostly due to over preservation of the leaflets causing weakness of the wall of the left ventricle and some LVOTO which was unfortunately underestimated. Ten hours postoperatively, bleeding was noticed and it took us about 8 h to control the bleeding from a torn posterior wall of the left ventricle out flow tract opposite the inter-trigonal area. This may be the first report of a posterior LVOT wall rupture post MVR. From our point of view, this new type of LV rupture in the post LVOT area below the left coronary cusp was related to the normal position of the mitral valve bioprosthesis. It was very hardly controlled only through completely transecting the aorta and repairing the tear. The patient died due to acute hepato-renal failure 7 days postoperatively. Cardiac autotransplantation could have helped a lot. Following the New York University experience will decrease ventricular wall rupture [2] avoiding undue traction on the leaflets and careful insertion of sutures into the mitral annulus. A left ventricular vent was avoided. Use of translucent obturators constructed so the position of the posterior post of the prosthetic valve, and its relation to the left ventricular wall, could be observed before the prosthesis was inserted. The chordae of the mitral valve have been preserved to part or all of the mural leaflet. The residual mural leaflet has actually facilitated insertion of porcine prostheses, providing additional substance for insertion of sutures through the annulus, much as described by Lillehei in 1964. With a metallic prosthesis, care is taken, of course, to be certain that the residual leaflet does not interfere with the motion of the poppet of the prosthetic valve [3].