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

Figures

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  Fig. 1. Coronary CT on admission. (A) The area marked with red diagonal lines demonstrates aneurysmal dilatation covered with patches and felt strips. (B) 3D CT revealed complete occlusion of the proximal left anterior descending artery and aneurysmal dilatation located cranial to the felt strips. (C) Pericardial effusion and fluid collection at the inferior margin of the median sternotomy wound. Red arrowheads show fluid collection.

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  Fig. 2. Transthoracic echocardiography demonstrated an aneurysm of the anterior wall. Ao, aorta; EF, ejection fraction; LV, left ventricle

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  Fig. 3. An aneurysmal change was identified under the bovine pericardial covering. Blue arrowheads show an aneurysmal change.

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  Fig. 4. Active bleeding was observed from the aneurysmal area.

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  Fig. 5. A 3 × 3-cm myocardial tissue defect was observed.

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  Fig. 6. The defect was closed using a 4 × 4-cm 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). A left ventricular vent was inserted through the patch, and rewarming was then performed.

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  Fig. 7. Proposed mechanism of myocardial rupture and subsequent remodeling in the blow-out-type. In the blow-out-type, a myocardial cleft develops within the infarcted myocardium, allowing blood to enter the subepicardial space from the ventricular cavity. Subsequent disruption of the epicardium results in bleeding. Even when hemostasis is achieved by compression with a pericardial patch and a hematoma is formed, hematoma formation may also occur within the myocardial cleft. As the hematoma progressively enlarges, the myocardial cleft is presumed to expand, and the resulting myocardial tissue defect is gradually replaced by an organizing hematoma. Left: Initial myocardial rupture and subepicardial bleeding. Right: Progressive hematoma formation and replacement of the myocardial defect.