Incidence of left ventricular free wall rupture is about 7%-24% following acute myocardial infarction. Mortality is up to 90% without surgery. Hemodynamic status of the patient prior to surgery and the extent of myocardial necrosis are the major factors influencing the surgical outcome. Ventricular assist devices (VADs) have been successfully used as a “bridge to recovery” after myocardial infarction. We report a case in which the Abiomed BVS-5000 left ventricular assist device (VAD) was used as ‘bridge’ to stabilize the patient following post-infarction left ventricular rupture.
A 66-year old male was emergently operated due to left ventricular rupture secondary to acute posterolateral myocardial infarction. Extensive necrosis was noted in the posterolateral wall of the left ventricle extending to the apical region. No attempt was made to perform definitive repair at that time due to the presence of extensive necrosis. Abiomed BVS-500 LVAD was placed using left atrium and aorta for the inflow and outflow conduits respectively. The patient was successfully weaned off cardiopulmonary bypass (CPB) on moderate pressor support. Postoperative anticoagulant regimen included heparin and clopidogrel. He was extubated on 3rd postoperative day. Cardiac catheterization on 6th postoperative day showed subtotal occlusion of two marginal arteries. Plan was made to explant LVAD and repair LV on 10th postoperative day. On 9th postoperative day, moderate decrease in LVAD flows was noted. Patient was taken to surgery. Left ventricular wall appeared to have reasonably well healed. LVAD was explanted and left ventricle was repaired using an endocardial pericardial patch and buttressed with epicardial teflon felt. Subsequent postoperative recovery was uneventful. He was discharged home on 14th postoperative day . Echocardiography at the time of discharge showed an ejection fraction of 40-45%. He returned back to full work 3 months after surgery.
: Mortality rates following repair of ruptured ventricle vary depending on the hemodynamic status of the patient at the time of repair. Various approaches have been described1,2. These included definitive immediate repair with various patch techniques, both sutured and sutureless3. Definitive primary surgical repair of post-infarction myocardial rupture is always the first option if feasible. However our patient was in severe cardiogenic shock at the time of initial surgery. We postulated that LVAD support would allow time for organ recovery and would greatly diminish left ventricular diastolic and systolic pressures, therebylessening the chance for further bleeding, and would allow time for better demarcation of necrotic myocardium and formation of adequate scar tissue. Definitive repair could therefore be performed under more controlled conditions with the myocardium holding the repair better. The ideal time period for adequate myocardial scar tissue formation following extensive necrosis is not known, although we chose to wait 10 days. To the best of our knowledge, this is the first such repair using the Abiomed LVAD BVS 5000 as a ‘bridge’ to recovery.
LVAD can be used in selected cases of post-infarction myocardial rupture in the presence of extensive myocardial necrosis as a ‘bridge’ to recovery. Definitive repair can be undertaken once adequate myocardial scar has formed and the patient has recovered from shock.
Rammohan Marla, None.