CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 3, September – October 2024 AFRICA 191 ischaemic preconditioning and presentation with a first myocardial infarction. It can occur in two types. An acute form, also referred to as blowout, involves sudden pulseless electrical activity and death. The subacute form of free wall rupture (also referred to as oozing) does not involve cardiac arrest, but describes cases of moderate-to-severe pericardial effusion, chest pain, hypotension, dyspnoea, cyanosis and confusion.1 In our study it was a subacute blowout type of LVFWR. Cardiac ruptures can occur in any portion of the heart depending on the myocardial infarction involvement area, most frequently in the end regions supplied by the left anterior descending artery, especially in the anterior and lateral walls. Factors causing rupture include thinning of the wall in the coronary end-flow area, lack of collateral circulation, and deterioration of elastic structures in the tissue after transmural myocardial infarction. LVFWR is common during the early stages following the onset of myocardial infarction.3 It usually leads to haemopericardium. Immediate pericardiocentesis will temporarily relieve tamponade, but pericardiosentesis cannot always be performed in cases of severe haemodymic collapse. Moreover, it is often unsuccessful because much of the pericardial space is taken up by undrainable clots. In this case, we did not perform pericardiocentesis because the patient’s clinical condition allowed cardiac surgery. Intraaortic balloon pumping (IABP) is sometimes used to reduce the afterload of the left ventricle. In cases of circulatory collapse, rapid placement on extracorporeal membrane oxygenation (ECMO) support may provide sufficient circulation, but poor venous return in cases with tamponade may limit ECMO blood flow.4 We did not use IABP or ECMO. Diagnosis can be made by several imaging techniques, including echocardiography, computed tomography, contrast ventriculography and magnetic resonance imaging.5 Echocardiography may demonstrate a pericardial effusion and typical findings of cardiac tamponade. Køber et al.6 suggested that in cases of a small amount of pericardial effusion after myocardial infarction, the possibility of wall rupture should be considered as the first stage, patients should be approached with suspicion of rupture until proven otherwise, and hourly echocardiography follow ups should be performed. Contrast echocardiography, has the potential to diagnose LVFWR prior to the development of cardiac tamponade. Contrast material can be visualised into the myocardium before reaching the pericardial space, suggesting an impending rupture. Trindade et al.7 and Okabe et al.8 revealed the early diagnosis of LVFWR by contrast echocardiography. Cardiac magnetic resonance imaging is especially useful in detecting rupture location and size in haemodynamically stable patients.9 In this case, we confirmed the diagnosis with TTE and thoracic computed tomography. The principles of surgical treatment of LVFWR are to relieve tamponade, close the rupture area and prevent recurrence of rupture or pseudoaneurysm formation.5 The preferred technique is linear closure supported by Teflon felt. However, in the presence of excessive necrosis, an infarctectomy is followed by closure with materials such as dacron or pericardium.10 Roberts et al.11 treated a LVFWR that developed nine days after myocardial infarction with a dacron patch. The ventricular wall rupture was closed with interrupted polyproplene horizontal mattress sutures buttressed by twoTeflon felt under cardiopulmonary bypass in our patient. Tissue surrounding the injury site is usually in a poor condition and vulnerable to manipulation. Surgical techniques can sometimes be ineffective in cases of poor tissue quality, increasing the risk of enlargement of the rupture. Padró et al.12 reported 13 successful cases treated by a sutureless procedure. They applied a polytetrafluoroethylene patch over the infarcted area, which was attached to the heart surface with surgical glue. Misava et al.13 reported a sutureless technique can be a promising strategy for the treatment of ischaemic rupture, but serial echocardiographic studies should be mandatory for diagnosing a left ventricular pseudoaneurysm formation thereafter. Bergman et al.14 demonstrated the feasibility of using collagen sponges and haemostatic matrix sealant for effective haemostatic closure of ventricular free-wall ruptures when the tissue quality is poor. The use of intrapericardial fibrin-glue and thrombin injection, as an alternative sealant, have also been reported.15,16 Fig. 5. Intra-operative photograph showing rupture is closed with interrupted polyproplene horizontal mattress sutures buttressed by twoTeflon felt.
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