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Ventricular septal perforation followed by papillary muscle rupture with acute myocardial infarction: efficacy of venoarterial extracorporeal membrane oxygenation

Ventricular septal perforation followed by papillary muscle rupture with acute myocardial... The occurrence of multiple mechanical complications after myocardial infarction in the same patient may be extremely rare, and the surgical strategy may be very complex because each mechanical complication can be extremely fatal. The case of a patient who underwent repair of a ventricular septal perforation by venoarterial extracorporeal membrane oxygenation (VA-ECMO), then mitral valve replacement and VA-ECMO for papillary muscle rupture 2 weeks after the ventricular septal perforation repair, is reported. Immediate preoperative stabilization with VA-ECMO may play a crucial role in treating multiple mechanical complications after myocardial infarction. INTRODUCTION fatal. The case of a patient who underwent VSP repair by venoar- terial extracorporeal membrane oxygenation (VA-ECMO), then Mechanical complications after acute myocardial infarction (MI) are relatively rare but are potentially fatal pathologies. A sub- mitral valve replacement and VA-ECMO for PMR 2 weeks after the VSP repair, is presented. analysis of the APEX-AMI trial, in which primary percutaneous coronary intervention was performed in 5745 patients, reported that the frequencies were 0.52% for cardiac free wall rupture, CASE REPORT 0.17% for ventricular septal perforation (VSP) and 0.26% for pap- A 76-year-old man presenting with acute onset dyspnea, chest illary muscle rupture (PMR) [1]. However, the occurrence of mul- pain and loss of consciousness was referred to our institution. He tiple mechanical complications after MI in the same patient may was a current smoker and had hypertension treated with several be extremely rare, and the surgical strategy may be very complex antihypertensive agents. His vital signs on admission were blood because each mechanical complication can itself be extremely Received: April 29, 2020. Accepted: May 20, 2020 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2020. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 Downloaded from https://academic.oup.com/jscr/article/2020/7/rjaa188/5870355 by DeepDyve user on 27 August 2020 2 R. Ushioda et al. Figure 1: Preoperative chest X-ray (A), electrocardiogram (B) and coronary angiography: right coronary (C), and left anterior descending and left circumflex (D), and right coronary artery (E). pressure 117/58 mmHg with support of 7γ of dopamine, heart VA-ECMO was restarted on the general ward, and the patient rate 121 beats/min and SpO 94% with oxygen at 6 L. Cardiac was transferred directly to the OR. Emergency mitral valve and pulmonary auscultation were unremarkable on admission. replacement with a biological prosthesis (Magna Ease 27 mm, Congestive heart failure (CHF) was found on the initial chest Edwards Lifesciences, Irvine, CA, USA) was performed in the X-ray (Fig. 1A). Troponin T was elevated (4.2 ng/mL), as were CK standard fashion. Intraoperatively, the ruptured posterior (722 U/L) and CK-MB (86.4 U/L). The electrocardiogram showed papillary muscle was confirmed. VA-ECMO could be weaned ST elevations in leads II, III and aVF, consistent with acute immediately after the surgery. After the two emergency opera- inferior MI (Fig. 1B). Due to on-going cardiogenic shock, he was tions, his course was uneventful, and he gradually recovered. treated with an intra-aortic balloon pump (IABP) and mechanical He was then transferred to another hospital on POD 77 for ventilation. Emergent coronary artery angiography showed a rehabilitation. completely occluded right coronary artery (RCA), 75% stenosis in the proximal-to-mid portion of the LAD and 90% stenosis in the proximal portion of the left circumflex artery (Fig. 1C and D). DISCUSSION The occluded lesion of the RCA was treated with drug-eluting In the present case, VSP and delayed PMR as mechanical com- stents (Fig. 1E), and he was transferred to the intensive care plications after MI in the same patient were treated success- unit (ICU). fully by emergency operations with preoperative bridge use of A few hours after treatment, his blood pressure collapsed VA-ECMO. despite the use of high-dose inotropic support and IABP. On As described in the introduction, the incidence of multiple cardiac auscultation, a holosystolic murmur had clearly devel- mechanical complications after MI is extremely rare. In the oped at the left lower sternal border. Since transthoracic echocar- APEX-AMI trial including 5745 patients with ST-elevation MI, diography showed VSP with a left-to-right shunt (Fig. 2A and B), there were only three patients who had two mechanical compli- VA-ECMO was started in the ICU and then the patient was cations. Because each complication can be fatal, there were only transferred to the operating room (OR). Through the median ster- reports of pathological studies regarding multiple mechanical notomy, cardiopulmonary bypass was established with aortic complications after MI in the early days [3]. and bicaval cannulations, and cardiac arrest was induced with With recent improvements of surgery and perioperative antegrade cold blood cardioplegia. The ventricular septum was management, however, there have been several reports of approached through the right ventricle parallel to the right pos- survivors of multiple mechanical complications after MI [4–6]. Of terior descending artery. The VSP was repaired with an extended these, the report by Levantino et al. [6] was quite similar to the sandwich patch described by Asai et al. [2] Simultaneous coro- present case. Their 82-year-old female patient underwent VSP nary artery bypass grafting to the LAD was also performed using repair followed by emergency MVR for PMR on POD 13. However, a vein graft. VA-ECMO was removed in the OR, and the IABP was their patient had a relatively stable hemodynamic condition; removed on postoperative day (POD) 7. His CHF clearly improved the patient was stabilized only with IABP and inotropic support (Fig. 2C), and he was extubated on POD 8. when VSP occurred and without any mechanical support when However, he again developed severe cardiogenic shock PMR occurred. On the other hand, the present patient had suddenly on POD 14 (Fig. 3A). Transthoracic echocardiogra- severe cardiogenic shock with the VSP and the delayed PMR, so phy showed PMR and severe mitral regurgitation (Fig. 3B–D). Downloaded from https://academic.oup.com/jscr/article/2020/7/rjaa188/5870355 by DeepDyve user on 27 August 2020 Ventricular septal perforation followed by papillary muscle rupture 3 Figure 2: Transesophageal echocardiography showed a defect with a left-to-right shunt (A). Ventricular septal perforation (VSP) (B). Postoperative chest X-ray (C). Figure 3: X-ray at 14 days after first operation (A). transthoracic echocardiographic images showing posterior papillary muscle rupture (arrowhead, B)(C). Posterior papillary muscle rupture (arrowhead, D). VA-ECMO was used each time. Recently, there have been several REFERENCES encouraging reports of preoperative VA-ECMO in patients with 1. French JK, Hellkamp AS, Armstrong PW, Cohen E, Kleiman post-infarction mechanical complications [7,8], and we consider NS, O’Connor CM et al. Mechanical complications after per- that the preoperative ECMO therapy may have played a crucial cutaneous coronary intervention in ST-elevation myocardial role in the present case. infarction (from APEX-AMI). Am J Cardiol 2010;105:59–63. In conclusion, a rare case requiring repeated surgical 2. Asai T, Hosoba S, Suzuki T, Kinoshita T. Postinfarction interventions for VSP and secondary PMR after acute MI ventricular septal defect: right ventricular approach-the was presented. Immediate preoperative stabilization with VA- extended "sandwich" patch. Semin Thorac Cardiovasc Surg ECMO may play a crucial role for treating multiple mechanical 2012;24:59–62. complications after MI. 3. Edwards BS, Edwards WD, Edwards JE. Ventricular septal rup- ture complicating acute myocardial infarction: identification of simple and complex types in 53 autopsied hearts. Am J Cardiol 1984;54:1201–5. CONFLICT OF INTEREST STATEMENT 4. Tahalele P, Prasmono A, Puruhito, Prayitno BW, Rahardjo P, None declared. Adipranoto J et al. Surgical repair of an impending rupture Downloaded from https://academic.oup.com/jscr/article/2020/7/rjaa188/5870355 by DeepDyve user on 27 August 2020 4 R. Ushioda et al. of left ventricular (LV) aneurysm with septal perforation and ventricular septal defect. Interact Cardiovasc Thorac Surg rupture of papillary muscle after acute myocarial infarction. 2010;10:823–4. Ann Thorac Cardiovasc Surg 2000;6:401–4. 7. Matos D, Madeira M, Nolasco T, Neves JP. The role of extracor- 5. Walts PA, Gillinov AM. Survival after simultaneous left ven- poreal membrane oxygenation in an acute basal ventricular tricular free wall, papillary muscle, and ventricular septal septal rupture. Eur J Cardiothorac Surg 2020;57:799–800. rupture. Ann Thorac Surg 2004;78:e77–8. 8. Ram E, Kogan A, Orlov B, Raanani E, Sternik L. Preopera- 6. Levantino M, Anastasio G, Guarracino F, Bortolotti U. Delayed tive extracorporeal membrane oxygenation for postinfarction papillary muscle rupture following repair of post-infarction ventricular septal defect. Innovations (Phila) 2019;14:75–9. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Ventricular septal perforation followed by papillary muscle rupture with acute myocardial infarction: efficacy of venoarterial extracorporeal membrane oxygenation

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Oxford University Press
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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2020.
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Abstract

The occurrence of multiple mechanical complications after myocardial infarction in the same patient may be extremely rare, and the surgical strategy may be very complex because each mechanical complication can be extremely fatal. The case of a patient who underwent repair of a ventricular septal perforation by venoarterial extracorporeal membrane oxygenation (VA-ECMO), then mitral valve replacement and VA-ECMO for papillary muscle rupture 2 weeks after the ventricular septal perforation repair, is reported. Immediate preoperative stabilization with VA-ECMO may play a crucial role in treating multiple mechanical complications after myocardial infarction. INTRODUCTION fatal. The case of a patient who underwent VSP repair by venoar- terial extracorporeal membrane oxygenation (VA-ECMO), then Mechanical complications after acute myocardial infarction (MI) are relatively rare but are potentially fatal pathologies. A sub- mitral valve replacement and VA-ECMO for PMR 2 weeks after the VSP repair, is presented. analysis of the APEX-AMI trial, in which primary percutaneous coronary intervention was performed in 5745 patients, reported that the frequencies were 0.52% for cardiac free wall rupture, CASE REPORT 0.17% for ventricular septal perforation (VSP) and 0.26% for pap- A 76-year-old man presenting with acute onset dyspnea, chest illary muscle rupture (PMR) [1]. However, the occurrence of mul- pain and loss of consciousness was referred to our institution. He tiple mechanical complications after MI in the same patient may was a current smoker and had hypertension treated with several be extremely rare, and the surgical strategy may be very complex antihypertensive agents. His vital signs on admission were blood because each mechanical complication can itself be extremely Received: April 29, 2020. Accepted: May 20, 2020 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2020. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 Downloaded from https://academic.oup.com/jscr/article/2020/7/rjaa188/5870355 by DeepDyve user on 27 August 2020 2 R. Ushioda et al. Figure 1: Preoperative chest X-ray (A), electrocardiogram (B) and coronary angiography: right coronary (C), and left anterior descending and left circumflex (D), and right coronary artery (E). pressure 117/58 mmHg with support of 7γ of dopamine, heart VA-ECMO was restarted on the general ward, and the patient rate 121 beats/min and SpO 94% with oxygen at 6 L. Cardiac was transferred directly to the OR. Emergency mitral valve and pulmonary auscultation were unremarkable on admission. replacement with a biological prosthesis (Magna Ease 27 mm, Congestive heart failure (CHF) was found on the initial chest Edwards Lifesciences, Irvine, CA, USA) was performed in the X-ray (Fig. 1A). Troponin T was elevated (4.2 ng/mL), as were CK standard fashion. Intraoperatively, the ruptured posterior (722 U/L) and CK-MB (86.4 U/L). The electrocardiogram showed papillary muscle was confirmed. VA-ECMO could be weaned ST elevations in leads II, III and aVF, consistent with acute immediately after the surgery. After the two emergency opera- inferior MI (Fig. 1B). Due to on-going cardiogenic shock, he was tions, his course was uneventful, and he gradually recovered. treated with an intra-aortic balloon pump (IABP) and mechanical He was then transferred to another hospital on POD 77 for ventilation. Emergent coronary artery angiography showed a rehabilitation. completely occluded right coronary artery (RCA), 75% stenosis in the proximal-to-mid portion of the LAD and 90% stenosis in the proximal portion of the left circumflex artery (Fig. 1C and D). DISCUSSION The occluded lesion of the RCA was treated with drug-eluting In the present case, VSP and delayed PMR as mechanical com- stents (Fig. 1E), and he was transferred to the intensive care plications after MI in the same patient were treated success- unit (ICU). fully by emergency operations with preoperative bridge use of A few hours after treatment, his blood pressure collapsed VA-ECMO. despite the use of high-dose inotropic support and IABP. On As described in the introduction, the incidence of multiple cardiac auscultation, a holosystolic murmur had clearly devel- mechanical complications after MI is extremely rare. In the oped at the left lower sternal border. Since transthoracic echocar- APEX-AMI trial including 5745 patients with ST-elevation MI, diography showed VSP with a left-to-right shunt (Fig. 2A and B), there were only three patients who had two mechanical compli- VA-ECMO was started in the ICU and then the patient was cations. Because each complication can be fatal, there were only transferred to the operating room (OR). Through the median ster- reports of pathological studies regarding multiple mechanical notomy, cardiopulmonary bypass was established with aortic complications after MI in the early days [3]. and bicaval cannulations, and cardiac arrest was induced with With recent improvements of surgery and perioperative antegrade cold blood cardioplegia. The ventricular septum was management, however, there have been several reports of approached through the right ventricle parallel to the right pos- survivors of multiple mechanical complications after MI [4–6]. Of terior descending artery. The VSP was repaired with an extended these, the report by Levantino et al. [6] was quite similar to the sandwich patch described by Asai et al. [2] Simultaneous coro- present case. Their 82-year-old female patient underwent VSP nary artery bypass grafting to the LAD was also performed using repair followed by emergency MVR for PMR on POD 13. However, a vein graft. VA-ECMO was removed in the OR, and the IABP was their patient had a relatively stable hemodynamic condition; removed on postoperative day (POD) 7. His CHF clearly improved the patient was stabilized only with IABP and inotropic support (Fig. 2C), and he was extubated on POD 8. when VSP occurred and without any mechanical support when However, he again developed severe cardiogenic shock PMR occurred. On the other hand, the present patient had suddenly on POD 14 (Fig. 3A). Transthoracic echocardiogra- severe cardiogenic shock with the VSP and the delayed PMR, so phy showed PMR and severe mitral regurgitation (Fig. 3B–D). Downloaded from https://academic.oup.com/jscr/article/2020/7/rjaa188/5870355 by DeepDyve user on 27 August 2020 Ventricular septal perforation followed by papillary muscle rupture 3 Figure 2: Transesophageal echocardiography showed a defect with a left-to-right shunt (A). Ventricular septal perforation (VSP) (B). Postoperative chest X-ray (C). Figure 3: X-ray at 14 days after first operation (A). transthoracic echocardiographic images showing posterior papillary muscle rupture (arrowhead, B)(C). Posterior papillary muscle rupture (arrowhead, D). VA-ECMO was used each time. Recently, there have been several REFERENCES encouraging reports of preoperative VA-ECMO in patients with 1. French JK, Hellkamp AS, Armstrong PW, Cohen E, Kleiman post-infarction mechanical complications [7,8], and we consider NS, O’Connor CM et al. Mechanical complications after per- that the preoperative ECMO therapy may have played a crucial cutaneous coronary intervention in ST-elevation myocardial role in the present case. infarction (from APEX-AMI). Am J Cardiol 2010;105:59–63. In conclusion, a rare case requiring repeated surgical 2. Asai T, Hosoba S, Suzuki T, Kinoshita T. Postinfarction interventions for VSP and secondary PMR after acute MI ventricular septal defect: right ventricular approach-the was presented. Immediate preoperative stabilization with VA- extended "sandwich" patch. Semin Thorac Cardiovasc Surg ECMO may play a crucial role for treating multiple mechanical 2012;24:59–62. complications after MI. 3. Edwards BS, Edwards WD, Edwards JE. Ventricular septal rup- ture complicating acute myocardial infarction: identification of simple and complex types in 53 autopsied hearts. Am J Cardiol 1984;54:1201–5. CONFLICT OF INTEREST STATEMENT 4. Tahalele P, Prasmono A, Puruhito, Prayitno BW, Rahardjo P, None declared. Adipranoto J et al. Surgical repair of an impending rupture Downloaded from https://academic.oup.com/jscr/article/2020/7/rjaa188/5870355 by DeepDyve user on 27 August 2020 4 R. Ushioda et al. of left ventricular (LV) aneurysm with septal perforation and ventricular septal defect. Interact Cardiovasc Thorac Surg rupture of papillary muscle after acute myocarial infarction. 2010;10:823–4. Ann Thorac Cardiovasc Surg 2000;6:401–4. 7. Matos D, Madeira M, Nolasco T, Neves JP. The role of extracor- 5. Walts PA, Gillinov AM. Survival after simultaneous left ven- poreal membrane oxygenation in an acute basal ventricular tricular free wall, papillary muscle, and ventricular septal septal rupture. Eur J Cardiothorac Surg 2020;57:799–800. rupture. Ann Thorac Surg 2004;78:e77–8. 8. Ram E, Kogan A, Orlov B, Raanani E, Sternik L. Preopera- 6. Levantino M, Anastasio G, Guarracino F, Bortolotti U. Delayed tive extracorporeal membrane oxygenation for postinfarction papillary muscle rupture following repair of post-infarction ventricular septal defect. Innovations (Phila) 2019;14:75–9.

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Journal of Surgical Case Reports – Oxford University Press

Published: Jul 1, 2020

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