Hybrid Epicardial Pericardial Insulation Repair of Subacute Ventricular Rupture

This video demonstrates a case of subacute left and right ventricular free wall rupture. A 69-year-old man with delayed presentation of inferior ST-elevation myocardial infarction presented to a regional hospital 50 km away with recurrent persistent chest pain. His troponin-T was 1051 ng/L, NT-proBNP was 6230 ng/L, lactate was 6.4 mmol/L, ALT was 314 U/L, and serum creatinine was 243 umol/L (GFR 22 ml/min). He was loaded with 300 mg clopidogrel, but not thrombolyzed because of pericardial effusion with features of tamponade. He was transferred to the authors’ center in Vancouver for emergency surgery. Coronary angiogram confirmed occlusion of his right coronary artery, sparing his left coronary arteries. A posterobasal left ventricular pseudo-aneurysm with a filling defect suspicious for a sealed perforation was seen on left ventriculogram.

His COVID-19 status was uncertain at the time of surgery in the middle of the night, hence he was presumed positive, and the necessary precautions were taken. His hemodynamics improved with pericardiotomy. A large right ventricular infarct extending over to the posterior left ventricle was noted straddling the posterior descending coronary artery. In light of the fragile tissue and multi-system dysfunction, a simple modified epicardial patch repair was performed. A bovine pericardial patch was sewn onto healthy myocardium surrounding the infarct, and Nu-knit surgicel was used to reinforce the epicardial surface tensile strength. Fibrin sealant (comprising fibrinogen, thrombin, and fibrinolytic) was used along the suture lines. Bioglue was used to fill the space within the pericardial patch, and also between the patch and the posterior pericardium once the heart was restored to its anatomical position.

The patient was weaned off cardiopulmonary bypass uneventfully on low dose milrinone and norepinephrine after 85 minutes of cardiopulmonary bypass and 75 minutes of cardioplegic rest. He was extubated within 12 hours of surgery, discharged from the intensive care unit a day later, and sent home well five days after surgery. His left heart function was normal (LVEF 55%), with residual moderate right ventricular dysfunction (TAPSE 1.5cm), and trivial tricuspid regurgitation.

Morgagni first reported a case of left ventricular free-wall rupture in 1765. Fifty years since the first repair of a right ventricular rupture by Hatcher et al., surgical techniques have evolved to become less invasive with patches and glues featuring more prominently in recent years. A successful repair of a subacute right and left ventricular free-wall rupture during the COVID-19 pandemic was described with this hybrid epicardial pericardial insulation (HEpPI) patch technique. It’s a “HEpPI” day when both patient and surgeon get to go home!

Reference

Matteucci M, Fina D, Jiritano F, Meani P, Blankensteijn WM, Raffa GM, et al. Treatment strategies for post-infarction left ventricular free-wall rupture. Eur Heart J Acute Cardiovasc Care. 2019;8(4):379-87.