Cardiac autotransplantation for repair of left ventricular rupture after mitral valve replacement

Abstract

Left ventricular rupture is an infrequent but potentially fatal complication of mitral valve replacement. We report a case of large posterior mid-ventricular rupture following mitral valve replacement, which was successfully treated by a patch repair and autotransplantation.

Introduction

First reported by Roberts and Morrow in 1967 [1], rupture of the left ventricle (LV) is a frequently lethal complication of mitral valve replacement (MVR). The incidence varies from 0.5 to 14% with an average of 1.2% [2]. The mortality rate of this complication is 75% or higher and it is responsible for 18% of all deaths from mitral valve replacement [3]. The different techniques used to repair this complication still carry high mortality due to poor exposure and technical difficulty. We report our experience for repairing a left ventricular rupture after mitral valve replacement by cardiac autotransplantation.

Case report

A 57-year-old man was diagnosed with rheumatic valvular disease with severe mitral stenosis, severe tricuspid regurgitation, and chronic atrial fibrillation. An elective mitral valve (MV) replacement with a 29-mm mechanical bileaflet valve (Sorin Bicarbon) and tricuspid valve annuloplasty (30-mm Medthronic 3 dimensional (3D) ring) was performed. Severely thickened and calcified MV leaflets were completely excised during the surgery. Weaning from cardiopulmonary bypass (CPB) was uneventful. Shortly after protamine administration, massive arterial hemorrhage was noted from the posterior side of the LV. CPB was then reinstituted immediately, and a subepicardial hematoma with active bleeding in the posterior wall of the left ventricle was discovered. A 5-cm length tear was found in the posterior mid-LV. Given the poor exposure and projected difficulty of repair, we decided to explant the heart. The standard Stanford technique for heart transplantation was used: the right atrium, left atrium, and main pulmonary artery were cut at the midportions, and the aorta was severed between the aortic valve and the aortic clamping site. The explanted heart was placed on a tray; the left ventricle was carefully examined from outer to inner sides. There was a type II rupture with a length of 5 cm (Fig. 1). We did not remove the prosthetic mitral valve. We used 3–0 Prolene sutures and polyester patch to repair the rupture. The patch was placed outside the ventricle by transmural stitches in an interrupted manner and stripes of Teflon felt at the endocardial and epicardial surface of the left ventricle (Fig. 2). The heart was reimplanted using the standard technique for heart transplantation. After hemodynamic stability, CPB was discontinued. There was no further bleeding from the ventricle. Postoperatively, the patient needed inotropic support for 3 days. He had an uneventful recovery. The patient came from a disadvantaged environment and therefore even though he was fit to be discharged it was decided to keep him in the hospital longer. He was discharged on the 30th post-operative day. He remains under follow-up for 14 months and remains well.

Fig. 1.

The rupture of the left ventricle after explantation of the heart

Fig. 2.

The repair of rupture of the posterior wall of the left ventricle

Discussion

Ventricular rupture is a potentially fatal adverse event of cardiac operations, mainly related to MV replacement. Type I: located at the atrio-ventricular (A-V) groove, the most common type, results from any injury of the MV annulus, such as excessive decalcification, insertion of an oversize prosthesis, deep sutures entering the myocardium, and manual cardiac compression. Type II: Rupture of the LV posterior wall at the base of the papillary muscle. Primarily due to excessive resection of the posterior papillary muscle, with local hemorrhage and rupture. Type III: Rupture of the LV posterior wall between the base of the papillary muscle and the A-V groove [4, 5]. Preservation of the posterior leaflet has been suggested to preserve diastolic dimension and geometry of the LV, which is thought to prevent posterior LV rupture. The present case had several risk factors for LV rupture such as gender, severe mitral stenosis, and complete excision of the posterior leaflet due to calcification.

The difficulties in the repair of a left ventricular rupture after mitral valve replacement are the following:

• The ventricular muscle is friable and cannot hold the stitch well if the stitches are partially made on the inner or the outer wall.

• Poor exposure of the anatomy of the rupture site

• Technical inaccessibility for making stitches through the ventricular wall, which is usually near the atrioventricular groove and circumflex coronary artery.

Extracardiac repair may be attempted, or the MV may be extracted by left atriotomy or the transseptal approach for intracavity repair, but such operations are challenging. As the present case presented with relatively long tear (5 cm), classic approaches may not have been satisfactory to securely expose internal tear of the LV. Thus, we decided to undertake cardiac autotransplantation.

Cardiac autotransplantation has been successfully used for surgical removal of malignant neoplasm in the left atrium or ventricle and areas that were difficult to access. Reviewing the literature, we found three publications describing 4 cases of autotransplantations of the heart for repair of LV rupture after MV replacement [6]. For the first reported case, the rupture site was successfully repaired, but the patient died of coagulopathy. The other 2 cases reported by Wei and colleagues [3] showed satisfactory short-term outcomes; however, the patients were complicated by complete atrioventricular block, which may relate to the Stanford technique for cardiac autotransplantation. The fourth case had a favorable outcome and has been reported to be well at 2 years follow-up. While autotransplantation is certainly more complicated and is an extensive procedure, we believe that cardiac explantation allows a detailed evaluation of the rupture. It also facilitates accurate repair using full-thickness sutures, which are the key components for a successful repair.

Despite, the use of the Stanford technique for cardiac autotransplantation our patient did not develop atrioventricular block.

Conclusion

Autotransplantation of the heart may be considered a valid option to rescue patients who develop left ventricular rupture after mitral valve replacement.

Compliance with ethical standards

Conflicts of interest

The authors declare no conflict of interest.

Ethical approval

Not applicable.

Statement of human and animal rights

Not applicable.

Informed consent

Informed consent was obtained.

Funding

Nil