Off-pump suture repair of left ventricular rupture utilizing TachoComb® sheet: a case report and literature review
© Yamaguchi et al.; licensee BioMed Central Ltd. 2013
Received: 15 April 2013
Accepted: 23 July 2013
Published: 27 July 2013
A 70-year-old woman was admitted to our institution with acute myocardial infarction. Coronary angiography demonstrated total occlusion of the left anterior descending artery, which was successfully revascularized. Four days later, the patient suddenly went into shock. The subsequent emergency operation revealed a blowout rupture of the left ventricular free wall. Several TachoComb® (CSL Behring, Tokyo, Japan) sheets were applied to control bleeding and avoid the need for a cardiopulmonary bypass. Horizontal mattress sutures were used in combination with a pair of Teflon felt strips for reinforcement. The combination of TachoComb® sheets and sutures is a novel hybrid method and an effective life-saving procedure for the treatment of left ventricular blowout ruptures. This approach avoids the need for a cardiopulmonary bypass. Sutureless repairs with TachoComb® sheet achieve rapid hemostasis without the need for cardiopulmonary bypass. This stabilizes patient hemodynamics immediately and preserves the fragile myocardium. This allows emergency room physicians to open the chest and apply the TachoComb® sheet to stabilize the patient before the cardiac surgeons arrive at the operating room. This technique will be very useful in emergency situations.
KeywordsMyocardial infarction Left ventricular rupture Off-pump surgery Emergency room
Left ventricular (LV) free wall rupture is a serious complication of acute myocardial infarction that may result in acute cardiac tamponade and sudden death. Among the various surgical procedures available for its treatment, sutureless repair using layered sheets of collagen fleece with fibrinogen-based impregnation (TachoComb®, CSL Behring, Tokyo, Japan) has proved the most effective[1–3]. Unlike prepare-to-use fibrin sealants, which require the coating of fibrin glue onto fleece or patching immediately before or during surgery, TachoComb® is a ready-to-use fixed combination that is activated by moisture upon application, providing adherence to the resection surface. Hemostasis is generally achieved after 3–5 min of compression. However, this technique alone is associated with a potential risk for future complications such as pseudoaneurysm formation and rerupture[5, 6]. We therefore developed a novel hybrid method for the treatment of blowout ruptures of the LV free wall that combines TachoComb® sheets with suture repair, avoiding cardiopulmonary bypass (CPB). Because this procedure can be performed without CPB, it is easily applicable even in an emergency room.
A 70-year-old woman was admitted to our hospital with a 3-day-old acute myocardial infarction. Although the patient reported adherence to the prescribed medication regimen, she developed heart failure with hypotension and oliguria the next day. Coronary angiography performed under intra-aortic balloon pumping demonstrated total occlusion of the proximal left anterior descending artery (LAD). Subsequent percutaneous coronary intervention achieved successful revascularization of LAD. The patient recovered steadily and gradually. However, four days later, her condition deteriorated suddenly and she went into shock. Her echocardiography results revealed cardiac tamponade with substantial pericardial effusion. Pericardiocentesis was performed, resulting in massive continuous drainage, and she was referred to us for emergency surgery.
Discussion and literature review
LV free wall rupture is the third-most serious complication and the second-most common cause of death after myocardial infarction[1, 7]. The patient reported herein was in an extremely serious condition on referral, and the emergency surgery performed at our institution was necessary to save her life. The new hybrid method described here was designed to control the bleeding as quickly as possible without increasing the risks for future complications such as pseudoaneurysms and reruptures[5, 6].
Reference review for surgical repair of the left ventricular free wall rupture
No. of pts.
Stiegel et al.
Suture closure and patch repair
Sutherland et al.
Reardon et al.
Infarctectomy and patch repair
Iemura et al.
Oozing (n=14), Blow-out (n=3)
Infarctectomy and patch repair (n=1), Direct closure (n=4), Patch repair (n=4), Sutureless patch repair (n=7), Endventricular patch closure (VSP) (n=1)
Lachapelle et al.
Oozing (n=3), Blow-out (n=3)
Sutureless patch repair (n=6)
Fukushima et al.
Sutureless repair with TachoComb
Nishizaki et al.
Sutureless repair with TachoComb
Muto et al.
Sutureless repair with TachoComb
Kimura et al.
Sutureless repair with TachoComb
Sakaguchi et al.
Unknown (n=28), Blow-out(n=4)
Sutureless repair with autologous pericardial patch and gelatinresorcin formaldehyde glue +− additional sutures
Pocar et al.
Sutureless repair with TachoSil combined with pericardial patch and fibrin glue
Raffa et al.
Oozing (n=4), Blow-out (n=2)
Sutureless repair with TachoSil
The advantages of sutureless repairs with TachoComb® sheets include rapid hemostasis without the need for CPB, which allows for the immediate stabilization of patient hemodynamics and preservation of the fragile myocardium[2, 3, 5, 6]. Furthermore, even physicians in an emergency room can open the chest and apply a TachoComb® sheet to stabilize the patient before the cardiac surgeons arrive at the operating room. We therefore developed a new hybrid method that combines use of the TachoComb® sheet with suture closure to utilize the advantages of both procedures. Because of the risk of mechanical tearing, we do not recommend the use of this technique for tears >1 cm. However, the procedure can be performed safely without CPB, which represents a substantial advantage in emergency situations.
Although TachoComb® has frequently been used for the treatment of both venous and arterial bleeding, anaphylactic reactions have been reported after the repeated use of hemostatic agents such as TachoComb® that contain aprotinin. Because aprotinin is also associated with risks of renal failure, a new product, TachoSil® (Nycomed, Zurich, Switzerland), which lacks aprotinin and contains human rather than bovine thrombin, has been developed. TachoSil® is known to be equally hemostatic to TachoComb®. Several cases of LV rupture have been treated successfully utilizing TachoSil® (Table 1)[13, 14].
Our report has some limitations. First, the report here describes a single case. Further investigation including postoperative follow-up in a large number of patients will be necessary to support our hypothesis. Second, our technique does not address LV aneurysms, which could lead to heart failure and/or thromboembolisms. TachoComb® sheets covering the LV surface could complicate a concomitant or subsequent coronary artery bypass graft. Indeed, Iemura et al. maintain that if subsequent coronary artery bypass grafting is needed, identification and exposure of the coronary artery will be difficult because of the widely and deeply piled collagen hemostats. However, the main goal of surgery for LV rupture is to save the patient’s life by relieving the cardiac tamponade and to close the rupture[2, 3]. We believe that our method maximizes the chance of patient survival and provides a novel option for emergency room physicians.
A novel hybrid method that combines TachoComb® sheets with reinforcing sutures was effective in quickly achieving hemostasis without the need for CPB. This represents a substantial advantage in the context of emergency medicine.
Written informed consent was obtained from the patient’s family for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors would like to thank Enago (http://www.enago.com) for the English language review.
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