When Joseph, 70, was wheeled into the emergency care of the Jubilee Mission Medical College and Research Institute in Thrissur, Kerala, his blood pressure had hit the nadir and he was heavily medicated for bringing it up. The doctors who checked on him found that he had a ruptured heart (left ventricular free wall rupture), because of a massive heart attack. He was shifted to the operation theatre for an emergency lifesaving surgery.
The blood bank was informed, and a team comprising an anesthesiologist, physician-assistant, perfutionist and nurses was assembled in a jiffy. Since the pumping chamber muscle had got ruptured, blood was leaking into the pericardium, the covering of the heart. To circumvent the problem, the heart was supported by a heart-lung machine (cardio pulmonary bypass) through a femoral artery-femoral vein (major blood vessels of the lower limb) route.
Joseph's heart was ready for the scalpel. The pericardium was opened, and as expected, it had the signs of a massive heart attack involving the back side of the heart (posterior wall myocardial infarction). Posterior muscle rupture is one of the toughest to deal with, and a teflon patch was used to repair the damage.
The repair procedure really challenged the team, because there was no healthy area of heart muscle (myocardium) for placing the stitches, which makes the success rate for this procedure very low. After fixing the heart, Joseph was taken off the heart-lung machine.
So far, so good. But the team foresaw another complication. The bleeding could start again if the sutures, unable to withstand the force of contraction of the muscles, come undone. So, to ease the pumping of the heart, an intra-aortic balloon pump or IABP was used.
Joseph was lucky because he got the best care possible. On the 14th day of the surgery, the doctors and nurses saw him off.
Left ventricular free wall rupture is a rare complication resulting from massive heart attack. The heart muscle of the affected area will give way as it loses strength due to lack of blood supply. Even though the most common cause is acute myocardial infarction or heart attack, the rupture could also happen because of blunt or penetrating trauma to the heart, cardiac infection, aortic dissection and primary or secondary tumours of heart.
Up to two per cent of people who have myocardial infarction (MI) could develop left ventricular free wall rupture. When muscles give away, blood pumped into the heart would leak into the space between the heart and its covering. The leak would eventually lead to the compression of the heart, resulting in pump failure and collapse of the patient.
The survival rate of people having cardiac rupture due to acute MI occurring outside hospital is extremely low. Overall mortality is 60 to 80 per cent while surgical mortality is 35 to 45 per cent.
Most of the patients would collapse immediately. A few would develop breathing difficulty associated with or without chest pain. Clinically, doctors cannot differentiate between heart attack and muscle rupture due to heart attack. Blood pressure would be very low and patients would feel palpitation.
The patient has to be made comfortable first. Once the patient is shifted to an ambulance or on reaching hospital he should be supplemented with oxygen. Medications should be started to achieve optimum blood pressure.
Definitive treatment is surgical repair using a patch (artificial membrane).
Multiple surgical strategies have been proposed. Most common methods include a direct closure using a patch or infarctectomy (excision of the infarcted segment) and subsequent repair using a patch. Surgical repair is done with cardio pulmonary bypass support. In these cases, conventional CPB (direct cannulation of heart and major blood vessels) cannot be done as the patient would bleed to death if pericardium is opened. Other strategies include using surgical glue, but the failure rate is high. Percutaneous device closure has been suggested of late.
Male heart patients above the age of 65 are at high risk to developing ventricular septal rupture. As this condition is commonly associated with heart attack, post operative care include care of surgical situation and treatment for heart attack. Post operative care is the same as in other cardiac surgery procedures. Bleeding, heart rate, blood pressure and urine output will be monitored. Multiple Echocardiogram will be done to find out re-bleed and improvement of cardiac function. Some medications for treating heart attack have to be avoided after surgery. The recovery will be slow compared to other cardiac surgery procedures.
Patients would be fit for discharge in 12 to 14 days post surgery, by when they would be able to walk without help. Patients can start walking exercise for five minutes in the first week after discharge, increase it to 10 minutes in the second and gradually increase it to one hour in two months. They have to be on a low fat diet.
Dr Austin Raj is chief cardiovascular surgeon at Jubilee Mission Medical College. The name of the patient has been changed to protect identity.
