Willian Harvey described LVFWR in 1647 at autopsy of a knight who had suffered severe chest pain(4). Subsequently, VSR was described by Latham at an autopsy in 1847(5), which led Brunn in 1923(6) to make the first antemortem diagnosis of post-AMI VSR. The first surgical repair of VSR was reported by Cooley in 1957(7). It was 15 years later when Fitzgibbon reported the first successful surgical repair of the LVFWR(4).
The combination of LVFWR and VSR is termed "Double Myocardial Rupture (DMR)"(8) and is a late presentation of AMI (1 to 14 days). Risk factors for developing DMR are patients over 65, relative freedom from coronary arterial disease, hypertension, the first AMI, continued activity (stuttering) AMI and delayed treatment(8). Two forms of DMR, true and junctional, are described, as seen in Fig. 3(9,10). The true form matches our patient (Video 1).
DMR is seen in 0.3% of all patients with AMI(9). Patients who sustain any cardiac rupture have a high mortality rate and even after a successful surgical correction of DMR, the four month-survival rate post-operation remains high at 37.5%(9).
Cooley (1957) described using a polyvinyl sponge to plug VSR post-AMI and Daggett (1977) proposed infarctectomy and closure with a patch with a short suture line. However, both Cooley and Daggett's techniques had drawbacks with sacrifice of healthy septal myocardium and a high incidence of post-operatively ventricular septal defects (VSD), mortality, and poor long-term survival(11). The most widely used technique, as in our case is based on a procedure first attempted by David and colleagues in 1995, which used a pericardial patch, tissue glue and felt reinforcement. The technique retains healthy myocardium and has been found to have lower 30-day mortality and higher long-term survival (11,12). Nevertheless there is a 30% incidence of residual or recurrent shunt and, as in our case, a significant risk of compromising the mitral apparatus in inferior repairs(11).
There have been other more recent suggestions for VSR repair; Caimmi and colleagues (2010) proposed a double-patch technique via a right ventriculotomy in which two patches, supported by tissue glue, equally sandwich the infarcted septum between the left and right ventricles. Sugimoto and colleagues (2008)(13) have suggested the triple-patch technique in which the first pericardial patch closes the VSR, and the second patch is cut into two sufficient sizes, sutured to non-infarcted endocardium on the same side. The third patch is sutured to the non-infarcted endocardium on the ventricular free wall on the same side again. Finally, fibrin glue fills the cavity between the first patch and the pouch created with the second and third patches. Triple-patching is said to provide robustness with a solid barrier to prevent recurrent rupture and resistance to suture stress(14).
The use of tissue adhesive and surgical glues have facilitated suture-less techniques to treat LVFWR(15). Digital pressure to achieve clot formation is followed by tissue glue directly onto the affected area with or without additional support from a cellulose product or pericardium to stabilize it(16). This method was employed successfully in this patient when a new rupture was identified following initial chest closure.
Our patient suffered a complicated postoperative recovery, surviving multiple organ failures. Organ failure has been associated with increased mortality, ranging from 12% (single organ failure) to more than 60% with double or triple organ failure(17, 18). During his 56 days in ICU, he required prolonged ventilatory support, haemofiltration, and haematological support for heparin induced thrombocytopenia. Despite his arrest in tamponade, he escaped neurological compromise.
Time is of the essence in the management of AMI yet during the COVID-19 pandemic, there was a 38% decrease in STEMI presentations and a 48% decrease in AMI hospitalisations in the USA(1). Others have confirmed delays in STEMI patients seeking medical attention during COVID-19(19). A 43% reduction in admission for AMI was noted in Italy(20). Patient apprehension about contracting COVID-19 in hospital could have contributed to these findings. It is well known that mechanical complications post-AMI increase with pre-hospital delay and are associated with poorer outcomes (21). Three case reports have shown that LVFWR has been rising throughout the COVID-19 pandemic as patients delay seeking care over the fear of contracting COVID-19 (1,22,23). The NHS national cardiac audit programme (NCAP) 2022, showed 40% fewer patient were admitted with NSTEMI’s and there was a 25% reduction in STEMI admissions. Only 37% patients with STEMI received PCI, a key reperfusion intervention to reduce AMI complications (24).
Initial misdiagnosis (as in our patient) is common and contributes to the problem. Nearly a third (29.9%) of patients with AMI have been initially misdiagnosed prior to or on admission to hospital(25). Common misdiagnoses include oesophageal reflux, gastritis and musculoskeletal pain, in both hospital and primary care. Early, accurate diagnosis is key to a successful outcome.