King’s College Hospital has achieved a world first in cardiac surgery. For the first time, an acute rupture of the inner wall of the heart1 was closed using a device instead of conventional surgery. The new surgical technique used in this case is less invasive on the heart and may allow the patient a quicker recovery with less risk of complications.
The patient, a 75-year old man, experienced a rupture of the ventricular septum (the wall dividing the right and left heart chambers) after a myocardial infarction2. A rupture of this inner wall is an acute complication after a myocardial infarction, and is fatal without treatment. The hole allows blood flow from the high pressure left heart chamber into the low pressure right heart chamber, which can cause severe breathlessness and low blood pressure. There is also risk of multiple organ failure. Without immediate medical intervention, 95 percent of people with this condition suffer severe heart failure and die. The conventional treatment for an inner heart rupture is open-heart surgery, where a patch is stitched over the hole. Depending on the condition of the patient, the surgeon must assess whether they are eligible for the procedure. Of those who undergo conventional open-heart surgery, up to 50 percent do not survive. However, in this case the patient’s recovery chances were greatly improved by the use of a less invasive surgical technique, where a device was used to close the hole in the heart.
The patient had gone to his local hospital suffering from physical discomfort with mild breathlessness, but showing no typical signs of a heart attack. He was diagnosed with an acute myocardial infarction that led to a rupture (hole) in the inner wall of his heart and was immediately transferred to King’s College Hospital for further assessment and treatment.
Taking a multidisciplinary approach to the care and treatment of the patient, a team of cardiac specialists, under the leadership of interventionist cardiologist Dr Jonathan Hill, worked together to treat the patient. He was stabilised using an intraaortic balloon pump to improve cardiac function. The intraaortic balloon pump is placed in the main artery of the body, the aorta. It increases the blood supply to the heart, and can relieve the heart muscle’s workload by up to 20 percent. After six days of recovery to regain his strength, the patient then underwent treatment for the myocardial rupture using the new surgical approach.
In this procedure, the patient was taken to theatre and placed on the heart-lung-machine . This machine relieves pressure on the heart and circulates the patient’s blood supply during the surgery. A surgical team, led by cardiothoracic consultant surgeon Mr Olaf Wendler, carried out a coronary bypass operation3. After a normal blood supply of the heart was restored, a tiny device4 just over 10mm in length was placed through a surgical incision in the right heart. Under direct vision, the device was placed into the rupture of the inner wall of the heart where it safely attaches to the margins of the rupture due to its shape. The right heart was closed and the patient weaned off the heart-lung-machine. This technique allowed the surgeon to perform the operation without cardiac arrest and without opening the left heart, which is necessary for the conventional operation. The patient was taken off the mechanical ventilator the next morning. After a few weeks, he was able to return to the comfort of his own home to fully recuperate.
The device used in this procedure has never before been used to treat an acute myocardial rupture during open surgery. Historically, it been used to treat children who are born with heart defects, or patients with longer term (chronic) holes in the inner wall of the heart. Although there have been reports of interventional placement of the device – done by cardiologist with a catheter through the femoral artery – it is more technically difficult in the setting of an acute myocardial infarction.
Following the surgery, Mr Wendler said: “This represents a huge step forward in treatment of heart rupture. Until now, the only way we had of treating inner rupture to the heart was the conventional open-heart surgery, with its high risk. Because we are now able to use this less invasive approach we hope to have better results in the future. We are encouraged by this outcome, and we will be exploring the possibility of establishing this as a regular procedure at King’s College Hospital for suitable patients.”
Each year around 230,000 people in the UK experience a heart attack5 and of those around one to two percent experience an inner rupture of the heart wall. While conventional surgery can be used, it places a strain on the body and risks leaving the patient less able to fully recover. There is also a risk of a repeat hole in the inner wall of the heart if stitches to the heart do not hold or heal properly. Because of these complications the conventional surgical approach carries a high risk for patients. This new technique presents an exciting breakthrough that may lead to less invasive surgical procedures and more successful outcomes for those who experience heart rupture.