Ann Thorac Surg 1995;60:1430-1431
© 1995 The Society of Thoracic Surgeons
How To Do It
New Surgical Technique for Repair of Ventricular Septal Perforation
Katsuhiko Matsuda, MD, PhD,
Teiji Oda, MD, PhD,
Hiromu Terai, MD,
Michiya Hanyu, MD,
Toshihiko Ban, MD, PhD
Department of Cardiovascular Surgery, Kyoto University School of Medicine, and Division of Cardiovascular Surgery, Otowa Hospital, Kyoto, Japan
Accepted for publication June 26, 1995.
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Abstract
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We describe a technique for repairing the ventricular septal perforation using porcine pericardium tailored in a conical shape. This technique may allow a good operating view and facilitate suturing to the left ventricular cavity.
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Introduction
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In 1957, Cooley and associates [1] performed the first operation for ventricular septal perforation (VSP) after acute myocardial infarction. Although ventricular septal perforation occurs in 1% to 2% of all patients after myocardial infarction, operation for this disease remains a challenge [2]. Recently, Komeda and associates [3] reported a new technique for ventricular septal perforation. Using their theory as a basis, we modified their method and designed a new technique.
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Technique
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An 82-year-old man underwent a radical operation for anterior septal perforation in August 1994. Echocardiogram showed a large left to right shunt at the ventricular level, and the pulmonary-to-systemic flow ratio was 5.24. Coronary angiogram showed 50% stenosis in the right coronary artery and 100% stenosis in the left anterior descending artery. The pulmonary artery pressure was 45/15 mm Hg, and cardiac output was 1.54 L•min-1• m-2 by Swan-Ganz catheter analysis.
The patient was managed with an intraaortic balloon pump before operation. Under extracorporeal circulation, moderate systemic hypothermia was obtained. The heart was arrested using cold blood cardioplegia. A longitudinal incision parallel to the interventricular artery transected the infarcted area. The septal perforation was seen in the midportion of the interventricular septum. During core cooling, the porcine pericardium, measuring 8 cm x 16 cm, was trimmed into a conical sack (Fig 1
). Four 4-0 polypropylene U stay sutures with Dacron pledget were placed on the healthy endocardium proximal to the infarct in the septum and lateral ventricular wall. These sutures then were run through the base of conical porcine pericardium. At this stage, the tip of the cone pointed to the base of the heart. The porcine pericardium was sunk into the ventricular cavity and the four U stay sutures were knotted. Continuous running sutures were placed between the knots. After that, the porcine pericardium was pulled. The ventriculotomy was closed with large muttressed sutures, and nothing was done about the VSP (Fig 2). Aortocoronary bypass was not performed. The bypass and cross-clamp times were 141 minutes and 50 minutes, respectively.
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Fig 2. . Ventricular septal perforation (VSP) after completion. The shape of the ventricular cavity is maintained after repair.
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Weaning from the pump was smooth and easy, and the intraaortic balloon pump was removed after 5 days. The patient required dopamine and dobutamine for 10 days after the operation. Cardiac output was 2.68 L•min-1• m-2, and pulmonary artery pressure was 20/8 mm Hg on the 10th postoperative day. Echocardiography showed no shunt between the right and left ventricle, good movement of the pericardial sack, and no thrombi between the sack and the ventricle at 2 months after operation (Fig 3).
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Fig 3. . Postoperative echocardiogram showing good movement of pericardial sack (arrow) and no thrombi between sack and ventricle (2 months after operation).
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Comment
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The site of VSP determined the surgical mortality. It has been demonstrated that repair of posterior VSP showed a higher operative mortality than repair of anterior VSP [4]. Moore and colleagues [5] reported that greater impairment of right ventricular function and greater elevation of right ventricular pressure increased mortality in a review of 25 patients with postinfarction VSP. Komeda and associates and Cooley [6] reported that preservation of right ventricular function affected the outcome of patients with postinfarction VSP. Therefore we chose a technique that allowed a surgical procedure to be performed on the left side of the heart by excluding the VSP and the infarcted myocardium from the left ventricle, and we modified Komeda and associates' technique (patch technique) using an endocardiac repair with conical porcine pericardium (sack technique).
Our surgical technique has several advantages: it is very easy to determine the suture line because the suture line is always a circle, so suturing time may be diminished. The surgical view is good, because the conical porcine pericardial patch is placed in the base of the left ventricular cavity during suturing. When the patch is not big enough, there is concern that the patch may be torn off during the diastolic phase by the left ventricular pressure. We know of such a case. However, there is no such concern with our sack technique because we can use a pericardial sack that is large enough. Currently we have applied this technique to only 1 case, so it is difficult to evaluate this technique thoroughly. We intend to apply this technique to additional cases and to follow up the long-term results.
In conclusion, we designed a new technique for repairing VSP using a conical porcine pericardial patch (sack technique). We performed this new technical method with a good operating view and were able to shorten the duration of operation. Postoperative echocardiography demonstrated the absence of a shunt between the left and right ventricles. Improvement of left ventricular function was obtained. We suspect that this technique can be applied for left ventricular free wall rupture after myocardial infarction or mitral valve replacement.
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Footnotes
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Address reprint requests to Dr Matsuda, Department of Cardiovascular Surgery, Kyoto University, School of Medicine, 54, Kawara-cho Shogoin, Sakyo-ku, Kyoto, 606-01 Japan.
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References
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- Cooley DA, Belmonte BA, Zeis LB, Schnur S. Surgical repair of ruptured interventricular septum following acute myocardial infarction. Surgery 1957;41:930–7.[Medline]
- Hutchins GM. Rupture of the interventricular septum complicating myocardial infarction: pathologic analysis of 10 patients with clinically diagnosed perforations. Am Heart J 1979;97:165–73.[Medline]
- Komeda M, Fremes SE, David TE. Surgical repair for postinfarction ventricular defect. Circulation 1990;82(Suppl 4):243–7.
- Daggett WM, Guyton RA, Mundth ED, et al. Surgery for post myocardial infarct ventricular septal defect. Ann Surg 1977;186:260–71.[Medline]
- Moore CA, Nygaard TW, Kaiser DL, Cooper AA, Gibson RS. Postinfarction ventricular septal rupture: the importance of location of infarction and right ventricular function in determining survival. Circulation 1986;74:45–55.[Abstract/Free Full Text]
- Cooley DA. Repair of the difficult ventriculotomy. Ann Thorac Surg 1990;49:150–1.[Abstract]
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Abstract
Introduction
