Ann Thorac Surg 1996;62:486-488
© 1996 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Early Repair of Postinfarction Ventricular Septal Defect With Gelatin-Resorcin-Formol Biological Glue
Francesco Musumeci, MD,
Vinayak Shukla, MD,
Carmelo Mignosa, MD,
Giovanni Casali, MD,
Shahid Ikram, MD
Department of Cardiac Surgery, University Hospital of Wales, Cardiff, United Kingdom
Accepted for publication March 18, 1996.
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Abstract
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Background. Early surgical repair of postinfarction ventricular septal defect has improved early mortality rate. Mortality remains high in patients presenting within 1 week of infarction, or when rupture has occurred in the inferior part of the septum.
Methods. We describe a surgical technique for repair of postinfarction ventricular septal defect that involves no infarctectomy: continuous suturing of a bovine pericardial patch to healthy myocardium around the infarcted area and use of gelatin-resorcin-formol biological glue as a sealant between the patch and the interventricular septum.
Results. We have used this technique successfully in 3 consecutive patients in whom repair was performed within 1 week of myocardial infarction. The rupture of the interventricular septum was located anteriorly in 2 patients and inferiorly in the other. They all made an uneventful recovery, and at follow-up there was no evidence of residual shunt.
Conclusions. This technique can be a useful adjunct to the surgical management of this difficult group of patients.
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Introduction
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Myocardial infarction is complicated by rupture of the interventricular septum in 1% to 2% of cases [1]. Due to the poor outcome after initial medical management, early operation has been advocated [2, 3]. With this approach, improvement in the early mortality rate has been widely reported [4, 5]. The mortality has, however, remained significant when ventricular septal rupture occurs within 1 week of infarction [4, 6], after thrombolysis [7], or if the rupture is located inferiorly in the septum [4, 6]. Furthermore, patients who survive the operation may require reoperation because of residual or recurrent ventricular septal defect due to dehiscence around the suture lines [4, 6]. Recently Séguin and colleagues [8] described the use of a fibrin sealant to reinforce the necrotic interventricular septum and ventricular wall, creating a more solid implantation site for the closure of the ruptured area with a Dacron patch.
We report 3 cases of postinfarction ventricular septal rupture successfully repaired by using gelatin-resorcin-formol (GRF) glue (Pharmacie Centrale, CHU, Henri Mondor, Creteil, France) as a sealant between the bovine pericardial patch and the interventricular septum.
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Material and Methods
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Three consecutive patients with a postinfarction ventricular septal rupture were operated on within 1 week of myocardial infarction. Two were women (aged 68 and 70 years) and 1 was a man (aged 65 years). They were admitted in cardiac failure 2, 4, and 6 days, respectively, after the ischemic event. One patient had received thrombolytic treatment. Echocardiography with color Doppler flow imaging confirmed the rupture of the interventricular septum, which was located anteriorly in 2 patients and inferiorly in the other. Coronary angiography revealed single-vessel disease in 2 patients (respectively, occlusion of the right coronary and left anterior descending arteries). The third patient, who received streptokinase for an inferior infarct, had proximal disease of the right coronary artery and a significant stenosis of the left anterior descending artery, which was grafted at the time of the operation. All patients had an intraaortic balloon pump inserted percutaneously in the catheter room and were then transferred directly to the operating theater. Operation was performed on the day of admission.
The operation was performed with cardiopulmonary bypass and moderate systemic hypothermia (25°C). Cold crystalloid cardioplegia (St. Thomas's solution) was used. The defect was approached through a left ventriculotomy, which was parallel to and 5 to 10 mm away from either the anterior or the posterior descending arteries, according to the area of infarction. The demarcation line between infarcted and healthy myocardium was identified. No infarcted tissue was excised. A patch of bovine pericardium was sutured to the viable muscle around the infarcted septum using a running suture of 3-0 polypropylene. The free edge of the patch was brought outside the ventriculotomy. The circulation was then stopped and, on a dry field, the GRF glue was applied between the infarcted interventricular septum and the patch (Fig 1
). The patch and the septum were pressed together for about 5 minutes until polymerization had taken place and the glue became adhesive. Circulation was restarted and, on rewarming, the ventriculotomy was closed using a strip of Teflon on either side of the incision and including the free edge of the bovine pericardial patch.
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Fig 1. . Repair of postinfarction ventricular septal defect. (A) Patch of bovine pericardium anchored with continuous suture to the left side of the ventricular septum. Gelatin-resorcin-formol glue is applied between the patch and the interventricular septum. (B) Repair completed. (LV = left ventricle.)
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Results
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All patients left the operating room with small doses of inotropic drugs. Intraaortic balloon counterpulsation was electively maintained for 48 hours postoperatively. All patients made an uneventful recovery and at a mean follow-up of 8 months were in New York Heart Association class I. Transthoracic echocardiography performed before discharge and at the last follow-up demonstrated paradoxical septal motion with good overall left ventricular function and no evidence of a residual or recurrent shunt.
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Comment
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Early surgical intervention has been a major determinant in the improved outcome of patients with postinfarction ventricular septal defect [2–55]. However, an operative mortality between 20% and 40% is still reported in the literature, mainly related to technical difficulties encountered in closing defects in the inferior part of the septum or to the fragility of the recently necrosed myocardium when operation is undertaken within the first week after infarction [4, 6]. A further impact on the operative mortality has come from the use of thrombolysis for the treatment of myocardial infarction, as patients tend to present within the first 48 hours of the onset of pain with the ruptured septum showing the feature of an hemorrhagic infarct [7].
Innovations in operative techniques have been proposed to overcome these technical difficulties. Komeda and associates [5] have used a single patch of bovine pericardium sutured to the healthy myocardium around the infarcted area on the left side of the septum, excluding the infarcted myocardium from the left ventricular cavity, and reported no operative deaths in 12 consecutive patients. Séguin and colleagues [8] reported no deaths in 3 patients operated on within 4 days of myocardial infarction by using fibrin sealant to reinforce the recently necrosed myocardium and adhere the patch to the septum.
In our method of repair we have combined the technique of no infarctectomy and continuous suturing of the patch to healthy myocardium around the infarcted area, which allows a rapid and secure positioning of the patch, with the use of glue for its capacity to reinforce the infarcted myocardium and provide firm adhesion between the infarcted septum and the patch, preventing early dehiscence of the patch and recurrence of the ventricular septal defect. Our experience with GRF biological glue for reinforcement of the aortic wall in surgery for acute dissection of the aorta encouraged us to use it in the repair of postinfarction ventricular septal defects. Concern has been expressed about its intracardiac use because of the possible toxic effect of formol on the myocardium [8]. Once the mixture of gelatin and resorcin glue is injected with formol they will irreversibly bind together. The risk of contamination of the circulation with formol is therefore remote and no greater than the risk when GRF glue is used for the repair of aortic dissection. Furthermore, the glue is applied to already necrotic myocardium, which, once the healing process is complete, will become fibrous tissue. In our opinion, therefore, the risk of further damage to the myocardium due to formol is likely to be insignificant, as indeed the clinical outcome and the echocardiographic data of our patients have shown. The use of a short period of circulatory arrest to create a completely dry field necessary for the glue to dry will also prevent the theoretical risk of formol entering the circulation. Similarly to Séguin and colleagues [8], we have not encountered any embolic complication related to the intracardiac use of glue.
The results of our experience, although limited to 3 patients, demonstrate that this technique based on exclusion of the infarcted myocardium and use of GRF biological glue can be a useful adjunct to the early surgical management of this difficult group of patients.
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Addendum
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Since submission of this article, 1 further patient, aged 76 years, with an anterior postinfarction ventricular septal defect has successfully been operated on 6 days after the ischemic event. She had received thrombolytic treatment.
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Footnotes
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Address reprint requests to Dr Musumeci, Department of Cardiac Surgery, University Hospital of Wales, Heath Park, Cardiff, CF4 4XW, UK.
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References
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- Jonas V, Hynick V, Shlumsky J, Chlumska A. Eight-year survival after perforation of ventricular septum in myocardial infarction. Acta Univ Carik [Med] 1970;16:133–44.
- Gaudiani VA, Miller DC, Stinson EB, et al. Postinfarction ventricular septal defect: an argument for early operation. Surgery 1981;89:48–55.[Medline]
- Daggett WM, Buckley MJ, Akins CW, et al. Improved results of surgical management of postinfarction ventricular septal defect. Ann Surg 1982;196:269–77.[Medline]
- Skillington PD, Davies RH, Luff AJ, et al. Surgical treatment for infarct-related ventricular septal defects. Improved early results combined with analysis of late functional status. J Thorac Cardiovasc Surg 1990;99:798–808.[Abstract]
- Komeda M, Fremes SE, David TE. Surgical repair of postinfarction ventricular septal defect. Circulation 1990;82(Suppl 4):243–7.
- Jones MT, Schofield PM, Bray CL, et al. Surgical repair of acquired ventricular septal defect: determinants of early and late outcome. J Thorac Cardiovasc Surg 1987;93:680–6.[Abstract]
- Westaby S, Parry A, Ormerod O, Gooneratne P, Pillai R. Thrombolysis and postinfarction ventricular septal rupture. J Thorac Cardiovasc Surg 1992;104:1506–9.[Abstract]
- Séguin JR, Frapier JM, Colson P, Chaptal PA. Fibrin sealant for early repair of acquired ventricular septal defect. J Thorac Cardiovasc Surg 1992;104:748–51.[Abstract]
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Abstract
Introduction
