Ann Thorac Surg 1996;62:903-904
© 1996 The Society of Thoracic Surgeons
How To Do It
Transatrial Approach to Posterior Postinfarct Ventricular Septal Defects
Barry B. K. Chan, MD,
Stanton P. Nolan, MD,
Irving L. Kron, MD
Department of Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia
Accepted for publication May 10, 1996.
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Abstract
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Repair of posterior postinfarct ventricular septal defects via the transinfarct left ventriculotomy is technically challenging and can be associated with significant morbidity. A transatrial approach avoids incising through the acutely infarcted myocardium and, in selected cases, offers a safe and reliable repair of these defects.
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Introduction
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Successful repair of postinfarct ventricular septal rupture is technically one of the most challenging problems in the management of patients with myocardial infarction [1]. The standard transinfarct left ventriculotomy in acute infarction can potentially cause significant operative morbidity. Transatrial repair of an inferoposterior postinfarct ventricular septal defect was performed in 3 consecutive patients with satisfactory results.
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Technique
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Standard cardiopulmonary bypass with bicaval venous cannulation and a left ventricular vent placed via the right superior pulmonary vein was instituted. After antegrade blood cardioplegic arrest was obtained, a right atriotomy was made. The tricuspid valve leaflets were retracted, and the location of the ventricular septal defect amidst right ventricular trabeculation was confirmed by injection of saline solution through the left ventricular vent (Fig 1
). The defect was closed with a bovine pericardial patch and a running 5-0 polypropylene suture. The repair was tested by infusing saline solution through the left ventricular vent. Coronary revascularization was then performed, followed by closure of the atriotomy upon removal of the aortic cross-clamp.
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Fig 1. . Postinfarct ventricular septal defect as seen via a right atriotomy with retraction of the tricuspid leaflets. (ANT. = anterior; Ao = aorta; AV = atrioventricular; IVC = inferior vena cava; LV = left ventricular; POST. = posterior; RA = right atrium; RV = right ventricle; SVC = superior vena cava; V. = valve.)
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Comment
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The principles behind successful management of postinfarct ventricular septal rupture include preoperative stabilization of the patient with intraaortic balloon support, a transinfarct left ventriculotomy, and patch closure of the septal defect and ventriculotomy without tension [2]. Coronary artery bypass at the time of ventricular septal defect repair has also been shown to improve long-term survival [1]. Overall hospital mortality has been reported to vary between 10% and 25% [1, 3]. Posterior defects, which are associated with transmural infarction in the distribution of the posterior descending and circumflex coronary artery systems, carry the highest mortality [2]. Factors contributing to this include a difficult exposure and the technical management of the friable and necrotic tissue in the posterior wall of the heart. In these cases, the defects in the septum are usually located high and posterior, where it is smooth with relatively few trabeculations, and can be readily exposed by retraction of the tricuspid leaflets and the ventricular trabeculae [4]. The septal leaflet can also be detached from the annulus to improve exposure of the defect. In some cases, however, the defect is atypically located close to the apical septum in an area of dense trabeculation. It might be more appropriate to approach these defects via the standard transinfarct ventriculotomy. Wide bites into viable myocardium must be taken to ensure solid anchoring of the patch. We found that brief injection of saline solution via the vent was helpful in locating the defect and in testing the repair for leaks. Three patients with this defect have had repairs by this technique, and all were discharged from the hospital in good condition. Intraoperative transesophageal echocardiography and postoperative transthoracic echocardiography confirmed successful closure of the ventricular septal defect. We propose that if the goal of the operation is to eliminate the left-to-right shunt in these acutely ill patients, a transatrial approach is a safe and reliable method to repair these defects.
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Footnotes
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Address reprint requests to Dr Kron, Division of Thoracic and Cardiovascular Surgery, University of Virginia Health Sciences Center, Charlottesville, VA 22908.
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References
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- Muehrcke DD, Daggett WM. Current surgical approach to acute ventricular septal rupture. Adv Cardiac Surg 1995;6:69–91.[Medline]
- Daggett WM. Surgical technique for early repair of posterior ventricular septal rupture. J Thorac Cardiovasc Surg 1984;84:306–12.[Medline]
- Skillington PD, Davis RH, Luff AD, 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]
- Rousou JA, Engleman RM, Breyer RH, et al. Transatrial repair of postinfarction posterior ventricular septal defect. Ann Thorac Surg 1987;43:665–6.[Abstract]
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Abstract
Introduction
