ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Toshihiko Shibata
Shigefumi Suehiro
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Shibata, T.
Right arrow Articles by Kinoshita, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Shibata, T.
Right arrow Articles by Kinoshita, H.
Related Collections
Right arrowRelated Article

Ann Thorac Surg 1997;63:1165-1167
© 1997 The Society of Thoracic Surgeons

Case Report

Repair of Postinfarction Ventricular Septal Defect With Joined Endocardial Patches

Toshihiko Shibata, MD, Shigefumi Suehiro, MD, PhD, Takumi Ishikawa, MD, Koji Hattori, MD, PhD, Hiroaki Kinoshita, MD, PhD

Second Department of Surgery, Osaka City University Medical School, Osaka, Japan

Accepted for publication November 4, 1996.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Comment
 References
 
We describe a technique for repair of ventricular septal defect with two bovine pericardial patches joined to make a single pouch. The size of the finished pouch can be adjusted as desired after both patches are sutured to the myocardium, unlike when one patch is used. Suturing is easier than when a single patch is used.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Comment
 References
 
See also page 1167.

A 64-year-old man was transferred to our hospital for surgical repair of a ventricular septal defect associated with myocardial infarction of the anterior wall 9 days after the infarction. Echocardiograms showed ST elevation at V1 to V4. Doppler echocardiography showed shunt flow through a ventricular septal defect. The pulmonary-to-systemic flow ratio was 2.4 and the left-to-right shunt was 57%. Chest roentgenograms showed pulmonary congestion. An intraaortic balloon pump was inserted on the night of admission because of worsening heart failure (blood pressure less than 90 mm Hg), and emergency surgical repair was undertaken. Coronary angiography was not done before operation. A cardiopulmonary bypass was established and the heart was arrested with a cold crystalloid cardioplegic solution. Repair was done through a left ventriculotomy in the infarcted anterior wall parallel to the left anterior descending artery. Stay sutures were passed through the ventricular muscle to facilitate exposure of the ventricular cavity. The ventricular defect measured 1.5 x 1.5 cm. Gentian violet was used to outline on the noninfarcted myocardium where we planned to make a line of sutures. A bovine pericardial patch fixed with glutaraldehyde was cut into an oval so that half of the circumference of the patch was slightly longer than half of the suture line. The pericardial patch was then sutured with its outside surface being held against the inner surface of the noninfarcted ventricular septal muscle with continuous 4-0 Prolene suture and SH needle (Ethicon, Somerville, NJ). The suture was changed to another suture every several stitches. For anchoring of the edge of the pericardial patch, the final suture was brought outside of the heart through a felt pledget at the 6 o'clock and 12 o'clock positions. Another bovine pericardial patch was sutured to the anterolateral ventricular wall in the same way. The edges of both pericardial patches were overlapped and fixed with a buttressed suture through another felt pledget placed outside of the heart. These two pericardial patches were then cut so that the size and shape of the finished bovine pericardial pouch would fit the left ventricular cavity. In this case, the maximum width of each pericardial patch was 4 cm. The two patches were joined with continuous 4-0 Prolene suture (Fig 1Go), forming a pouch. Before final closure of the patches, the pericardial pouch was inflated with the cardioplegic solution to check its size and shape. The left ventriculotomy was closed with a buttressed suture (2-0 Prolene suture) on a Teflon felt strip. No additional coronary bypass grafting was done. The cardiopulmonary bypass was discontinued without incident. Aortic cross-clamping time was 120 minutes, and operation time was 280 minutes. The postoperative recovery was uneventful, and the intraaortic balloon pump was removed on the day after operation. Doppler echocardiography showed no residual shunt through the pericardial patch. Left ventriculography showed satisfactory left ventricular volume. The patient was discharged from hospital 4 weeks after operation.



View larger version (31K):
[in this window]
[in a new window]
  		Fig 1. . Diagram of the finished pericardial pouch. The shape and size are decided after the two bovine patches are sutured to the myocardium.

 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Comment
References
 
The repair of postinfarction ventricular septal defect has been associated with high operative mortality. The surgical treatment established by Daggett and colleagues [1] is one of the most successful of the various techniques that have been suggested, both in terms of the low mortality and satisfactory cardiac function. Komeda and co-workers [2] and Cooley [3] independently suggested a new concept of surgical repair of postinfarction ventricular septal defect without removal of the infarcted ventricular muscle. This infarction exclusion technique further improved surgical mortality [4]. One bovine pericardial patch is used to protect the area of infarcted myocardium. A continuous running suture is started at the ventricular septal side and then extended to the anterolateral wall. One disadvantage of this method is the difficulty in suturing the patch at the anterolateral wall unless the edge is brought toward the operator as shown in Figure 2AGo. The reports of the technique do not mention how this twisting can best be implemented.



View larger version (16K):
[in this window]
[in a new window]
  		Fig 2. . Comparison of the technique with one (A) and two (B) patches. A running suture is used from the inner side of the patch on the septal side, but from the outer side of the patch on the anterolateral side. The patch must be twisted as shown. (B) Each patch can be sutured from its inner side, and the surgical view is not blocked. The final shape and size of the pouch are decided after the patches are sutured to the myocardium.

 
Our surgical technique has some advantages. Postinfarction ventricular septal defect is rare, therefore the method for its surgical repair should not require much experience. In our method, the surgical field is readily seen both on the septal and anterolateral sides, and each patch can be sutured from its inner side with little difficulty (Fig 2BGo). Under these conditions, leakage can be prevented. Another advantage is that the shape and size of the pericardial pouch can be adjusted as necessary. We decide on the size and shape of the patches after they have been sutured to the myocardium. Matsuda and colleagues [5] reported a technique in which a pericardial sack is tailored in a conical shape to make this suturing to the myocardium easier. In their technique, the size of the sack must be decided beforehand. These investigators pointed out that the suture line may be stressed to the point of failure in the diastolic phase if the patch is too small to fit the cavity. This problem can be prevented by careful fitting of the pouch, as is possible with our technique.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Comment
 References
 
Address reprint requests to Dr Shibata, Second Department of Surgery, Osaka City University Medical School, 1-5-7 Asahimachi, Abeno, Osaka 545, Japan.


   References
Top
 Footnotes
 Abstract
 Introduction
 Comment
 References
 

  1. Daggett WM, Guyton RA, Mundth ED, et al. Surgery for post-myocardial infarct ventricular septal defect. Ann Surg 1977;186:260–71.[Medline]
  2. Komeda M, David TE, Fremes SE. Surgical repair of postinfarction ventricular septal defect. Circulation 1990;82(Suppl 4):243–7.
  3. Cooley DA. Repair of the difficult ventriculotomy. Ann Thorac Surg 1990;49:150–1.[Abstract]
  4. David TE, Dale L, Sun Z. Postinfarction ventricular septal rupture: repair by endocardial patch with infarct exclusion. J Thorac Cardiovasc Surg 1995;110:1315–22.[Abstract/Free Full Text]
  5. Matsuda K, Oda T, Terai H, Hanyu M, Ban T. New surgical technique for repair of ventricular septal perforation. Ann Thorac Surg 1995;60:1430–1.[Abstract/Free Full Text]

Related Article

Invited Commentary
Denton A. Cooley
Ann. Thorac. Surg. 1997 63: 1167. [Extract] [Full Text]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
H. Imagawa, S. Takano, T. Shiozaki, M. Ryugou, F. Shikata, and K. Kawachi
Two-patch technique for postinfarction inferoposterior ventricular septal defect.
Ann. Thorac. Surg., August 1, 2009; 88(2): 692 - 694.
[Abstract] [Full Text] [PDF]

Home page
 ICVTSHome page
T. Shimamoto, A. Marui, Y. Saji, and M. Komeda
Infarction-exclusion technique with the on-pump beating heart approach for ventricular septal perforation
Interactive CardioVascular and Thoracic Surgery, December 1, 2008; 7(6): 1207 - 1209.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
T. Sugimoto, S. Yoshii, K. Yamamoto, K. Sakakibara, Y. Iida, A. Uehara, T. Mishima, and S. Kasuya
A modified infarct exclusion technique: Triple-patch technique for postinfarction ventricular septal perforation
J. Thorac. Cardiovasc. Surg., March 1, 2008; 135(3): 702 - 703.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
T. lto, H. Hagiwara, and A. Maekawa
Entire septal patch technique for postinfarction ventricular septal rupture
Ann. Thorac. Surg., July 1, 2000; 70(1): 273 - 274.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Toshihiko Shibata
Shigefumi Suehiro
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Shibata, T.
Right arrow Articles by Kinoshita, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Shibata, T.
Right arrow Articles by Kinoshita, H.
Related Collections
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS