Ann Thorac Surg 1998;65:853-854
© 1998 The Society of Thoracic Surgeons
How to Do It
Early Repair of Postinfarction Ventricular Septal Rupture: Infarct Exclusion, Septal Stabilization, and Left Ventricular Remodeling
Hans D. de Boer, MD,
Wim J. de Boer, MD
Department of Cardiothoracic Surgery, University Hospital Groningen, Groningen, the Netherlands
Accepted for publication September 24, 1997.
Dr Wim J. de Boer, Department of Cardiothoracic Surgery, Groningen University Hospital, PO Box 30.001, 9700 RB Groningen, the Netherlands (e-mail: w.j.de.boer@thorax.azg.nl).
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Abstract
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A surgical technique for safe early repair of ventricular septal rupture is described. The technique consists of exclusion of the infarcted area, septal stabilization, and remodeling of the left ventricle with an internal two-patch method. This technique is simple and reliable, and it appeared favorable in an elderly patient group. Six of 7 patients were treated with good results.
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Introduction
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Ventricular septal rupture (VSR) is a rare but life-threatening complication of myocardial infarction. Ventricular septal rupture develops in less than 2% of the cases of myocardial infarction. The first successful surgical repair was reported by Cooley and associates in 1957 [1]. Since then many authors have reported different surgical techniques of postinfarction VSR repair with various results. Although these techniques have improved, the early mortality after repair of postinfarction VSR remains high [2][3][4]. As increasing age at operation is a risk factor for early death, a reliable surgical technique for postinfarction VSR repair is needed especially for elderly patients [5]. We report a surgical technique for stable repair of postinfarction VSR with good results in an elderly patient group.
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Technique
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Cardiopulmonary bypass is established with moderate systemic hypothermia. Without cross-clamping the aorta, an incision is made through the infarcted area of the left ventricle. No infarcted tissue is excised. The infarcted ventricular septum including the VSR is covered with a patch of Teflon felt (Meadox, Oakland, NJ). This septal patch is fixed with atraumatic Ethibond 1 XLH mattress sutures (Ethicon, Norderstedt, Germany) through the noninfarcted septum and the right ventricular free wall to a semicircular strip of Teflon felt. In this way stabilization of the septum is achieved. Now a Gel-Seal patch (Vascutec Prostheses, Renfrewshire, Scotland) is cut in the shape of the area of infarcted left ventricle. This Gel-Seal patch is fixed in a circular fashion through the septal patch and the noninfarcted right and left ventricular wall with atraumatic Ethibond 1 XLH mattress sutures to circular strips of Teflon felt. After this technique the infarcted septum and infarcted left ventricular wall are excluded from the left ventricular cavity and remodeling of the left ventricular cavity is achieved without infarctectomy. Now the cavity between the Gel-Seal patch and endocardium of the left infarcted ventricle is filled with gelatin-resorcin-formol glue (Colle Biologique, FFI, Saint-Just-Malmont, France) and the primary incision in the infarcted left ventricle is closed with a running suture of 2-0 Prolene (Ethicon) (Fig 1).
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Cross-section of the heart as seen from below with schematic representation of the closure of an anteriorly located ventricular septal rupture through a left ventriculotomy. The infarcted tissue is excluded from the left ventricular cavity. To get an impression of the repair of an inferiorly located VSR, please turn the page and hold it upside-down in front of a source of light. (Dotted area = infarcted area; hatched area = gelatin-resorcin-formol glue.)
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The gelatin-resorcin-formol glue is also applied to buttress the semicircular and circular strips of Teflon felt. After this repair of the postinfarction VSR, coronary artery revascularization is performed, during a short period of cardioplegic arrest, if significant stenosis of main arteries is present.
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Patients and Results
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Between December 1989 and January 1997, seven elderly patients underwent surgical repair of postinfarction VSR with the described surgical technique. The mean age of these patients was 75 years, ranging from 72 to 80 years. There were 4 men and 3 women. Postinfarction VSR occurred between 1 and 5 days after the acute myocardial infarction. The acute myocardial infarction was the first event of ischemic heart disease in all patients. Ventricular septal rupture was diagnosed by clinical features, by transesophageal echocardiography, and by oximetry with a Swan-Ganz catheter. Coronary angiography was performed to exclude coronary artery disease. Surgical repair followed between 1 and 4 days after diagnosis of postinfarction VSR. All patients were in hemodynamic shock and were treated with intraaortic balloon counterpulsation before the operation. Four anterior and three inferior postinfarction VSRs were found. In 2 patients additional revascularization was needed for significant stenosis of main coronary arteries. All patients were in sinus rhythm postoperatively. No surgical reintervention was needed for bleeding. Postoperative transesophageal echocardiography showed good geometry of the left ventricle. No residual shunt was seen. The right ventricular function recovered in all patients. One patient died 2 days postoperatively of insufficient residual vital myocardial reserve of the left ventricle. In all patients the intraaortic balloon pump was removed within 2 days.
The mean intubation time was 8 days (range, 2 to 32 days). The mean stay in the intensive care unit was 9 days (range, 4 to 39 days). The main complication was critical illness polyneuropathy. All survivors were fully mobilized at a mean of 19 days after the surgical repair of the postinfarction VSR (range, 7 to 45 days). The mean follow-up was 27 months (range, 6 to 87 months). Kidney function was preserved in all surviving patients. At present all surviving patients are in New York Heart Association class I or II, without a residual shunt (Table 1).
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Comment
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The development of a VSR due to acute myocardial infarction is a life-threatening complication. Early surgical repair is essential to preserve kidney function and to avoid general deterioration [4]. Diagnosis immediately after admission is made by transesophagal echocardiography and Swan-Ganz catheter oximetry. After the VSR is confirmed, an intraaortic balloon pump is installed and coronary angiography is performed. Especially in elderly patients, a group with high early mortality, a reliable surgical technique is needed [5]. The surgical technique used in our patients is simple but efficient and stable. The infarcted area is completely excluded from the left ventricular cavity without excision of infarcted tissue. Through the fixation of the septal patch to the right ventricular free wall a stable septum is regained. We think that this septal stabilization prevents further deterioration of the right ventricular dysfunction. The remodeling of the left ventricular cavity preserves the ventricular geometry and reduces stress on the repair. No surgical reintervention for bleeding is needed. The repair is very stable, which results in less chance of renewed rupture and residual shunt. The long-term results of early surgical repair of postinfarction VSR in this elderly patient group using this technique are excellent, regarding survival and functional status. Therefore we propose this reliable surgical technique for early repair in all patients with postinfarction VSR.
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References
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- Cooley DA, Belmonte BA, Zeis LB, et al. Surgical repair of ruptured interventricular septum following acute myocardial infarction. Surgery 1957;41:930-937.[Medline]
- Dagget WM, Guyton RA, Munth ED, et al. Surgery for post myocardial infarct ventricular septal defect. Ann Surg 1977;186:260-270.[Medline]
- Da Silva JP, Cascudo MM, Baumgratz JF, et al. Postinfarction ventricular septal defect. An efficacious technique for early surgical repair. J Thorac Cardiovasc Surg 1989;97:86-89.[Abstract]
- David TE, Dale L, Sun Z Postinfarction ventricular septal rupture: repair by endocardial patch with infarct exclusion. J Thorac Cardiovasc Surg 1995;110:1315-1322.[Abstract/Free Full Text]
- Skillington PD, Davies RH, Luff J, et al. Surgical treatment for infarct-related ventricular septal defects. Improved early result combined with analysis of late functional status. J Thorac Cardiovasc Surg 1990;99:798-808.[Abstract]
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Abstract
Introduction
