Ann Thorac Surg 2003;75:301-302
© 2003 The Society of Thoracic Surgeons
How to do it
Modified Daggett’s technique for early repair of postinfarct posterior ventricular septal rupture
Masato Nakajima, MDa*,
Kouji Tsuchiya, MDa,
Hidenori Inoue, MDa,
Yuji Naito, MDa,
Eiki Mizutani, MDa
a Cardiovascular Surgery, Yamanashi Central Hospital, Kofu City, Yamanashi, Japan
Accepted for publication June 20, 2002.
* Address reprint requests to Dr Nakajima, Department of Cardiovascular Surgery, Yamanashi Central Hospital, 1-1-1 Fujimi, Kofu City, Yamanashi 400-0027, Japan
e-mail: m-nakajima2a{at}ych.pref.yamanashi.jp
 |
Abstract
|
|---|
A surgical modification for safe early repair of posterior septal rupture is described. This technique is based on the method described by Daggett, but adds one internal patch, plus the application of fibrin glue between the internal and external patch for minimizing bleeding. This modification is a simple and reliable one for repairing posterior ventricular septal rupture.
|
Introduction
|
|---|
Early surgical repair of posterior ventricular septal rupture (VSR) is associated with significant mortality and morbidity because of its technical difficulty. Minimization of bleeding from ventriculotomy and maintenance of left ventricular geometry after closing the perforation are considered to be important factors in this procedure. We present a successful modified Daggett’s technique using three patches (one patch added to the inside of the left ventricle) and fibrin glue (applied between the two patches of the left ventriculotomy). This modification was useful and effective for decreasing intraoperative bleeding and surgical mortality.
A 78-year-old man was admitted to our hospital with a diagnosis of acute inferior myocardial infarction. Echocardiography revealed significant shunt flow through the ruptured posterior ventricular septum. Emergency coronary angiography showed total occlusion of the right coronary artery in segment 3, with no significant stenosis of the left coronary artery. The calculated pulmonary-to-systemic flow ratio was 2.1. An intraaortic balloon pump (IABP) was inserted, but the patient’s hemodynamic status deteriorated. Therefore, surgical repair was indicated.
|
Technique
|
|---|
Through a median sternotomy, standard cardiopulmonary bypass with bicaval venous cannulation and left heart venting via the right upper pulmonary vein was instituted. After antegrade blood cardioplegic arrest was obtained, the left ventricle was incised on the left side and parallel to the posterior descending coronary artery. The septal defect and the margin of the infarcted myocardium were carefully inspected, and the necrotic tissue was excised. The defect was closed with a Dacron patch, applied on the left side, using interrupted mattress sutures passed from right ventricle to left ventricle. The left ventriculotomy was closed with two patches (the inner side being a Xenomedica patch [Baxter Healthcare Co, Deerfield, IL] and outer side being a Dacron patch with autopericardium), using interrupted mattress sutures passed from inside to outside of the left ventricle. Also, before tying all stitches, fibrin glue was injected between the two patches (Fig 1).
The patient was weaned from cardiopulmonary bypass without difficulty, but with IABP assistance. The bypass time was 80 minutes, and aortic cross-clamping lasted 61 minutes. Intraoperative bleeding amounted to 156 mL. The patient was weaned from the IABP on postoperative day 2, and from the ventilator on day 3. The patient was discharged without complications.
View larger version (17K):
[in this window]
[in a new window]
|
Fig 1. Operative schema. (a) Original Daggett’s method described in 1982 [2]. (b) Our modification adding one inner patch and fibrin glue. (LV = left ventricle; RV = right ventricle.)
|
|
|
Comment
|
|---|
Surgical treatment of posterior ventricular septal rupture (VSR) still carries a higher mortality than does anterior VSR. However, better long-term survival in patients with posterior VSR compared with those with anterior VSR was suggested by Skillington and colleagues [1]. Therefore, to achieve successful repair of posterior VSR with decreased mortality, it is important to decrease intraoperative bleeding and myocardial damage, to prevent the residual shunt and mitral insufficiency, and to maintain left ventricular geometry.
Certainly, Daggett’s method (using two prosthetic patches for closing the VSR and the defect created by infarctectomy) improved the surgical results of this catastrophic postinfarct complication [2–4]. However, the risk of bleeding from left ventriculotomy still remained because the suture lines are directly stretched by left ventricular pressure.
The infarct exclusion method described by David and associates was useful for restoration of left ventricular geometry, and minimizes the length of incision of the left ventricle [5]. However, the technical difficulty of direct closure of ventriculotomy without a patch still remains in cases of posterior VSR. The method reported by Pathi and associates was also useful in cases with widely excised infarcted posterior wall [6].
We modified the classical Daggett’s technique using three patches: a Dacron patch for the septal perforation, with both a Xenomedica and a composite patch (Dacron patch and autopericardium) for closing the left ventriculotomy. Fibrin glue was infused between the two patches used for ventriculotomy. The combination of two patches with fibrin glue was able to prevent bleeding from the suture lines in the left ventricular wall. This modification is a simple and effective way to decrease the surgical risk of this catastrophic postinfarct complication.
|
References
|
|---|
- Skillngton P.D., Davies R.H., Luff A.J., et al. Surgical treatment for infarct-related ventricular septal defects. J Thorac Cardiovasc Surg 1990;99:798-808.[Abstract]
- Daggett W.M. Surgical technique for early repair of posterior ventricular septal rupture. J Thorac Cardiovasc Surg 1982;84:306-312.[Medline]
- Daggett W.M., Buckley M.J., Akins C.W., et al. Improved results of surgical management of postinfarction ventricular septal rupture. Ann Surg 1982;196:269-277.[Medline]
- Daggett W.M. Postinfarction ventricular septal defect repair: retrospective thoughts and historical perspectives. Ann Thorac Surg 1990;50:1006-1009.[Abstract]
- David T.E., 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]
- Pathi V., Kumar R., Naik S. Inferoposterior ventricular septal rupture: repair with maintenance of ventricular geometry. Ann Thorac Surg 1995;60:719-720.[Abstract/Free Full Text]
Top
Abstract
Introduction
