Ann Thorac Surg 2003;76:622-623
© 2003 The Society of Thoracic Surgeons
Case report
Transatrial approach of acquired posterior ventricular septal rupture and double orifice technique in tricuspid valve repair
Mario Zogno, MDa,
Anna Maizza, MD, PhDa*,
Ernesto Tappainer, MDa,
Nicola Pederzolli, MDa,
Vinicio Fiorani, MDa,
Andrea Nocchi, MDa
a Cardiac Surgery Unit, "C. Poma" Hospital, Mantova, Italy
Accepted for publication December 23, 2002.
* Address reprint requests to Dr Maizza, Cardiac Surgery Unit, "C. Poma" Hospital, 46100 Mantova, Italy
e-mail: maizz30{at}hotmail.com
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Abstract
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We present a successful transatrial repair of ventricular septal rupture and tricuspid valve reconstruction, using the "edge-to-edge" technique, as a serious complication of a posterior myocardial infarction in an 83-year-old woman.
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Introduction
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Despite improvements in surgical technique, inhospital mortality after postinfarct ventricular septal rupture (VSR) repair remains high in most large series (20% to 40%), even in the most recent reports [1–5]. Repair of a postinfarction posterior VSR, usually performed by ventricolotomy in the infarct area, is technically challenging and carries a significant mortality and morbility [3–5]. A transatrial approach avoids incising through the acutely infarcted myocardium and offers a better exposition, especially for a high and posterior located rupture [6–8]. Factors contributing to a difficult exposition include the septal leaflet and the tendinous cords of the tricuspid valve. The defect can be readily exposed by detaching the septal leaflet from the annulus, or cutting the papillary muscle.
An 83-year-old woman, with the diagnosis of VSR as a serious complication of a posterior myocardial infarction (MI), was admitted to our hospital. After an initial low cardiac output syndrome, she was started on inotropic drug (dobutamin) and was stable with mild congestive failure. On day 9, despite the intraaortic balloon support and inotropic drugs, the patient developed cardiogenic shock (systolic pressure below 80 mm Hg, oliguria) and she was taken to the operating room. Standard cardiopulmonary bypass was established with bicaval venous and ascending aorta cannulation. The VSR was approached through the right atriotomy and was located by cutting the papillary muscle of the septal tricuspid leaflet (Fig 1).
The VSR was closed not with patch material, but with buttressed mattress sutures. The reconstruction of the tricuspid valve was performed using an "edge-to-edge" technique, as previously described [9]. The postoperative course was uneventful and the patient was discharged on day 8 after surgery.
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Fig 1. Intraoperative view of the ventricular septal rupture (forceps) through the transatrial approach, and the papillary muscle of the tricuspid septal leaflet (arrow).
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Comment
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In selected patients the aforementioned technique described is easily reproducible and represents a simple solution to a complex problem.
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References
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- Petre R., Ye Q., Grunenfelder J., Lachat M., Vogt P.R., Turina M.I. Operative results of "repair" of ventricular septal rupture after acute myocardial infarction. Am J Cardiol 1999;84:785-788.[Medline]
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Abstract
Introduction
