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Ann Thorac Surg 2009;87:1421-1425. doi:10.1016/j.athoracsur.2009.02.011
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Long-Term Results After Surgical Repair of Postinfarction Ventricular Septal Rupture by Infarct Exclusion Technique

Nestoras Papadopoulos, MDa,*, Anton Moritz, MD, PhDa, Omer Dzemali, MDa, Andreas Zierer, MDa, Amin Rouhollapour, MDa, Hanns Ackermann, PhDb, Farhad Bakhtiary, MD, PhDa

a Department of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Hospital, Frankfurt/Main, Germany
b Center of Health Science, Institute for Biostatistics and Mathematical Modelling, Johann-Wolfgang-Goethe University Hospital, Frankfurt/Main, Germany

Accepted for publication February 6, 2009.

* Address correspondence to Dr Papadopoulos, Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Theodor Stern Kai 7, Frankfurt/Main, 60590, Germany (Email: nestoras.papadopoulos{at}gmail.com).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Ventricular septal defect (VSD) is one of the most serious and life-threatening complications of acute myocardial infarction. The aim of this study was to evaluate the early and long-term results of the patients after surgical repair of postinfarction VSD by infarct exclusion technique.

Methods: A total of 32 consecutive patients (mean age, 62.5 ± 10.5 years) underwent postinfarction VSD repair using a standardized technique in our department. A retrospective analysis of clinical and operative data, predictors of early mortality, and long-term survival was performed. The localization of VSD was posterior in 50% and anterior in 50% of the patients.

Results: The hospital mortality was 31.2% (10 patients). The most common cause of hospital death was persistent low cardiac output. The mortality of the posterior VSD group was significantly lower than that of the anterior VSD group (18.7% and 43.7%, respectively, p = 0.01). Intra-aortic balloon pump support and absence of cardiac shock were significantly associated with a lower risk of hospital mortality (p = 0.0001 and p = 0.0009, respectively). The actuarial survival rates of in-hospital survivors at 5 and 10 years were 79% ± 2% and 51% ± 3%, respectively.

Conclusions: The repair of postinfarction VSD by the infarct exclusion is feasible and safe. This technique seems to offer sufficient favorable early and long-term results compared with other techniques. Early indication, preoperative intra-aortic balloon pump support may improve the surgical results. Preoperative cardiogenic shock carries a poor prognosis for this patient group.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
One of the most serious and life-threatening complications of acute myocardial infarction (MI) is the development of a ventricular septal defect (VSD). Septal rupture occurs in 1% to 2% of patients after acute MI. A sharp increase in the mortality rate of patients with VSD treated medically was observed in the first 3 weeks after VSD and was due to complications such as heart failure or cardiogenic shock, or both [1]. Hence, patients should be considered for urgent or emergent surgical repair, although the ideal time to operate on patients with VSD is after the replacement of the necrotic muscle by fibrous tissue.

David and colleagues [2, 3] introduced a new operative procedure in 1987, whereby both the left to right shunts can be eliminated and the ventricular remodeling and aneurysm formation of the infarcted myocardium can be prevented. This report describes our long-term results after surgical repair of postinfarction VSD, as described by David and colleagues [2, 3] for this high-risk group.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Between March 1995 and September 2007, a total of 32 consecutive patients underwent postinfarction VSD repair in our department. Data collection was performed retrospectively and focused on intraoperative and postoperative data, location of VSD, use of intra-aortic balloon pump (IABP), and perioperative complications. Data were also obtained for 30-day mortality, in-hospital mortality, and long-term outcome. The study was approved by the Johann Wolfgang Goethe University Ethics Committee; individual consent for the study was waived.

Preoperatively, echocardiography and coronary angiography were performed in all patients, whereas right-side heart catheterization was performed only in 8 patients. The mean left to right shunt was 51% ± 21.5%, and the mean left ventricular ejection fraction (LVEF) was 47.18% ± 18.57%. Seven patients (21.8%) were operated on within 24 hours after the septal rupture. Ten patients (31.2%) were referred to our unit within 2 to 7 days after the septal rupture, and another 15 patients (47%) were operated on between 8 and 35 days after the septal rupture. The operation was performed urgently 1 ± 1.4 days after admission to our department. The mean interval from infarct to operation was 9.3 ± 7.6 days, whereas the mean interval from onset of VSD and operation was 7.1 ± 6.7 days.

There were 12 women (37.5%) and 20 men (62.5%). The mean age was 62.5 ± 10.5 years (range, 43 to 77). Sixteen patients (50%) presented with posterior VSD and 16 (50%) with anterior VSD. Coronary angiography showed triple-vessel disease in 4 patients (12.5%), double-vessel disease in 13 patients (40.6%), and single-vessel disease in 10 patients (31.2% [right coronary artery stenosis in 7 patients and left anterior descending artery stenosis in 3]).

At the time of admission, 10 patients (31.2%) were in cardiogenic shock with low cardiac output. An IABP was inserted in 13 patients (40.6%) before operation. Table 1 contains patient demographics and preoperative risk profile of 32 patients.


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  		Table 1 Preoperative Clinical Profile
 
The operations were performed by five different surgeons. A repair by the endocardial patch technique with infarct exclusion as originally described by Dr Tirone E. David and associates [2–4] was performed in all patients. The basic steps were as follows: incision through the infarcted muscle to approach the intraventricular septum; identification of the VSD and the margins of the infarcted muscle; exclusion of infarct and VSD by a pericardial patch, which was sutured to the noninfarcted endocardium of the intraventricular septum and to the noninfarcted ventricular wall; and finally, closure of the ventriculotomy using prosthetic material such as bovine pericardium or Teflon (Impra Inc, subsidiary of L.R. Bard, Tempe, AZ) felt.

Myocardial revascularization was performed in all patients at the surgical repair. Excision of left ventricular aneurysm was required in 4 patients (12.5%). Other associated procedures included replacement of the ascending aorta in 1 patient, aortic valve reconstruction in 1 patient, and mitral and tricuspid valve reconstruction in 1 and 2 patients, respectively.

The mean cross-clamp time was 87 ± 24.4 minutes (range, 48 to 122) and cardiopulmonary bypass time was 166 ± 54.3 minutes (range, 70 to 270).

Statistical Analysis and Data Collection
All statistical analyses were performed with the Statview program (SAS Institute, Cary, NC). Categorical variables are expressed as percentage and were evaluated with the {chi}2 or Fisher exact tests. Continuous variables are expressed as mean ± SD, as well as median and range, and were evaluated using the Student t test. Logistic regression analysis was used to determine the predictors of survival and in-hospital mortality. Long-term survival was calculated by the Kaplan-Meier method. Follow-up information was collected between December 2007 and January 2008 by patient or physician contact. Operative mortality was defined as death within 30 days of operation. A p value less than 0.05 was considered as significant. The follow-up period ranged between 8 months and 12 years (mean follow-up time, 4.5 ± 4.4 years).


   Results
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 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
The in-hospital mortality was 31.2% (10 patients). One patient died on the day after operation as a result of rupture of the left ventricular free wall. The left ventricular free wall rupture was not a ventriculotomy dehiscence. It occurred in another site of the left ventricle by extended anterior MI. One patient died 2 days after operation and another died 12 days after operation after cardiac arrest. Seven patients died of persistent low cardiac output (22%). The mortality rate for the posterior VSD group was lower than for the anterior VSD group (19% and 44%, respectively; p = 0.01). We observed 1 recurrence of a posterior VSD (3%), which was successfully reoperated on 2 years after the first VSD repair.

Reexploration for postoperative bleeding or tamponade had to be performed in 3 patients (9%); renal failure occurred in 10 patients (31%) with need for continuous venovenous hemofiltration. Fourteen patients (44%) needed prolonged inotropic support (need for inotropic agents longer than 3 days) because of low cardiac output, and 7 (22%) required prolonged assisted ventilation. One patient (3%) had a neurologic event 1 week after the operation, and 1 patient (3%) had a complete atrioventricular block and required permanent pacemaker implantation. Five patients (12.5%) required extracorporeal membrane oxygen support owing to severe biventricular failure; 2 of them died within 30 days of operation.

The mean intensive care unit stay for survivors was 18.5 ± 35 days The mean hospital stay for patients who needed inotropic support because of low cardiac output was 39 ± 56 days, and for hemodynamically stable patients, it was 21 ± 21 days.

The following variables were tested for in-hospital mortality: age older than 60 years, VSD location, single- or multiple-vessel disease, cardiogenic shock, IABP support, one or more cardiovascular disease risk factors in the medical history, previous MI, renal insufficiency in the medical history, and left ventricular function. The influence of these variables on early mortality is illustrated in Table 2.


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  		Table 2 Risk Factors for In-Hospital Mortality
 
Late Outcome
All perioperative survivors who underwent VSD repair in our department have been followed from 8 months to as long as 12 years, with a mean follow-up of 4.5 years. The Kaplan-Meier estimate of survival after postinfarction VSD is illustrated in Figure 1.


Figure 1
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  		Fig 1. Kaplan-Meier survival curve. Five-year cumulative survival, 79% ± 2%; 10-year cumulative survival, 51% ± 3%. Numbers of patients at risk are shown in parentheses.

 
There were 6 late deaths. The causes of death were left-side heart failure (n = 2, 6%) and sudden death (n = 2, 6%). In 2 follow-up cases, it was impossible to report the precise cause of death. The actuarial survival rates of in-hospital survivors at 5 and 10 years were 79% ± 2% and 51% ± 3%, respectively.


   Comment
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 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
After the first reported surgical repair of a postinfarction VSD in 1957 by Cooley and colleagues [5], many surgeons attempted to develop new operative techniques to lower the high mortality rate that has been associated with this operative procedure.

In 1977, Daggett and coworkers [6] reported lower perioperative mortality rates achieved by the use of prosthetic material to replace necrotic muscle and by a transinfarct incision regardless of infarct location. Since that time, other classic operative techniques, including infarctectomy and reconstruction of the ventricular septum and free wall of the heart with Dacron (C.R. Bard, Haverhill, PA) patches, have been performed [7–9]. David and colleagues [2–4] introduced, in 1987, a new operative procedure, whereby both the left to right shunts can be eliminated, and the ventricular remodeling and aneurysm formation of the infarcted myocardium can be prevented. The prevention of additional damage of the already dysfunctional right ventricle and the restoration of the left ventricle geometry, by the above-described method, may be the reason it leads to a lower operative mortality rate [4].

Because of the very impressive results of using this technique, this operative procedure has been applied in all of the 32 consecutive patients who underwent repair of postinfarction ventricular septal rupture in our department between June 1995 and September 2007. In our series, the hospital mortality was 31.2%, a rate that is similar to the mortality reported in previous studies, especially the results of the last 10 years [10–14]. Indeed, the hospital mortality in our series was higher than the 19% mortality reported by David and Armstrong [15], who were using the same technique. Delay in surgical indication to repair VSD may result in multiple organ failure and early death [16].

In our series, we found also a significantly low mortality rate for the posterior VSD group (19%), which is similar to the mortality rate of the posterior VSD group reported by David and coworkers [4]. Conversely, the delay in surgical intervention for half our patients because of late admission through the cardiologists to our cardiac unit may explain our patients' outcomes.

Other studies also identify posterior VSD location as a risk factor for high mortality [11, 17–21] due to difficulties of the surgical exposition and repair or due to a higher incidence of right ventricular failure. Moore and colleagues [22] reported that the increased mortality in their series was due to a greater impairment of right ventricular function and greater elevation of right ventricular pressure. The repair of postinfarction VSD by infarct exclusion described by David and associates [4] seems to improve the results of surgery for patients with posterior VSD, as shown in our series. This technique may solve the difficulties of the posterior VSD repair, as this is physiologically sound and may leave the right ventricle undisturbed [4].

Other predictors of early mortality have been determined in our series. The influence of these variables on early mortality is illustrated in Table 2. As described by other groups, there is a high mortality rate for patients with preoperative cardiogenic shock, especially for those whose hemodynamic status is not improved by IAPB support [11, 12, 14–17, 23, 24].

Intra-aortic balloon counterpulsation, implantable turbine-pump, and percutaneous cardiopulmonary bypass support are counted among the different cardiac-assist devices available to cardiologists and cardiac surgeons to stabilize the patient after acute MI before operation. The basic goals of the less invasive IABP counterpulsation are to stabilize circulatory collapse, to increase coronary perfusion and myocardial oxygen supply, and to decrease left ventricular workload and myocardial oxygen demand. Counterpulsation has also been shown to be useful in achieving pulsatile cardiopulmonary bypass and in assisting high-risk patients through the operation [25]. In our series, preoperative IABP support and absence of cardiogenic shock were associated with a significantly lower risk of hospital mortality (p = 0.0001 and p = 0.0009, respectively). Based on this finding, we believe that patients with preoperative cardiogenic shock should be promptly treated with IABP, inotropic agents, and vasodilators before any diagnostic examination. Preoperative intra-aortic counterpulsation may increase cardiac output and improve coronary perfusion, and may lead to a decrease of the left to right shunt.

In all of our patients, we performed coronary artery angiography and myocardial revascularization before the repair of VSD, when a 70% stenosis existed. Because the hemodynamic status of the postinfarct VSD patient can suddenly deteriorate, some reports [17] strongly advise against coronary artery angiography. In our experience, none of our patients with septal rupture died during the angiography. We believe, as do others [4, 14, 23], that coronary artery angiography should be performed in every patient who can be stabilized hemodynamically. Patients in cardiogenic shock who cannot be stabilized with IAPB support or medical treatment should immediately undergo operation.

The incidence of residual VSD reported varies from as low as 4.7% [12] to as high as 43% [10]. Cox and colleagues [23] described a residual VSD in 22.9% of the patients in their series; 60% of them have undergone reoperation because of clinically significant shunt. In our series, only 1 patient (3.1%) received a redo procedure after 24 months of the first correction because of clinically significant residual shunt. The low incidence of residual VSD in our series as well as in the series by David and associates [4] may be explained by the application of the infarct exclusion technique with the suturing of the pericardial patch to the healthy endocardial tissue surrounding the infarcted muscle of the ventricular septum and the ventricular wall.

Several limitations of this study must be considered. In 2 follow-up cases, it was impossible to report precisely the cause of death, mainly because autopsy was not performed in these cases. Also, the study investigates a small number of patients. Overall, a larger number of patients are necessary to corroborate our findings.

Percutaneous closure of the smaller VSDs with catheter-based devices may now offer a different treatment option for critically ill patients who have a small postinfarction ventricular septal rupture [26]. However, the same authors raise concerns over the possibility of further increasing the size of the rupture and destroying the atrioventricular valves or the ventricles through the devices [27].

In conclusion, the repair of postinfarction ventricular septal rupture by the infarct exclusion technique described by David and associates [2–4] can be done safely. This technique seems to improve the results of surgery for patients who have posterior VSD and avoids the recurrence of the VSD after the first correction. From our data, it appears that preoperative cardiogenic shock carries a dismal prognosis. We support the strategy of preoperative IABP implantation as an important tool for the preoperative support of hemodynamically unstable patients with postinfarction ventricular septal rupture.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Fox AC, Glassman E, Isom OW. Surgically remediable complications of myocardial infarction Prog Cardiovasc Dis 1979;21:461-484.[Medline]
  2. David TE. Surgical treatment of postinfarction ventricular septal rupture Aust J Thorac Cardiovasc Surg 1992;1:7-10.
  3. Komeda M, Fremes SE, David TE. Surgical repair of postinfarction ventricular septal defect Circulation 1990;82:243-247.
  4. David TE, Dale L, Sun Z. Postinfarction ventricular septal rupture: repair by endocardial patch with infarct exclusion J Thorac Cardiovasc Surg 1995;10:1315-1322.
  5. Cooley DA, Belmonte BA, Zeis LB, Schnur S. Surgical repair of ruptured interventricular septum following acute myocardial infarction Surgery 1957;41:930-937.[Medline]
  6. Dagett WM, Guyton RA, Mundth ED, et al. Surgery for post-myocardial infarct ventricular septal defect Ann Surg 1977;186:260-271.[Medline]
  7. Balkanay M, Eren E, Keles C, Toker ME, Guler M. Double-patch repair of postinfarction ventricular septal defect Tex Heart Inst J 2005;32:43-46.[Medline]
  8. Matsuda K, Oda T, Terai H, Hanyu M, Ban T. New surgical technique for repair of ventricular septal perforation Ann Thorac Surg 1995;60:1430-1431.[Abstract/Free Full Text]
  9. Tabuchi N, Tanaka H, Arai H, et al. Double-patch technique for postinfarction ventricular septal perforation Ann Thorac Surg 2004;77:342-343.[Abstract/Free Full Text]
  10. Deja MA, Szostek J, Widenka K, et al. Post infarction ventricular septal defect—can we do better? Eur J Cardiothorac Surg 2000;18:194-201.[Abstract/Free Full Text]
  11. Dalrymple-Hay MJ, Monro JL, Livesey SA, Lamb RK. Postinfarction ventricular septal rupture: the Wessex experience Semin Thorac Cardiovasc Surg 1998;10:111-116.[Medline]
  12. Labrousse L, Choukroun E, Chevalier JM, et al. Surgery for post infarction ventricular septal defect (VSD): risk factors for hospital death and long term results Eur J Cardiothorac Surg 2002;21:725-732.[Abstract/Free Full Text]
  13. Prêtre R, Ye Q, Grünenfelder J, Lachat M, Vogt PR, Turina MI. Operative results of "repair" of ventricular septal rupture after acute myocardial infarction Am J Cardiol 1999;84:785-788.[Medline]
  14. Prêtre R, Ye Q, Grünenfelder J, Zund G, Turina MI. Role of myocardial revascularization in postinfarction ventricular septal rupture Ann Thorac Surg 2000;69:51-55.[Abstract/Free Full Text]
  15. David TE, Armstrong S. Surgical repair of postinfarction ventricular septal defect by infarct exclusion Semin Thorac Cardiovasc Surg 1998;10:105-110.[Medline]
  16. Heitmiller R, Jacobs ML, Daggett WM. Surgical management of postinfarction ventricular septal rupture Ann Thorac Surg 1986;41:683-691.[Abstract/Free Full Text]
  17. Skillington PD, Davies RH, Luff AJ, et al. Surgical treatment for infarct-related ventricular septal defects. Improved early results combined with analysis of late functional status. Thorac Cardiovasc Surg 1990;99:798-808.
  18. Hill JD, Stiles QR. Acute ischemic ventricular septal defect Circulation 1989;79:112-115.
  19. Fananapazir L, Bray CL, Dark JF, Moussalli H, Deiraniya AK, Lawson RA. Right ventricular dysfunction and surgical outcome in postinfarction ventricular septal defect Eur Heart J 1983;4:155-167.[Abstract/Free Full Text]
  20. Jones MT, Schofield PM, Dark JF, et al. Surgical repair of acquired ventricular septal defect. Determinants of early and late outcome. J Thorac Cardiovasc Surg 1987;93:680-686.[Abstract]
  21. Anderson DR, Adams S, Bhat A, Pepper JR. Post-infarction ventricular septal defect: the importance of site of infarction and cardiogenic shock on outcome Eur J Cardiothorac Surg 1989;3:554-557.[Abstract/Free Full Text]
  22. Moore CA, Nygaard TW, Kaiser DL, Cooper AA, Gibson RS. Postinfarction ventricular septal rupture: the importance of location of infarction and right ventricular function in determining survival Circulation 1986;74:45-55.[Abstract/Free Full Text]
  23. Cox FF, Morshuis WJ, Plokker HW, et al. Early mortality after surgical repair of postinfarction ventricular septal rupture: importance of rupture location Ann Thorac Surg 1996;61:1752-1758.[Abstract/Free Full Text]
  24. Chaux A, Blanche C, Matloff JM, DeRobertis MA, Miyamoto A. Postinfarction ventricular septal defect Semin Thorac Cardiovasc Surg 1998;10:93-99.[Medline]
  25. Lamberti JJ, Anagnostopoulos CE, Al-Sadir J, et al. Mechanical circulatory assistance for the treatment of complications of coronary artery disease Surg Clin North Am 1976;56:83-94.[Medline]
  26. Pienvichit P, Piemonte TC. Percutaneous closure of postmyocardial infarction ventricular septal defect with the CardioSEAL septal occluder implant Catheter Cardiovasc Interv 2001;54:490-494.[Medline]
  27. Birnbaum Y, Fishbein MC, Blanche C, et al. Ventricular septal rupture after acute myocardial infarction N Engl J Med 2002;347:1426-1432.[Medline]

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