Ann Thorac Surg 2009;88:692-694. doi:10.1016/j.athoracsur.2008.11.049
© 2009 The Society of Thoracic Surgeons
How To Do It
Two-Patch Technique for Postinfarction Inferoposterior Ventricular Septal Defect
Hiroshi Imagawa, MD*,
Shinnji Takano, MD,
Takahiro Shiozaki, MD,
Masahiro Ryugou, MD,
Fumiaki Shikata, MD,
Kanji Kawachi, MD
Organ Regenerative Surgery, Ehime University School of Medicine, Ehime, Japan
Accepted for publication November 20, 2008.
* Address correspondence to Dr Imagawa, Organ Regenerative Surgery, Ehime University School of Medicine, To-on, Ehime, 791-0295, Japan (Email: imagawa{at}m.ehime-u.ac.jp).
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Abstract
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We describe 4 patients with postinfarction inferoposterior ventricular septal defect treated by the two-patch technique for infarct exclusion operation. The ventricular septal defects were closed using two bovine pericardial patches as follows. The septal patch was sutured to the noninfarcted septum covering the defect, and the free wall patch was sutured to the endocardium adjacent to the posterior papillary muscle. The two patches were sutured together and all infarcted areas were excluded from the left ventricular pressure. This technique seems to be useful in specific circumstances, such as when the ventricular defect is located in the inferoposterior septum.
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Introduction
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Postinfarction ventricular septal defect (VSD) complicates 1% to 2% of all patients with acute, myocardial infarction and its natural course is ominous [1]. Despite improved diagnostic modalities and aggressive surgical strategies, the postinfarction VSD remains therapeutically challenging, especially when infarctions are located in the inferoposterior septum [2]. Here, we describe 4 patients with postinfarction inferoposterior VSD treated by infarction exclusion operation using a two-patch technique.
Between April 1997 and October 2006, 4 consecutive patients (aged 61 to 82 years; 2 males and 2 females) underwent repair of postinfarction inferoposterior VSD. Preoperative demographic characteristics in 4 patients are listed in Table 1. All patients underwent coronary angiography on admission, which indicated a single-vessel disease in 3 patients and double-vessel disease in 1. Every patient needed support of inotropic agents and an intra-aortic balloon pump (IABP). All underwent surgery within 9 days of myocardial infarction.
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Technique
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The operation was performed using total cardiopulmonary bypass with bi-caval drainage and a left ventricle (LV) venting tube. Cardiac arrest was obtained by antegrade and retrograde blood cardioplegia. The heart was lifted from the apex using a heart positioner (Starfish; Medtronic Inc, Minneapolis, MN) to expose the posterobasal aspect. A longitudinal incision was made in the LV myocardium parallel to and 10 mm from the posterior descending artery. Debridement of the fragile infarcted septum was not performed. We prepared one septal and one free wall patch using two pieces of xenopericardium (Equine Pericardial Patch; Edwards Lifesciences, Irvine, CA). The septal patch was attached to the noninfarcted area of the basal septum covering the defect using 5-0 polypropylene continuous sutures with a 22-mm needle 
c (D9525; Ethicon Inc, Somerville, NJ). The free wall patch was also continuously sutured using the same sutures, avoiding damages to the surrounding tissue, including the posterior papillary muscle. Some mattress sutures were added to fit the patch to the LV wall. The two patches were joined and then sutured together fitting the size and shape to the LV chamber (Fig 1). The infarcted area was entirely excluded from LV pressure. We closed the ventriculotomy simply over two strips of Teflon felt (Meadox Medical Inc, Oakland, NJ) using 4-0 interrupted full-thickness, horizontal mattress sutures.
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Fig 1. Shows operative procedures. (A) A longitudinal incision was made in the left ventricular myocardium parallel to and 10 mm from the posterior descending artery. The septal patch sutured covered the ventricular septal defect (VSD) using 5-0 polypropylene sutures. (B1) The free wall patch is easily sutured to the endocardium, adjacent to the posterior papillary muscle. The short-axis image shows infarct lesion, including the VSD, as well as two patches. (B2) The dotted arrow indicates ventriculotomy. (C) Both patches are sutured together, and the entire infarcted myocardium is excluded. (APM = anterior papillary muscle; PPM = posterior papillary muscle; VSD = ventricular septal defect.)
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Results
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We concomitantly performed coronary artery bypass grafting to the left circumflex coronary artery using the left radial artery in 1 patient. Mean aortic cross-lamp time was 128 minutes (82 to143 minutes). There were no operative deaths, although 1 of 4 patients died 3 months after surgery due to extant cerebral damage and renal failure (patient No. 4). Early postoperative echocardiographic studies revealed moderate leakage in 1, mild in 1, and trivial in 2.
Echocardiography at 1 year after surgery showed trivial residual shunt in 1 and none in two. Three patients were categorized into the New York Heart Association functional class 1 at the outpatient clinic and no additional cardiac events were observed during follow-up. Discussion of Cooley and colleagues [3] reported the first surgical repair for postinfarction ventricular septal defect in 1957. Daggett and colleagues [4] have improved both surgical prognosis and cardiac function after surgery. Komeda and colleagues [5] have originated the "infarct exclusion operation," which significantly decreased the surgical mortality rate.
However, the surgical results of treating postinfarction VSD in the inferoposterior septum have remained unsatisfactory. In the setting of compromised circulation supported with inotropics and an intra-aortic balloon pump, the repair must be directed to a simple, but effective technique with a minimal risk for residual or recurrent leak. The infarction exclusion operation for inferoposterior VSD is technically demanding, because deep, big sutures may damage ischemic fragile surroundings, including the posterior papillary muscle of the mitral valve.
The completion form after our procedure is the same as that of David infarct exclusion operation. The following two points seem to be of critical importance for success of David's infarct exclusion in patients with inferoposterior infarction. First, the septal side of the patch should be draped over the infarct lesion including VSD. Second, the free wall side should be sutured with watching papillary muscle apparatus, otherwise the big, deep bites would damage papillary muscles or inappropriate sutures would cause cuttings and also residual shunting. Use of two patches that are to be sutured separately would provide a fundamental solution for the difficulties with David's infarct exclusion. Our alternative manner has made the big, deep bites with the patch simple and safe because the surrounding tissue, including the posterior papillary muscle, was visible and confirmable while suturing (Fig 2).
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Fig 2. The frontal view of the left ventricle (A) demonstrates postinfarction inferoposterior ventricular septal defect (VSD) (arrow) and an incision (see dotted line) and (B) two patches covering and excluding the VSD. This technique has made the big, deep bites around the posterior papillary muscle simple and safe, because the surrounding tissue, including the papillary muscle was visible and confirmable while suturing. (IVS = interventricular septum; PPM = posterior papillary muscle; RV = right ventricle.)
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Moreover, when the two patches were sutured together, the size and shape could be easily fitted to the LV chamber [6]. This modification brought securing the visual field and preventing difficulties with sutures around the papillary muscle, as well as regulating the length of the patches.
In summary, the two-patch technique could be an effective tool in the infarct exclusion operation for postinfarction VSD located in the inferoposterior septum. Further experience is needed to verify its safety and efficacy.
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References
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- Topaz O, Taylor AL. Interventricular septal rupture complicating acute myocardial infarction: from pathophysiologic features to the role of invasive and noninvasive diagnostic modalities in current management Am J Med 1992;93:683-688.[Medline]
- 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]
- Cooley DA, Belmonte BA, Zeis LB, Schnur S. Surgical repair of ruptured interventricular septum following acute myocardial infarction Surgery 1957;41:930-937.[Medline]
- Daggett WM, Guyton RA, Mundth ED, et al. Surgery for post-myocardial infarct ventricular septal defect Ann Surg 1977;186:260-271.[Medline]
- Komeda M, Fremes SE, David TE. Surgical repair of postinfarction ventricular septal defect Circulation 1990;82(5 Suppl):243-247.
- Shibata T, Suehiro S, Ishikawa T, Hattori K, Kinoshita HI. Repair of postinfarction ventricular septal defect with joined endocardial patches Ann Thorac Surg 1997;63:1165-1167.[Abstract/Free Full Text]
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Abstract
Introduction
