Transatrial repair of post-infarction ventricular septal defect

A 72-year-old woman presented with a post-infarction ventricular septal defect, presumably within 10 days after the onset of acute myocardial infarction. An emergency surgery was performed because of hemodynamic instability. Using the sandwich patch technique, we approached the posteriorly oriented defect through a right atriotomy and detached tricuspid valve. By avoiding either left or right ventriculotomy, additional damage to the already infarcted ventricle and risk of bleeding were avoided. The patient showed an uneventful postoperative recovery, with no residual shunt detected. A transatrial approach combined with a sandwich patch technique is a good alternative in cases where the pathological anatomy is suitable.     

A successful repair of post-infarction left ventricular free wall rupture

Left ventricular free wall rupture secondary to acute myocardial infarction is almost invariably fatal. This report is the case presentation of a successful repair of left ventricular free wall rupture. A 55-year-old man, with a diagnosis of acute infero-lateral myocardial infarction, was transferred from another hospital to our CCU having recurrent chest pain on the fourth day after infarction. Shortly after admission, he lost his consciousness and fell into cardiogenic shock. Echocardiography showed a large pericardial fluid. He was immediately transferred to the operating room with the diagnosis of the heart rupture. After opening the pericardium containing 200 cc of blood, cardiac tamponade was relieved. The posterolateral portion of the left ventricle was found to be bluishly discolored, with a 8 mm-long tear of epicardium. Using cardiopulmonary bypass, the tear was closed with Teflon-reinforced sutures. The post-operative course was uneventful.     

'Double patch and glue' technique for early repair of posterior post-infarction ventricular septal defect

A surgical procedure that reduces the recurrence of post-infarction posterior ventricular septal defects is described. This technique is based on a double ventriculotomy without an infarctectomy, the use of two patches, and glue, which is applied between the two patches. Excellent results have been obtained in 18 consecutives patients with this simple and reliable technique.     

Transaortic repair of ventricular septal defect

A technique is described for repairing defects of the interventricular septum using an aortotomy incision. This approach allows excellent access to the membranous septum, where more than 80% of defects occur. While the standard transventricular or transatrial approach serves best in most instances, the transaortic exposure may be a useful alternative in the small defect, to avoid ventriculotomy, or in some complicated anomalies.     

A modified infarct exclusion technique for a post-infarction ventricular septal defect.

BACKGROUND: Operative mortality for a post-infarction ventricular septal defect (VSD) remains high. The infarct exclusion technique has been producing a favorable outcome for repairing this serious defect. However, there is the technical weakness, namely running suture along the base of the necrotic septum. We sutured a pericardial patch using multiple interrupted mattress sutures in such a manner as to exclude the infarct and VSD. METHODS: Over the past seven years, nine consecutive patients with a post-infarction VSD underwent an early repair in the same manner. The VSD was anterior in eight patients and posterior in one. We sutured a xenopericardial patch to the healthy myocardium around the infarct using interrupted mattress sutures instead of running sutures as the infarct exclusion technique. In addition, on the postero-inferior margin of the patch, one or two mattress sutures passing through the full thickness of the anterior papillary muscle were used. RESULTS: Only one patient died of pneumonia 50 days after surgery. The other eight patients were followed up and were functionally classified as NYHA class I or II. CONCLUSIONS: These findings suggest that our modified infarct exclusion technique using multiple mattress sutures is an effective alternative surgical technique.     

Three cases of successful early operations of post-infarction ventricular septal perforation

We reviewed three cases who underwent early operations for post-infarction ventricular septal perforation. Three patients were 56-year-old male, 66-year-old female, and 62-year-old female. These three cases had sustained antero-septal infarction with perforation. The periods to operations were 11 days, 86 hours, and 76 hours from the onsets of myocardial infarction. And 70 hours, 51 hours, and 42 hours from the onset of postinfarction ventricular septal perforation. Operations were performed after cardiac standstill using cold potassium cardioplegia and topical cooling. At first ventricular infarctectomy was performed and a large Teflon patch was used to create the septum after resection of the necrotic septum, and then resulting defect in the right and left ventricles was closed with Teflon strips and interrupted mattress sutures, incorporating the patch in the repair. Postoperative clinical courses were not smooth, but all the cases were going well. So we believed to get good results for early operations of post-infarction ventricular septal perforation, unless operative chances were lost.     

Liberal use of tricuspid valve detachment for transatrial ventricular septal defect closure

BACKGROUND: Although temporary tricuspid valve detachment is useful for improved visualization of ventricular septal defect through right atriotomy, liberal use of this adjunct is not widely supported, mainly because of concerns about iatrogenic complications such as heart blocks and tricuspid valve dysfunction. The objective of this study was to determine whether liberal use of this adjunct can improve operative outcome. METHODS: Between January 1997 and March 2002, trans-atrial closure of isolated ventricular septal defect (conoventricular or canal type) was performed in 87 consecutive patients. Tricuspid valve detachment was used in 4 out of 44 patients (prudent-use group) and 19 out of 43 patients (liberal-use group) in the first and second half of this period, respectively (p = 0.0002). Patient demographics and use of other surgical and cardiopulmonary bypass techniques remained virtually unchanged during this period. RESULTS: In the prudent-use group, there was one operative death with prolonged bypass time and one residual defect that required reoperation; neither of these patients underwent tricuspid valve detachment. All other patients (both groups) were free from mortality and clinically significant complications, including heart block, tricuspid regurgitation, and residual defect. The liberal-use group had shorter cardiopulmonary bypass time than the prudent-use group (59 +/- 14 vs 67 +/- 22 minutes, p = 0.037). CONCLUSIONS: Tricuspid valve detachment should be used liberally for moderate- or even low-difficulty exposure of ventricular septal defect, regardless of patient background, because it is a safe and effective adjunct that can improve speed, programmability, reproducibility, and reliability.     

A successful surgical treatment of postinfarction posterior ventricular septal defect through a right ventricular approach]

A 72-year-old man with acute postinfarction ventricular septal defect located posteriorly underwent successful operation through a right ventricular approach. Following cardiac catheterization revealed posterior ventricular septal defect with 82% left to right shunt ratio and coronary angiography showed three vessel disease, emergency operation was performed. The defect was exposed through anterior right ventriculotomy and closed by a teflon patch sutured right side of the interventricular septum, with added bypass grafting to left anterior descending artery. Postoperative course was uneventful and postoperative cardiac catheterization showed no residual shunt with patent bypass graft. He was discharged from our hospital about 2 months after operation.     

Surgical treatment of post-infarction ventricular septal defect without concomitant myocardial revascularization

Twenty one patients suffering from rupture of the ventricular septum (RVS) following acute myocardial infarction were operated upon between 1982-1985. Eighteen patients were operated upon urgently within 9.3 +/- 2.1 hours following diagnosis of RVS. In all, RVS occurred during the first infarction. None had concomitant myocardial revascularization. There were twelve operative survivors for an operative mortality of 42.5%. Two patients died 6 and 9 months postoperatively. All survivors are in functional class I, during a follow-up period of 14 to 56 months. The need for urgent repair of RVS is stressed and the value of concomitant coronary artery bypass is discussed.     

Surgical repair of postinfarction ventricular septal defect: modified Komeda-David procedure]

Since Cooley first reported surgical repair of postinfarction ventricular septal defect in 1957, there have been technical improvements in this procedure. However, the outcome of surgery has not been gratifying thus far. In 1990, Komeda and associates reported a single patch of bovine pericardium sutured to the healthy myocardium around the infarcted area on the left side of the septum that excludes the infarcted myocardium from the left ventricular cavity; a procedure based on a completely different idea. Since the satisfactory outcome of the surgical treatment in this procedure was obtained in a series of 12 patients, this surgical procedure has been in widespread use in Japan. On the other hand, this procedure has a drawback that there is a difficulty in suturing the patch and may lead to a postoperative residual shunt. We investigated a modified surgical procedure that could overcome this difficulty and would like to report it in this paper. At first, the perforated area should be covered with a felt strip and closed with mattress sutures. Secondly, the infarcted myocardium from the left ventricular cavity should be obliterated using a two-patch method. The primary advantage of this procedure is that it achieves a broader range of vision than a single patch method and enables easy suturing. Additionally, the development of a residual shunt can be prevented owing to the closure of perforation even if sutures fail to hold and leakage occurs. The tow-patch method has the advantage of avoiding tension against sutures since the patch is not everted around the sutures. However, the question arises whether only the healthy myocardium can be picked out and sutured without fail. In order to make the two-patch method more reloable the perforation should be closed in advance.     

Transatrial repair of postinfarction posterior ventricular septal defect

Repair of a postinfarction posterior ventricular septal defect generally has been performed by ventriculotomy in the infarct zone. This approach carries a significant mortality and morbidity from hemorrhage, extending infarction, or further compromise of ventricular function secondary to suture placement. A successful transatrial repair of a postinfarction posterior ventricular septal defect is presented. The simplicity of this operation and the patient's rapid recovery contrasted remarkably with the transventricular approach used in previous patients.     

Treatment of post-infarction ventricular septal perforation

Recently clinical course of ventricular septal perforation following myocardial infarction is made clear. It is concluded that postinfarction ventricular septal perforation constitutes a surgical emergency. However, cardiac function of these patients are not fully evaluated, as full-cardiac catheterization including coronary angiography is hazardous. The timing of surgical intervention must be determined according to the non-invasive evaluation such as echocardiogram. In this report, we review our experience with postinfarction ventricular septal perforation and attempt to determine from this review the management of these patients. Our cases are classified into three categories. Group 1 showed cardiogenic shock state after onset of ventricular septal perforation. Group 2 had severe congestive heart failure and required inotropic support. Group 3 had moderate congestive heart failure. Group 1 need emergency operation. Group 2 need intraaortic balloon support and respiratory support after the onset. After then surgical intervention should be considered. Group 3 can be operated on more than 6 weeks after myocardial infarction on an elective basis.     

Transcatheter closure of post-infarction ventricular septal defect with the Amplatzer Septal Occluder device

There is an 80-90% mortality rate within the first 2 months of the occurrence of a post-infarction ventricular septal defect (VSD) with medical treatment alone. The muscular VSD presents a technical problem for the surgeon. Surgical treatment was unsuccessful in two patients. They were treated successfully using the Amplatzer Septal Occluder, with improvement in their condition.     

Surgical experience of closure of ventricular septal defect with special reference to the transatrial approach

One hundred patients underwent closure of ventricular septal defect (VSD) during the years 1964-1977. The right transventricular approach was used in 92, the left ventricular in one, the pulmonary artery in one and the transatrial in the remaining 18 patients. Six patients (5.3%) died following operation. All of them suffered from severe pulmonary vascular resistance. Six patients have been reoperated successfully because of residual shunt. The transatrial approach is being used at present as a routine for closure of types II and III of VSD, particularly in patients with pulmonary vascular resistance. All the surviving 106 patients are in class one and two of the NYHA. At present, closure of VSD in asymptomatic patients is being performed electively at the ages of three to five, whereas symptomatic children, with high pulmonary vascular resistance and heart failure not responding to medical treatment, are operated on early in life usually with the use of deep hypothermic arrest.