Postinfarction ventricular septal perforation; tips of patch closure

There are several techniques, such as patch closure and David procedures, for surgical repair of postinfarction ventricular septal perforation (VSP). In any operation, postoperarive low output syndrome (LOS) and residual shunt are serious problems. We prefer to use patch closure method and we have some tips to prevent LOS and residual shunt. (1) Minimal part of the ventricular septum is resected. 4-0 SH-1 polypropylene mattress sutures reinforced with Teflon pledget are placed away from the edge of VSP. Stunned myocardium around VSP might recover after operation. (2) Sutures are placed about 2 cm inner of a large xeno-pericardial patch. Even if myocardial cutting and left-right shunt flow occurs, an excessive xeno-pericardium, like a skirt, should be caught by the left ventricular pressure. This might cover and close the 'residual shunt'. We applied this technique to 6 VSP patients, and the results were good.     

Minimally invasive transatrial repair of posterior left ventricular aneurysm

Left ventricular aneurysms (LVA) are a complication of myocardial infarction, that rarely involve the posterior wall; surgical repair of posterior LVA poses a technical challenge when associated with concomitant mitral regurgitation. We describe a minimally invasive treatment of ischemic MR and concomitant patch exclusion of posterior LVA through a right minithoracotomy. Using a transatrial approach, the aneurysm is closed with a “U” shaped dacron patch, whose base is anchored to the mitral annulus. Two patients were operated by this method with excellent results.     

Early operation for postinfarction ventricular septal perforation; report of three cases

Three patients underwent surgery for postmyocardial infarction ventricular septal perforation (VSP) within 3 to 21 days after onset of infarction. The hemodynamic stabilization was not obtained despite aggressive medical treatment including Intra-aortic Balloon Pumping (IABP) in one patient. The others had sudden hemodynamic deterioration during IABP support. In two of the three cases, the VSP were closed via transinfarct ventriculotomy with double Dacron patch, and ventricular wall reconstruction was performed to sandwich the double septal patch between ventricular free walls with Dacron felt strips. Two of the three patients survived. Our experience suggests that early surgical intervention is essential unless medical therapy results in clinical improvement and the double patch method may provide a successful operative repair and comeout.     

Surgical management of trabecular ventricular septal defects: the sandwich technique

BACKGROUND: Surgical closure of trabecular ventricular septal defects is difficult and often unsuccessful. OBJECTIVE: We performed closure of trabecular ventricular septal defects by sandwiching the septum between 2 polyester felt patches placed in the left ventricle and right ventricle without ventriculotomy. METHODS: Eleven patients (7 boys and 4 girls) underwent a sandwiching closure at a mean age of 4.7 years (range, 0.4-9.7 years) and a mean weight of 16.7 kg (range, 4.6-52 kg). Associated cardiac malformations were present in 9 of the 11 patients. Seven patients had undergone previous operations. The trabecular ventricular septal defects are exposed through the tricuspid valve and also from the left ventricular side through a coexisting large perimembranous ventricular septal defect or through the mitral valve through an interatrial septostomy. Two forceps, one each from the right and left ventricular side, lead a 3F Nelaton catheter through the trabecular defect. An oversized circular polyester felt patch mounted on a 3-0 Nespolen suture attached to the Nelaton catheter is then passed into the left ventricle. The suture ends are then passed through a slightly smaller polyester felt patch on the right ventricular side of the septum. The Nespolen suture is then tied, thereby sandwiching the septum between the 2 patches. RESULTS: Time required for the procedure was less than 20 minutes in each case. There were no hospital deaths, and the postoperative course was uneventful in all patients. There was no residual shunt in 3 patients, and a minimal residual shunt was observed in 5 patients. Mild residual shunt was observed in 3 patients. Cardiac catheterization was performed 1 month postoperatively in 8 patients in whom residual shunt was noted on echocardiography. Five of 8 patients had a minimal residual shunt (pulmonary blood flow/systemic blood flow ratio = 1.0). Three patients had a residual shunt (pulmonary blood flow/systemic blood flow ratio = 2.0, 1.6, and 1.2). The patient with a pulmonary blood flow/systemic blood flow ratio of 2.0 had a "Swiss cheese" ventricular septal defect, and a residual shunt remained around the patch. However, the residual shunt decreased to a pulmonary blood flow/systemic blood flow ratio of 1.6 at examination 16 months postoperatively. Echocardiography showed that the residual shunt had also decreased in another 2 patients. CONCLUSIONS: We conclude that the sandwich technique is safe and easy. Even in cases with a residual shunt present, the shunt is expected to decrease as time passes. Further experience and longer follow-up of these patients are necessary to conclude whether this technique is applicable to neonates and young infants.     

Posterior ventricular septal perforation successfully repaired through right ventricular approach

A 65-year-old man underwent a successful repair of a posterior ventricular septal perforation (VSP) 9 days after suffering an acute inferior myocardial infarction. After hospitalization, his hemodynamic condition gradually worsened, in spite of administering intensive medical therapy. Emergent operation was performed on the 4th day after onset. An equine pericardial patch was sutured around the VSP through the right ventricular side of the septum using the double-patch repair method and the right ventricular wall was closed as using the standard extracorporeal perfusion technique. The dimensions of the VSP measured 5 mm in diameter. Transesophageal echocardiography was performed on the 14th postoperative day. Cardiac catheter examination was done on the 18th postoperative day. No residual shunt was recognized and cardiac function was good. He was discharged on the 20th postoperative day. The occurrence of a posterior VSP is comparatively rare, and repair of VSP is difficult to perform during an acute period. Therefore, the operative results of VSP cases remain poor.     

A surgical case of ventricular septal perforation after repairing left ventricular free wall rupture.

A 78-year-old woman with diagnosis of acute myocardial infarction (AMI) in the anteroseptal area fell into cardiogenic shock suddenly just before starting percutaneous coronary intervention (PCI). Echocardiography showed left ventricular free wall rupture, then an emergent operation was performed by sutureless patch repair using collagen fleece with fibrinogen-based impregnation. Eight days later from the initial operation, the onset of ventricular septal perforation (VSP) was recognized. Fifteen days after, the infarct exclusion technique with endocardial patch was performed. She has been doing well 4 months after the operation without residual shunt. To our best knowledge, this is the first surgical case report that free wall rupture of left ventricle and VSP which are serious complications after myocardial infarction happened in succession.     

A successful transatrial repair of post-infarction ventricular septal defect]

A 63-year-male underwent successful operation for the ventricular septal perforation (VSP) caused by the inferior myocardial infarction. As the condition was stable, an operation was performed at the 43rd day after onset of myocardial infarction. Exposure was obtained by the opening the right atrium and retracting the tricuspid valve. The defect was in the posterior portion of the ventricular septum and closed using a Dacron patch. His postoperative course was uneventful. Postoperative examinations show no residual shunt. We believe that this approach may offer reduced mortality and morbidity in a selected group of patients with acquired posterior VSP, by avoiding such complications as further trauma to the ventricle, hemorrhage, and arrhythmias.     

Anomalous left anterior descending coronary artery from pulmonary artery with ventricular septal defect

Anomalous origin of the left anterior descending coronary artery with associated congenital defects is very rare. An angiogram of a 47-year-old woman admitted for a ventricular septal defect closure revealed an anomalous left anterior descending coronary artery arising from the left posterior sinus of the pulmonary artery. During the surgical procedure, the origin of the left anterior descending coronary artery was closed with pledgetted polypropylene sutures through the pulmonary artery. The ventricular septal defect was closed with a patch through the right atrium, and the left anterior descending coronary artery was bypassed with the left internal mammary artery.     

Suture biomechanics and static facial suspension

BACKGROUND: Static facial suspension (SFS) continues to play a role for rehabilitation in patients with facial paralysis. We perform SFS almost exclusively with a suture technique in our practice. Monofilament polypropylene suture (Prolene) is commonly used for SFS, but we have witnessed occasional failure and some stretching with this material. The purpose of this study was to establish and compare the biomechanical properties of 3 suture types-polypropylene, polybutilate-coated braided polyester (PBCP) (Ethibond Excel), and braided polyester impregnated with polytetrafluoroethylene (PIP) (Tevdek)-to assess their suitability for SFS. METHODS: Six samples of 0, 2-0, and 3-0 polypropylene, PBCP, and PIP were tested. The mean load to failure was calculated for each suture type. Stiffness and elongation at specific loads were calculated to compare stretch between materials. RESULTS: The load to failure of PBCP and PIP was significantly greater than that for polypropylene for all suture sizes. In addition, PBCP and PIP had significantly less elongation than did polypropylene at clinically relevant loads. CONCLUSIONS: Both PBCP and PIP had superior load-bearing properties and decreased stretch when compared with polypropylene. These properties suggest that, for SFS with suture, use of PBCP or PIP may reduce the incidence of breakage and elongation, improving outcomes.     

A successful surgical repair of ventricular septal perforation following acute myocardial infarction in a 83-year-old man

A 83-year-old man, who experienced a sudden severe malacia 13 days before, was admitted, complaining of dyspnea since 8 hours before. A loud systolic murmur of Levine IV/VI was audible on the left sternal border of the 4th intercostal space. The chest X-ray film demonstrated severe pulmonary congestion. The ECG showed abnormal Q waves in II, III, a VF and V1-5. The right heart catheterization revealed an intraventricular shunt from left to right and thus ventricular septal perforation (VSP) 13 days after acute anteroseptal-inferior myocardial infarction was diagnosed. Continuing an aggressive medical treatment with the intraaortic balloon pumping, an emergency operation for VSP was performed 2 days after the onset. A single Teflon patch was sutured on the left side of the septum around VSP (2.5 x 2.5 cm) and the ventricular free wall was closed including the patch with two felt strips. The patient survived through the operation and is doing well at the 11 months of follow-up. Twenty patients above 70 years old have been surgically treated with success for VSP after acute myocardial infarction in Japan. Our patient was the oldest.     

Repair of postoperative residual shunt of postinfarction ventricular septal perforation: report of a case

A 70 year-old man had the surgical repair of post-infarction ventricular septal perforation (VSP) with infarction exclusion technique. Five days after operation, residual shunt was observed by echocardiogram and he developed cardiac failure. Additional surgery for residual shunt was performed 1 month after 1st operation. The infracted myocardium was firm enough to closed directly, so the Xenomedica patch was sutured on the side of the perforated septum around VSP. The postoperative course was uneventful.     

Left ventricular aneurysmectomy in patients with poor left ventricular function.

Physical performance and left ventricular (LV) function in the resting state were assessed in 22 patients with postinfarction anterior-apical left ventricular aneurysm (LVA) and global ejection fraction less than or equal to 20% who subsequently underwent radical LVA resection. The basic findings in the 20 survivors of surgery were significant improvement of global systolic LV function and more or less complete recovery of regional ejection fraction in the predominantly viable low and high lateral LV wall. This improvement was evident in patients with concomitant bypass grafting as well as in those with isolated and ungraftable lesions of the left anterior descending (LAD) coronary artery. We conclude that postinfarction anterior-apical LVA in a poorly functioning LV is suitable for surgical treatment, which can be accomplished with acceptable risk. All graftable stenotic major coronary arteries should be bypassed, in addition to the LVA resection, but a minority of patients with isolated, ungraftable LAD disease are likely to benefit from aneurysmectomy alone.     

Repair of ventricular septal perforation with asymmetrical conical patch exclusion

We report a case of repair of the postinfarction ventricular septal perforation (VSP), using an equine pericardium tailored in an asymmetrical conical shape for exclusion (modified sack technique) and an additional direct patch closure of VSP. An asymmetrical conical patch is easily sutured to the normal septum away from the VSP edge by using the longer part of the cone border. The postoperative left ventriculogram 1.5 months after surgery revealed a minor leakage from the patch to the excluded left ventricle. However, no residual left to the right shunt was found in calculation from the oxygen saturation in blood samples. Echocardiography 1 year after surgery showed no residual patch leakage at all. We suggest that this modified sack technique is a simple and easy method by which to exclude the VSP.     

Left ventricular performance after patch reconstruction of the left ventricular wall for postinfarction left ventricular aneurysms]

Left ventricular performance in patients with a left ventricular aneurysm (LVA) treated with patch reconstruction is largely unknown. This study consisted of 15 patients, 14 men and 1 woman, with the average age of 59 +/- 8.5 years. The resected area of LVA was 40 +/- 27 cm2. The area of the woven Dacron patch used for reconstruction was 57 +/- 19% of the resected area including the sewing rim. The EF (Ejection Fraction, 1/3FF (Filling Fraction) and PFR (Peak Filling Rate) were calculated by 99mTc equilibrium cardiac pool scintigraphic images. The A/R ratio (peak velocity during atrial kick phase/peak velocity during the rapid filling phase) was measured using Doppler echocardiography, at the mitral orifice level. These parameters were determined before and 1 to 2 months after the operation. The time course was followed for A/R ratios. The preoperative resting global EF was 0.28 +/- 0.14 (0.44 +/- 0.13 for the contractile area) and the EF during exercise was 0.31 +/- 0.14. Resting and exercise EFs improved significantly (p < 0.01) to 0.40 +/- 0.11 and 0.43 +/- 0.10 postoperatively. The 1/3FF (%) and PFR (/sec) were low before operation (1/3FF, 11.3 +/- 8.3; PFR, 1.2 +/- 0.47). Postoperatively, the 1/3FF rose to 14.8 +/- 9.3 and the PFR showed a significant (p < 0.05) increase to 1.6 +/- 0.6. The A/R ratio significantly (p < 0.05) improved from preoperative 1.76 +/- 0.46 to 0.95 +/- 0.11 on the 3rd postoperative day. This improvement was maintained until the late postoperative period, with a value of 1.14 +/- 0.29 at month 16.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical repair of postinfarction ventricular septal perforation by endocardial patch with infarction exclusion]

We evaluated the surgical results of postinfarction ventricular septal perforation by endocardial patch with infarction exclusion. MATERIALS AND METHODS: We reviewed 8 patients complicating AMI who underwent surgical treatment at our institution from July 1997 to August 2000 (6 males, 2 females, mean age 73.9 +/- 9, range 57-87). The localization of AMI and VSP was anterior in 6 patients, inferior in 2. All patients had coronary angiography preoperatively. And 7 patients had the percutaneous transluminal coronary angioplasty of the infarct artery. RESULTS: There were 2 hospital deaths due to cerebral infarction and pulmonary hemorrhage. All deaths occurred in patients with cardiogenic shock. CONCLUSION: Good results were obtained by infarction exclusion technique. Better operative results may be expected with the preoperative coronary angioplasty of the infarct artery.     

Surgical repair of postinfarction ventricular septal rupture.

OBJECTIVES: Postinfarction ventricular septal rupture is fatal without surgical repair because of heart failure and secondary multiple organ failure. We investigated surgical results of postinfarction ventricular septal rupture and discussed the surgical strategy of postinfarction ventricular septal rupture. METHODS: Twelve patients (mean age 71.3 +/- 7.4 years, with range from 61 to 81 years) underwent surgical repair of postinfarction ventricular septal rupture, from 1990 to 1998 in our Institute. There were 6 women and 6 men. The ventricular septal rupture was anterior in 10 patients and inferior in 2. The operative technique for anterior ventricular septal rupture was reconstruction of the septum with a Dacron patch after infarctectomy, according to the method of Daggett et al. For posterior ventricular septal rupture, reconstruction of the septum with a Dacron patch after infarctectomy was performed and the ventricular incision was closed with a two-layer patch. Coronary artery bypass grafting was performed in 5 patients for severe proximal coronary artery stenosis using saphenous vein grafts. RESULTS: Overall hospital mortality was 0%. A postoperative residual shunt was recognized in 3 patients, but all were well-controlled conservatively and re-operation was not needed. The patients have been followed up for a mean of 59.5 months. There have been two late deaths due to non-cardiac problems. Acturial survival rate for the 12 patients was 90% at 1 year and 75% at 5 years. CONCLUSIONS: The Daggett method is simple and fast, and is an effective and reliable technique for the repair of ventricular septal rupture.     

Total right ventricular exclusion procedure: an operation for isolated congestive right ventricular failure

OBJECTIVE: To prevent possible deleterious effects of right ventricular volume overload on cardiorespiratory function, we developed a total right ventricular exclusion procedure for the treatment of end-stage isolated congestive right ventricular failure. METHODS: Since 1996, this procedure has been performed in 5 patients in New York Heart Association functional class IV: 2 adults with arrhythmogenic right ventricular dysplasia and 3 children with Ebstein anomaly. The entire right ventricular free wall was resected along the atrioventricular groove and then parallel to the interventricular septum, sparing the pulmonary valve and a skeletonized right coronary artery. The orifice of the tricuspid valve was closed with either a polytetrafluoroethylene patch or with its leaflets. The defect of the right ventricular free wall was covered with a polytetrafluoroethylene patch in the 2 patients with arrhythmogenic right ventricular dysplasia and directly closed with the remnant of the free wall in the 3 children with Ebstein anomaly. After resection of a redundant right atrial wall, coronary sinus blood flow was rerouted into the left atrium through an atrial septal defect. A total cavopulmonary connection was constructed in 4 patients and a bidirectional superior cavopulmonary anastomosis in 1 infant. The heart was controlled with a DDD pacemaker in 3 patients. RESULTS: The patients were extubated at a mean of 14 hours postoperatively (range, 1-38 hours). There were no early or late deaths. At follow-up, ranging from 8 to 57 months, the mean cardiothoracic ratio had decreased from 74% +/- 7% before the operation to 52% +/- 6% (P <.01). All patients are in functional class I. Neither of the patients with arrhythmogenic right ventricular dysplasia have had attacks of ventricular tachycardia nor are they using antiarrhythmic medication. CONCLUSIONS: The total right ventricular exclusion procedure provides effective decompression of the lung, as well as the left ventricle, and may result in more effective volume loading of a surgically created single ventricle with increased systemic output. We believe that this new surgical option offers rescue treatment for isolated end-stage right ventricular failure in critically ill patients.     

Double-patch technique for postinfarction ventricular septal perforation

A modified infarct-exclusion technique for postinfarction ventricular septal perforation is presented. The perforation is closed directly by a small patch next to the conventional patch, and biological glue is applied between the patches to induce stable polymerization. The patch stuck to the infarcted septum, and no residual shunt was observed in any patient because the wide adhesion prevents excessive pressure on the suture line. Seven of 9 patients in whom this method was used had good results. This technique appears suited for repair of ventricular septal perforations, especially those with extensive fresh infarction.     

Aortic valve regurgitation with aorto-right ventricular fistula following penetrating cardiac injury

Aortic valve perforation due to a penetrating cardiac injury is extremely rare, especially with an associated shunt between the right ventricle and the aortic valve. We report here the case of an 18-year-old male, who after suffering a chest stab injury, was seen at another institution where he underwent an emergency left anterolateral thoracotomy and right ventricular suture. During the following 30 days, his course was torpid, complicated by a ventilator-associated pneumonia and heart failure with acute pulmonary edema. Workup confirmed the presence of an acute aortic regurgitation due to perforation of the right coronary leaflet with an interventricular shunt. After implementing appropriate medical treatment, the valve was replaced with a mechanical prosthesis and the shunt was closed with an autologous pericardial patch.     

Technique for insertion of the inflow cannula of the INCOR left ventricular assist device

Our insertion technique for the inflow cannula of the INCOR left ventricular assist device (Berlin Heart AG, Berlin, Germany) is as follows. The apex ring is secured to the left ventricular apex using eight horizontal mattress sutures with full-thickness bites of myocardium. Another eight horizontal mattress sutures are then placed first through the Dacron felt pledgets (DuPont, Wilmington, DE) of the previously placed mattress sutures and then through the myocardium, the apex ring, and the suture collar of the inflow cannula. A double purse-string 3-0 polypropylene suture is placed on the Dacron pledgets around the apical hole and tightly tied.