Modified infarction exclusion technique for surgical treatment of postinfarction ventricular septal rupture

A ventricular septal rupture (VSR) is a fatal complication after an acute myocardial infarction. Surgical repair with an infarction exclusion technique (IET) has improved the surgical outcome for VSR. However, a residual shunt from the left ventricle to the right ventricle has been still one of the problems associated with this technique. We modified the IET so as to avoid the occurrence of the residual shunt In our modification, interrupted mattress sutures were placed transmurally to obtain a secure fixation of the pericardial patch. As for the interventricular septum, the VSR was enlarged to about 1.5 cm in diameter with a cavitron ultrasonic surgical aspirator to facilitate the placement of transmural sutures from the right ventricle to the left ventricle. We performed VSR repair with this modified IET in 3 patients, and have obtained beneficial results.     

Entire septal patch technique for postinfarction ventricular septal rupture

Postinfarction ventricular septal rupture is still a surgically challenging situation with high operative mortality. We report a case of ventricular septal rupture in a 75-year-old woman successfully treated with our newly devised technique, in which a pliable large septal path is fixed with transmural sutures placed in posterior left ventricular free wall and anterior ventriculotomy closing sutures, thus covering the septal wall almost entirely. Our method may simplify the operation and reduce the risk of residual leakage.     

Thrombolysis and postinfarction ventricular septal rupture.

We studied all patients with postinfarction ventricular septal rupture referred to the Oxford Heart Centre for operation over a 4 1/2-year period. Twenty one women and 8 men were admitted to the Centre, 13 of whom had received streptokinase and 16 of whom had not. The median interval between symptomatic onset of myocardial infarction and the development of septal rupture was 24 hours for those treated by early thrombolysis (all streptokinase) and six days for those who were not. Of the 26 patients who underwent surgical repair, three were operated on less than 36 hours after streptokinase infusion, in one case within 12 hours of thrombolytic treatment. Macroscopic observation of the disintegrating myocardium showed muscle bundles dissected by blood rendered incoagulable by thrombolytic treatment, together with the histologic features of reperfusion injury. The overall surgical mortality rate for the streptokinase group was 33% and for the others 21%. The patient operated on within 12 hours of thrombolytic treatment recovered uneventfully. Six of seven surgical deaths were caused by left ventricular or biventricular failure and one by gastrointestinal hemorrhage. All survivors were in New York Heart Association classes II or III between 2 weeks and 4 1/2 years after operation. We conclude that thrombolysis leads to early breakdown of the interventricular septum after acute myocardial infarction but does not preclude early repair.     

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.     

Surgical management of postinfarction ventricular septal rupture

Recognition and treatment of patients with ventricular septal rupture following infarction have improved over the past 25 years to the extent that survival with good long-term palliation is achieved in the majority of patients treated surgically for this catastrophic complication of acute myocardial infarction. The small minority of patients who, by the process of selection, are seen for surgical correction of septal rupture several weeks after infarction routinely have repair of the septal defect with an operative risk of less than 10%. With increasingly early diagnosis of septal rupture, the majority of patients are seen for consideration of surgical repair often within hours after septal rupture. Most such patients seen early after septal rupture exhibit cardiogenic shock. Refinement of operative techniques both for suture repair of freshly infarcted myocardium and for repair of defects in different anatomical locations has markedly improved survival in these critically ill patients. Deferral of operation for the patient in cardiogenic shock after septal rupture represents a failed therapeutic strategy. Conversely, emergency operation for the patient with septal rupture and cardiogenic shock has markedly improved survival in this high-risk group. Prolonged intraaortic balloon pump support and deferred operation should be reserved for the uncommon patient who, because of delayed diagnosis or referral, is seen in an advanced stage of multisystem failure in which the risks of early operative intervention involve the function of organs other than the heart.     

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.     

急性心肌梗死室间隔破裂的外科治疗

目的 探讨急性心肌梗死后室间隔破裂的发病特点、手术时机及治疗效果。方法 自１９８５年￣１９９９年共收治２０例急性心肌梗死后室间隔破裂患者,其中１４例行手术治疗,６例内科治疗,分析２组临床资料及治疗结果,并对手术治疗组进行随访４个月￣１４年。结果 ６例内科治疗的患者,于室间隔破裂后６ｈ￣７ｄ内全部死亡;１４例手术治疗的患者中,４例采用折叠每缝合修补室间隔破裂,１０例行补片修补,全部同期行室壁瘤切除,     

Sutureless patch technique for postinfarction left ventricular rupture

BACKGROUND: Left ventricular free wall rupture is an uncommon but catastrophic event after myocardial infarction and is associated with a high mortality. After prompt diagnosis some patients may be salvaged with immediate surgical intervention. Surgical techniques used to seal the rupture vary, as few surgeons have experience with this pathologic process. We report our experience using a sutureless patch technique to treat this entity. METHODS: A review of 6 consecutive patients during an 8-year period who were referred to one cardiac unit with postinfarction left ventricular rupture was conducted. RESULTS: There were 3 men and 3 women with an average age of 71.8 years. All were hemodynamically unstable, and 4 were in electromechanical dissociation. Echocardiography confirmed the diagnosis in 5 patients, and cardiac catheterization had been performed in 4 before rupture. All patients were treated promptly with fluid, inotropic agents, and, if needed, cardiopulmonary resuscitation and pericardiocentesis. Resuscitation was continued in the operating room, and the myocardial tear was sealed with a generous patch of unsupported felt secured to the heart with cyanoacrylate glue. Coronary artery bypass grafting was performed in 3 patients if the anatomy was known. All patients survived to the intensive care unit. One death occurred as a result of severe neurologic injury. Five patients were discharged from the hospital, and all were alive 2 months to 7.5 years after operation. CONCLUSIONS: A sutureless patch technique for the treatment of postinfarction rupture is simple, effective, and associated with a favorable outcome.     

Improved results of surgical management of postinfarction ventricular septal rupture.

Fifty-five patients had surgical repair of postinfarction ventricular septal rupture in Massachusetts General Hospital from 1968 through 1981. In patients operated more than three weeks after infarction, hospital survival has been 93% (14/15). Before 1975 in patients operated less than three weeks after infarction, hospital survival was 41% (7/17). In this same era patents operated for septal rupture with cardiogenic shock present before operation had a hospital survival rate of only 27% (3/11). Before 1975 patients with cardiogenic shock were supported with intra-aortic balloon pumping (IABP) and vasopressors, and operation deferred pending hemodynamic stabilization. Before 1975 patients with anterior septal rupture had a hospital survival rate of 64% (9/14), while patients with posterior septal rupture had a hospital survival rate of only 38% (5/13). This difference in survival according to the location of septal rupture occurred despite comparable numbers of patients in each group requiring early operation, as well as incidence of cardiogenic shock. Since January 1, 1975 patients operated less than three weeks after infarction have had an overall hospital survival rate of 70% (16/23). Of the 10 most recent patients operated early, nine are survivors. In patients with anterior defects 85% (11/13) survived, while in patients with posterior defects 67% survived (10/15). In patients operated with cardiogenic shock present before operation, survival has been 67% (10/15). Changes in management leading to improved results include (1) immediate operation for patients with cardiogenic shock, (2) cold cardioplegic protection of the myocardium, and (3) prosthetic replacement of posterior left ventricular free wall defect, after infarctectomy and septal repair, in patients with posterior septal rupture.     

Double patch technique for repairing postinfarction ventricular septal defect

We report 2 cases in which the double patch technique was used to repair an anterior postinfarction ventricular septal defect. To do this, we modified infarct exclusion as follows: In addition to a conventional patch excluding the infarcted muscle, another small patch is used to directly close the septal defect. Gelatin-resorcin-formal glue is applied between the double patches, which prevent the glue from being washed away and enhance it to polymerize stably, thereby rapidly stabilizing the infarcted myocardium with the endocardial patch. Echocardiography immediately after operation showed the infarcted septum had completely adhered to the endocardial patch. Both patients demonstrated satisfactory postoperative hemodynamics. Although 1 patient did well, the other died 6 months postoperatively due to complications of pneumonia and gastrointestinal bleeding secondary to colon carcinoma. This double patch technique appears useful, although further experience is needed to verify its safety and efficacy.     

Role of myocardial revascularization in postinfarction ventricular septal rupture

BACKGROUND: Postinfarction ventricular septal rupture requires urgent closure. The role of systematic coronarography and coronary revascularization needs clarification. METHODS: Fifty-four patients who underwent patch closure of postinfarction ventricular septal defect were reviewed. A coronarography had been systematically and myocardial revascularization selectively (when significant coronary artery stenosis existed) performed. RESULTS: No patient died or deteriorated during coronarography. Twenty-six patients showed no coronary artery disease besides the infarct-related artery, and 28 had associated disease. Threatened myocardial territories were revascularized usually with venous grafts (mean number of distal anastomosis, 2.5). Operative mortality was 19% and 32% (p = 0.36) and late mortality 43% and 53% (p = 0.75) in patients without and in patients with associated coronary artery disease, respectively. Survival curve in both group was similar, at least up to 8 years after operation. CONCLUSIONS: Myocardial revascularization controlled the added risk of associated coronary artery disease in the postoperative period and in median term. A coronarography should be performed in all patients who can be stabilized hemodynamically and myocardial revascularization performed in case of significant stenosis.     

Clinical experience with gelatin-resorcine-formol glue for repair of postinfarction ventricular septal rupture]

We report a surgical technique for treatment of postinfarction ventricular septal rupture (VSR). An 82-year-old woman underwent successful surgical repair of a VSR two days after suffering anterior myocardial infarction. After repair of the VSR with a Dacron patch, the left ventriculotomy was closed with mattress sutures over felt strips using the gelatin-resorcine-formol glue to reinforce the left ventricular wall. The patient was doing well four months after surgery.     

Infarct exclusion for postinfarction left ventricular free wall rupture with severe congestive heart failure

A 70-year-old man was transferred to our hospital with severe congestive heart failure and ventricular arrhythmia due to acute myocardial infarction. He had experienced chest pain 3 weeks previously and was admitted to another hospital for dyspnea, where he required assist ventilation, 1 week prior to the transfer. An echocardiogram revealed a broad anteroseptal infarction and very poor left ventricular function with an ejection fraction (EF) of 22%. He remained in a severe congestive heart failure condition despite a full administration of catecholamines. Coronary angiogram findings revealed an occlusion of the proximal left anterior descending coronary artery and 1 week later severe hypotension was suddenly presented. An echocardiogram showed pericardial effusion with signs of cardiac tamponade. A pericardiocentesis was performed and hemodynamic improvement was obtained for a short time, after which the patient underwent urgent open heart surgery. During the operation, exclusion of the anteroseptal akinetic area using an oval patch was performed under a cardiopulmonary bypass and ventricular fibrillation. Severe cardiac failure remained postoperatively and the patient could not be weaned from cardiopulmonary bypass, therefore, we implanted a percutaneous cardiopulmonary support (PCPS) and started intraaortic balloon pumping (IABP). The patient was weaned from PCPS at 26 days after surgery and from IABP at 30 days. Following hospital release, he has continued to do well without heart failure for 39 months after the operation.     

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.     

Sutureless technique for oozing type postinfarction left ventricular free wall rupture

We report our experience using a sutureless technique for oozing type postinfarction left ventricular free wall rupture. Several materials such as fibrin seat, autologous or heterologous pericardial patch, fibrin glue, and geratin-resorcin-formaldehyde (GRF) glue have been used. Nine patients, who developed postinfarction left ventricular free wall rupture, underwent surgical repair using a sutureless technique between 1999 and 2004. All patients survived and discharged our hospital without any postoperative complications. And all are alive an exellent condition in 5 to 44 months. A sutureless technique for the treatment of oozing type postinfarction left ventricular free wall rupture is simple, effective, and associated with a favorable outcome.