Postinfarction ventricular septal rupture: can we improve clinical outcome of surgical repair?

The left ventricular "lining" technique for repair of ischemic ventricular septal rupture

We describe a technique to repair ischemic ventricular septal rupture via a left ventriculotomy. It employs a large endoventricular patch as a "lining" over the locally patched septal defect and the free wall defect which is going to be roofed with an external patch. Both defects are then closed in double layers, holding a single continuous patch. The technique enhances the advantage of the left ventriculotomy in the repair and minimizes ventriculotomy-related morbidity.

Clinical characteristics, prognostic factors, and outcomes of ventricular septal rupture in patients with acute myocardial infarction

Ventricular septal rupture (VSR) is a rare but devastating complication in patients with acute myocardial infarction (AMI). This was a retrospective single-center observational study which aimed to assess the characteristics and outcomes of VSR patients and identify risk factors for in-hospital mortality of VSR patients in the era of percutaneous intervention. Patients with VSR after AMI at the First Affiliated Hospital of Xi'an Jiaotong University from January 2016 to December 2020 were enrolled. Among 5395 consecutive patients with AMI, 42 patients (0.78%) were diagnosed with VSR. Left anterior descending coronary artery was the culprit vessel in most cases (84.4%, 27/32). In the multivariate analysis, female sex (odds ratio (OR): 14.043, 95% confidence interval (CI): 1.396-141.283, p = 0.025) and lower platelet count on admission (OR: 0.979; 95% CI: 0.963-0.995; p = 0.009) were significant risk factors of in-hospital death in VSR patients. In all, 11 patients (26.2%) underwent surgical repair, and the rest were treated medically. The 1-year mortality was lower in the surgical group (36.4%, 4/11) than that in the conservative group (74.2%, 23/31) (p = 0.034). During the follow-up, VSR patients treated surgically tended to have a higher long-term survival rate than those treated medically (log rank χ² = 5.005, p = 0.025). The prognosis of patients with VSR remained poor in this study. Female sex and lower platelet count were independent risk factors of in-hospital death in VSR patients. The long-term survival rate of patients treated with surgical repair was significantly better than that of patients treated conservatively.

Management and outcome of post-myocardial infarction ventricular septal rupture-A Low-Middle-Income Country Experience

BACKGROUND

Ventricular septal rupture (VSR) is a rare complication after acute myocardial infarction (AMI) especially in the reperfusion era but its associated mortality has remained high. This case series evaluated in-hospital and intermediate-term mortality in VSR patients. Additionally, we also analyzed risk factors, clinical presentation, intervention, and predictors of in-hospital mortality in VSR patients.

METHODS

Data of 67 patients with echocardiography confirmed diagnosis of VSR from January 2011 to April 2020 was extracted from hospital medical records. Records were also reviewed to document 30 day and 1-year mortality, recurrent heart failure admission, repeat myocardial infarction, and revascularization. In addition, telephonic follow-up was done to assess health-related quality of life(HRQOL) assessed by KCCQ-12. SCAI shock classification was used to categorize severity of cardiogenic shock. Univariate and multivariable logistic regression was used to determine predictors of in-hospital mortality. Survival function was presented using the Kaplan-Meier survival curve.

RESULTS

Mean age of patients was 62.7 ± 11.1 years, 62.7% were males. 65.7% of the patients presented more than 24 hours after MI and did not receive reperfusion therapy. Median time from AMI to VSR diagnosis was 2 (1-5) days. VSR closure was attempted in 53.7% patients. In-hospital mortality was 65.7%. At univariate level, predictors of in-hospital mortality were non-surgical management, basal VSR, right ventricular dysfunction, early VSR post-MI, and severe cardiogenic shock at admission (class C, D, or E). Adjusted predictors of in-hospital mortality included non-surgical management, basal VSR and advanced cardiogenic shock. There were 5 deaths during median followup of 44.1 months. HRQOL in patients available on followup was good (54.5%) or excellent (45.5%).

CONCLUSION

High in-hospital mortality was seen in VSR patients. VSR closure is the preferred treatment to get long-term survival, however, timing of repair as well as severity of cardiogenic shock plays a significant role in determining prognosis.

Ventricular septal rupture after blunt chest trauma: a case report

Cardiac injury, including myocardial contusion and valvular damage, is a common complication of blunt chest trauma; however, traumatic ventricular septal rupture is a rare complication. We encountered a rare case of ventricular septal rupture following blunt chest trauma that was successfully repaired by emergency surgery. The mechanism underlying rupture may involve acute compression of the heart between the sternum and the vertebral column when the ventricle is filled, thereby causing a sudden increase in intraventricular pressure and leading to septal rupture. Emergency operation should be considered in cases of large defects and hemodynamic instability.

Outcomes of surgical repair of anterior or posterior ventricular septal rupture after myocardial infarction

BACKGROUND

Ventricular septal rupture (VSR) is a rare and fatal complication of myocardial infarction. Surgery is the main treatment for the condition. It is currently believed that surgery is less effective for posterior VSR than for anterior VSR. The objective of this study was to investigate the clinical outcomes of surgical treatment for myocardial infarction combined with an anterior or posterior VSR.

METHODS

This was a single-center, retrospective, observational, cohort study. Clinical data of 68 patients with myocardial infarction combined with VSR were retrospectively analyzed. According to the site of the VSR, patients were divided into the anterior (43 cases) and posterior (25 cases) VSR groups, and the general clinical data, preoperative examination results, surgery, and follow-up results were compared between the two groups.

RESULTS

Compared with the anterior VSR group, the operative time in the posterior VSR group was longer {300 [240, 360] vs. 360 [300, 400] min; P=0.003}, and the cardiopulmonary bypass time was longer (142.0±52.2 vs. 180.2±52.3 min; P=0.005), and the aortic clamp time was longer (84.0±32.5 vs. 115.9±39.8 min; P=0.001). There were no significant differences in the incidence of perioperative complications, including bleeding, low cardiac output, pulmonary, and cerebrovascular complications, and the incidence of perioperative death between the two groups (P>0.05). The patients were followed up for 1.0-10.5 (median, 4.2) years. There were no significant differences in the survival rate and the incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) including myocardial infarction, heart failure, revascularization, and cerebrovascular events between the two groups (P>0.05).

CONCLUSIONS

The perioperative risks and medium- and long-term outcomes of the surgical repair of anterior or posterior VSR after myocardial infarction were similar.

Urgent repair of postinfarct ventricular septal rupture with ECPELLA support: A case report

A 74-year-old woman developed inferior myocardial infarction due to right coronary artery occlusion and underwent percutaneous coronary intervention. Two days later, echocardiography revealed ventricular septal rupture, and Impella CP was inserted to avoid emergency surgery. However, the patient's hemodynamics deteriorated rapidly, necessitating additional venoarterial extracorporeal membranous oxygenation support with concomitant Impella support (ECPELLA). The ventricular septal rupture was surgically repaired using the extended sandwich technique via a right ventricular approach; the ascending aorta was clamped with the clampable portion of the Impella. The patient was successfully weaned from the Impella 3 days postsurgery. This case suggests that urgent surgery with ECPELLA support could be a useful option for patients with ventricular septal rupture, even in severe cases wherein emergency surgery is unavoidable.

Extended sandwich patch technique via right ventriculotomy for acute ventricular septal rupture

BACKGROUND

Surgical repair for post-infarction ventricular septal rupture (VSR) was still a challenging operation, especially when required in the acute phase or posterior VSR. ''Extended sandwich patch" technique is characterized by large double patches fixed by circumferential transmural large mattress sutures via right ventricle incision. In the present study, we report early and mid-term clinical and echocardiographic outcomes of this technique.

METHODS

Of 33 consecutive patients undergoing VSR repair using the extended sandwich patch technique between 2008 and 2018, 25 received surgery within 1 week from the onset of myocardial infarction (early group and 8 after 1 week (late group), including 12 patients with posterior VSR. All patients underwent surgery within 24 hours of VSR diagnosis.

RESULTS

Intraoperative transesophageal echo identified no residual shunt, but 2 patients received reoperative VSR repair at 9 days and 2 months after the first VSR repair. The 30-day mortality and one-year survival in the early and late groups were 20% and 12.5%, and 58% and 88%, respectively. After VSR repair, right and left heart chamber sizes were significantly decreased and these improvements were stable throughout the subsequent follow-up period (median 4.0 years). Tricuspid annular plane systolic excursion and right ventricular fractional area change remained constant throughout the observation period without changing after VSR repair.

CONCLUSIONS

The extended sandwich patch technique through a right ventriculotomy offered safe and simple, leak-free repair even in technically demanding acute phase or posterior VSR. No significant decline was found in the right heart function after surgery.

Sandwich repair for postinfarction ventricular septal rupture and left ventricular rupture

A 77-year-old woman who presented with chest pain was diagnosed with acute anterior myocardial infarction. Echocardiography revealed pericardial effusion, and she underwent sutureless repair for postinfarction left ventricular free wall rupture. Echocardiography performed 2 days postoperatively revealed ventricular septal rupture and left ventricular acute dilatation. Hemodynamic instability with ventricular tachycardia and rapid decline of kidney function developed. Four days after the primary surgery, we performed successful sandwich repair for ventricular septal rupture and the dilatation. Her postoperative course was uneventful, and postoperative evaluation did not show a residual shunt or left ventricular dilatation.

Structural Heart Disease Emergencies

Structural heart disease (SHD) emergencies include acute deterioration of a stable lesion or development of a new critical lesion. Structural heart disease emergencies can produce heart failure and cardiogenic shock despite preserved systolic function that may not respond to standard medical therapy and typically necessitate surgical or percutaneous intervention. Comprehensive Doppler echocardiography is the initial diagnostic modality of choice to determine the cause and severity of the underlying SHD lesion. Patients with chronic SHD lesions which deteriorate due to intercurrent illness (eg, infection or arrhythmia) may not require urgent intervention, whereas patients with an acute SHD lesion often require definitive therapy. Medical stabilization prior to definitive intervention differs substantially between stenotic lesions (aortic stenosis, mitral stenosis, left ventricular outflow tract obstruction) and regurgitant lesions (aortic regurgitation, mitral regurgitation, ventricular septal defect). Patients with regurgitant lesions typically require aggressive afterload reduction and inotropic support, whereas patients with stenotic lesions may paradoxically require β-blockade and vasoconstrictors. Emergent cardiac surgery for patients with decompensated heart failure or cardiogenic shock carries a substantial mortality risk but may be necessary for patients who are not eligible for catheter-based percutaneous SHD intervention. This review explores initial medical stabilization and subsequent definitive therapy for patients with SHD emergencies.

How to anastomose a patch to avoid residual leak in the infarct exclusion method

BACKGROUND AND AIM

Postinfarction ventricular septal defect is a potentially lethal complication of acute myocardial infarction for which surgical repair is mandatory. The infarct exclusion method has contributed to improving surgical outcomes, but a certain percentage of residual leakage continues to be reported. We considered possible mechanisms of residual leakage and modified the sewing method to overcome these mechanisms.

METHOD

A bovine pericardial patch and a Teflon felt strip between the patch and endocardium to achieve good fit were used. The patch and felt were anchored with U stay sutures and reinforced with a running suture.

RESULTS

Use of the modified method in seven cases showed improved outcomes. Only one patient had trivial leakage, compared to nine cases using the older method; six of nine patients had residual leaks, including three minor ones.

CONCLUSIONS

Our method is a rational approach that effectively reduces residual leakage.

Heartbreak: A case of post-infarction cardiogenic shock

Ventricular septal rupture is a rare but catastrophic complication of acute myocardial infarction. Although it has declined in incidence since the introduction of percutaneous coronary intervention, there hasn't been a significant change of mortality from the condition. In the chain of survival, prompt diagnosis and definitive surgery form the cardinal links. Prolonged medical management is not a feasible option as it is likely to be futile but the aim should be to reduce afterload with the help of intra-aortic balloon pump or support with ventricular assist devices. Echocardiography sits at the heart of the diagnosis of this time critical condition and will guide accurate therapy and intervention. We present the first reported case from an Australian emergency department, where the echocardiography done by the emergency physician clinched the diagnosis. We emphasise here the paramountcy of emergency physicians being proficient in basic echocardiography to achieve rapid diagnosis. Once diagnosed it is critical to have an individual case-tailored multi-disciplinary discussion between emergency medicine, cardiothoracic surgery, cardiology and intensive care as to plan the optimal timing of surgery.

Left Ventricular Aneurysm After Post-Infarction Ventricular Septal Defect Repair

The surgical indication and optimal approach for ischemic mitral regurgitation with ventricular septal defect remain uncertain. Very few studies have reported the occurrence of left ventricular aneurysms after repair of ischemic ventricular septal defects. We report a case of a left posterior ventricular aneurysm that developed after an urgent operation to repair an acute ischemic posterior ventricular septal defect using the double-patch sandwich technique via a right ventriculotomy.

Modified Double Patch Repair for Septal Rupture With Ventricular Wall Dissection

Ventricular septal rupture with ventricular free wall dissection is an extremely rare complication after inferior myocardial infarction, and the optimal surgical strategy remains unclear because of the limited number of survival cases. Electrocardiography-synchronized contrast computed tomography was performed before surgery to identify the dissected area and to set up a surgical strategy. We report on modified double patch repair with ventricular wall dissection exclusion, which might be effective for preventing residual shunt and maintaining cardiac function.

A modified multi-patch technique for double-layered repair of ischemic posterior ventricular septal rupture

BACKGROUND

The rupture of the posterior ventricular septum after acute inferior myocardial infarction is more challenging to repair than ruptures in other sites since it is less accessible and anatomically restricted. We described a modification of Daggett's original technique of multi-patch repair of ruptured posterior septum.

CASE PRESENTATION

The technique was employed in the operation of a 67-year-old male who presented with severe heart failure at the 10th day after he developed inferior myocardial infarction. His ventricular septum had ruptured at the level between the posteromedial papillary muscle and the mitral annulus. A large endoventricular patch covered separately over the locally patched septal defect and the ventriculotomy defect which was going to be roofed eventually with an external patch. Both defects were then individually closed in double layers, holding a single continuous patch in common. The common use of a single patch expedited multilayered closure of the left ventricular defects and could minimize geometric remodeling of the covered area. The patches on both the endocardial and the epicardial sides avoided potentially fatal bleeding from the ventriculotomy site. The transmural mattress sutures incorporating ventriculotomy patches required minimal bites toward the posteromedial papillary muscle and mitral annulus, thereby preserving the mitral valve function.

CONCLUSIONS

Thus, the technique enhances the advantage of the left ventriculotomy in the repair of posterior septal rupture and avoids ventriculotomy-related morbidity.

Modified double patch repair with infarct exclusion technique for ventricular septal perforation: a case study

Background

Ventricular septal perforation (VSP) after acute myocardial infarction (AMI) is accompanied by the worsening of rapid hemodynamics, resulting in a poor prognosis. In our department, infarct lesions are preoperatively detected with electrocardiogram (ECG)-synchronized contrast computed tomography, and the scope of approach and exclusion is determined. Furthermore, to effectively prevent a residual shunt, modified double patch repair and infarct exclusion techniques were used in combination to preserve left ventricular (LV) function. This method is reported because it considers both techniques as a surgical procedure that can be accomplished relatively easily and simultaneously.

Case presentation

We targeted two consecutive VSP patients who underwent this procedure. It took an average of 1 day from the onset of VSP to surgery. We performed double patch and infarct exclusion for VSP using bovine pericardium via an LV incision. Two patches were marked with a skin pen to anastomose eight mattresses equally. In addition, a one piece-coupled patch was made for infarct exclusion. The two patients were extubated on the day after surgery and intra-aortic balloon pump assistance was also withdrawn. Without perioperative complications, they could leave the intensive care unit after 6.5 days on average. Early postoperative ECG and magnetic resonance angiography showed good LV wall contraction, except at the infarcted area, with no evidence of a residual shunt.

Conclusion

The modified double patch repair with infarct exclusion technique is more effective for preventing a residual shunt and maintaining postoperative cardiac function than either of the techniques alone.

Pitfalls for the "Sandwich technique" via a right ventricular incision to repair post-infarction ventricular septal defects

BACKGROUND

We have reported "sandwich technique," via a right ventricular incision, to treat a post-infarction ventricular septal defect (VSD). This technique involves the placement of patches on both the left and right sides of the septum, pinching the VSD sealed with surgical adhesive between the two patches. In this study, we analyzed factors influencing 1-year mortality to determine the pitfalls in our procedure.

METHODS

We evaluated 24 consecutive patients with post-infarction VSD who underwent the "sandwich technique" via a right ventricular incision. One-year survival and major residual leak were used as the criteria for the analysis of survival and technical success, respectively. In protocol 1, clinical variables were evaluated as predictors of one-year mortality. In protocol 2, surgical techniques were evaluated as predictors of major residual leak, which was found to be related to one-year mortality in protocol 1.

RESULTS

In protocol 1, the one-year mortality was higher in patients with major residual leak (75 %, 3/4) than in those without (15 %, 3/20) (p = 0.035). In protocol 2, the patients with major residual leak had smaller patches than those without (41.9 ± 3.8 vs. 47.8 ± 4.8 mm, p = 0.031) and a smaller size difference between the patches and the VSD (22.5 ± 6.5 vs. 30.0 ± 5.7 mm, p = 0.028).

CONCLUSION

For the "sandwich technique" via a right ventricular approach to treat post-infarction VSD, the choice of patch size according to VSD size is an important variable for reducing major residual leak.