Postinfarct ventricular septal defect repair: effect of coronary artery bypass grafting

Post-Infarction Ventricular Septal Defect: A quarter century experience

Objectives

Post-infarction ventricular septal defect (VSD) is one of the known complications after acute myocardial infarction. This study investigated the clinical results after surgical repair of VSD.

Methods

This retrospective study included all patients undergoing surgical repair of VSD from 1996 to 2020 in Oman.

Results

Out of a total of 75 patients, 62.5% were men, with a mean age of 59 years. The mean follow-up was 17.2 (7.5) years. Of the 75 patients, 34 (45.3%) patients died within 30 days. Total survival was 41.3% at 5 years, while the 10-year survival rate was 33.3%. Outcomes and predictors for 30 days mortality were the number of concomitant coronary involvement and anastomoses performed, residual postoperative shunt and postoperative dialysis.

Conclusion

Even with surgical repair, early mortality of post-infarction septal defect is still considerably high. Early repair and the anatomically posterior rupture are predictors of early mortality. In patients surviving the immediate postoperative period, long-term survival is limited by pre-existing coronary artery disease, postoperative renal failure and the presence of a residual postoperative shunt.

Survival and risk factors associated with surgical repair of ventricular septal rupture after acute myocardial infarction: A single-center experience

Objective

To analyze the survival and risk factors associated with the surgical treatment of ventricular septal rupture (VSR) after acute myocardial infarction (AMI).

Methods

We retrospectively analyzed 45 consecutive patients with VSR after AMI whose procedures were performed in the Department of Cardiovascular Surgery at the General Hospital of Northern Theater Command between January 2012 and December 2021. Relevant clinical data, surgery-related conditions, and follow-up data of all patients were summarized. Patients were divided into the survival group and the death group. The Kaplan–Meier method and log-rank test were used to determine the cumulative incidence of all-cause mortality. Multivariate logistic regression was used to evaluate the independent risk factors for all-cause mortality.

Results

The average postoperative follow-up time was 42.1 ± 34.1 months. The overall mortality rate was 20% (9/45 patients) and the operative mortality rate was 8.9% (4/45 patients). Logistic analysis showed that the death group had higher serum creatinine (127.32 ± 47.82 vs. 82.61 ± 27.80 μmol/L, respectively; P = 0.0238) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) [8,654.00 pg/mL (6,197.00–11,949.00 pg/mL) vs. 4,268.96 pg/mL (1,800.00–7,894.00 pg/mL), respectively; P = 0.0134] levels than the survival group. The cardiopulmonary bypass time (CPB) was longer in the death group than in the survival group [131.00 min (121.00–184.00 min) vs. 119.00 min (103.00–151.50 min), respectively; P = 0.0454]. Significantly more red blood cells were transfused in the death group than in the survival group [11.60 units (6.10–16.50) vs. 3.75 units (0.00–7.00 units), respectively; P = 0.0025]. Intra-aortic balloon pump (IABP) implantation (P = 0.016) and ventilation time (P = 0.0022) were risk factors for mortality. A 1-month landmark analysis showed that compared with patients with VSR to surgical time >14 days, patients who underwent surgery within 14 days had a higher rate of all-cause mortality (25.00 vs. 3.33%; log-rank P = 0.023). Patients with VSR within 14 days also had a higher rate of residual shunts that were higher than moderate. Multivariate analysis showed that transfusion of red blood cells and NT-proBNP level were risk factors for all-cause mortality, as well as major adverse cardiovascular and cerebrovascular events.

Conclusions

Surgical repair resulted in good outcomes for patients with VSR after AMI. Patients with VSR to surgical time >14 days had a lower rate of all-cause mortality. Treatment strategies for VSR should be based on the patient's condition and comprehensively determined through real-time evaluation and monitoring.

Complete anatomic surgical myocardial revascularisation during postinfarction ventricular septal defect and ventricular aneurysm repair is associated with improved short- and long-term outcomes

BACKGROUND

Coronary artery bypass grafting (CABG) is recommended during acute postinfarction ventricular septal defect (PIVSD) repair, but clinical benefits of surgical revascularization in patients with subacute PIVSD have not been established. We aimed to evaluate the association of primary complete anatomic surgical myocardial revascularization (CASMR) during PIVSD and ventricular aneurysm (VA) repair on patients' short- and long-term outcomes.

METHODS

This was a retrospective observational study. The inclusion criterion was PIVSD. Patients with previous CABG and those with PIVSD due to vasospasm and normal coronary arteries on angiography were excluded.

RESULTS

From March 2002 to April 2021, 53 patients met the eligibility criteria. The median patient age was 65 years, and 28 (53%) were male. Compared to the non-CABG group, CABG patients had higher values of the median postoperative left ventricular (LV) end-diastolic volume, 100 ml, and 128.5 ml, respectively (p = .012), and the mean LV stroke volume, 49 ml, and 61 ml, respectively (p = .048). The mortality rates in the CABG and non-CABG groups were 3.6/100 person-years (95% confidence interval [CI]: 1.5-8.6/100 person-years) and 16.3/100 person-years (95% CI: 8.5-31.3/100 person-years), respectively. Cox regression adjusted for between groups imbalances demonstrated a 4-fold greater mortality risk (hazard ratio = 4.3; 95% CI: 1.1-16.7; p = .036) among the non-CABG patients than in the CABG patients. Kaplan-Meier survival analysis yielded a poorer overall survival of the non-CABG patients (p = .011).

CONCLUSION

Primary CASMR during PIVSD and VA repair is associated with improved postoperative cardiac function, lower hospital mortality, and better long-term survival. We recommend CASMR during PIVSD and VA repair.

A Case Report: Point-of-care Ultrasound in the Diagnosis of Post-Myocardial Infarction Ventricular Septal Rupture

INTRODUCTION

Ventricular septal rupture (VSR) is a rare complication of ST-elevation myocardial infarction (STEMI), typically discovered post-revascularization.

CASE REPORT

We present the first case of VSR detected on point-of-care ultrasound (POCUS) in the emergency department immediately prior to emergent angiography, with management positively affected by this discovery. The VSR was quickly confirmed via right heart catheterization. Subsequently, hemodynamic stability was achieved using an intra-aortic balloon pump. A delayed surgical VSR repair, with concomitant coronary artery bypass grafting, was implemented for definitive management.

CONCLUSION

This case highlights the utility of POCUS in a STEMI patient with a suspected mechanical complication.

Repair of ischemic ventricular septal defect with and without coronary artery bypass grafting

BACKGROUND AND AIM OF THE STUDY

Ventricular septal defect (VSD) following myocardial infarction (MI) is a relatively infrequent complication with high mortality. We sought to investigate the effect of concomitant coronary artery bypass graft (CABG) on outcomes following post-MI VSD repair.

METHODS

Electronic search was performed to identify all relevant studies published from 2000 to 2018. Sixty-seven studies were selected for the analysis comprising 2174 patients with post-MI VSD. Demographic information, perioperative variables, and outcomes including survival data were extracted and pooled for systematic review and meta-analysis.

RESULTS

Single-vessel disease was most common (47%, 95% confidence interval [CI], 42-52), left anterior descending coronary artery was the most commonly involved vessel (55%, 95% CI, 46-63), and anterior wall was the most commonly affected territory (57%, 95% CI, 51-63). Concomitant CABG was performed in 52% (95% CI, 46-57) of patients. Of these, infarcted territory was re-vascularized in 54% (95% CI, 23-82). A residual/recurrent shunt was present in 29% (95% CI, 24-34) of patients. Of these, surgical repair was performed in 35% (95% CI, 28-41) and transcatheter repair in 11% (95% CI, 6-21). Thirty-day mortality was 30% (95% CI, 26-35) in patients who had preoperative coronary angiogram, and 58% (95% CI, 43-71) in those who did not (P < .01). No significant survival difference observed between those who had concomitant CABG vs those without CABG.

CONCLUSIONS

Concomitant CABG did not have a significant effect on survival following VSD repair. Revascularization should be weighed against the risks associated with prolonged cardiopulmonary bypass.

Current diagnosis and treatments for critical congenital heart defects

Congenital heart defects (CHD) affect approximately 7% of infants, and account for 3% of all infant deaths. CHD is most often caused by the defects associated with ductus arteriosus, which is a vessel that usually closes shortly after birth. The types of CHD include tetralogy of fallot, hypoplastic left heart syndrome, pulmonary atresia, total anomalous pulmonary venous return, transposition of great arteries, tricuspid atresia and truncus arteriosus. There are some risk factors that can increase the chance of a fetus developing CHD such as prematurity, an existing CHD in a first-degree relative, genetic syndromes, infections in utero, maternal drug consumptions and disorders. CHD is diagnosed is through different techniques including pulse oximetry, echocardiograms and physical exams. In this review, we examined the current incidence of CHD, the risk factors associated with CHD, the current methods of diagnosis and surgical options used to repair the defects.

[Left ventricular aneurysm and interventricular communication complicating myocardial infarction]

L'association d'une communication interventriculaire post infarctus du myocarde et d'un anévrysme du ventricule gauche chez un même patient est extrêmement rare et survient habituellement durant la première semaine qui suit un infarctus du myocarde. Nous rapportons le cas insolite d'un patient âgé de 63 ans, admis pour choc cardiogénique en rapport avec une communication inter ventriculaire apicale et un anévrysme ventriculaire gauche causés par un infarctus du myocarde antérieur. La correction chirurgicale a consisté en une fermeture du défect septal par un patch en dacron via une ventriculotomie gauche associée à une anévrysectomie et un mono pontage coronaire. Cette observation illustre d'une part la rareté de l'association communication inter ventriculaire-anévrysme ventriculaire gauche post infarctus du myocarde, et d'autre part l'efficacité du traitement chirurgical qui reste la seule option salvatrice pour cette pathologie.

Post-infarction ventricular septal defect: surgical outcomes in the last decade

Background:

Post-infarction ventricular septal defects require surgical closure. Only a few studies have been conducted in Asian populations. This study reports the current outcomes and determinants affecting survival.

Methods:

Between January 1995 and January 2012, 40 patients underwent surgery for post-infarction ventricular septal defect. We analyzed demographics, clinical, angiographic, and echocardiographic parameters, operative data, postoperative morbidity, and survival. Mean follow-up was 5.2 ± 5.3 years. Univariate and multivariate analyses were used to determine the factors affecting 30-day mortality and long-term survival.

Results:

There was no intraoperative death. Our 30-day mortality was 20%. Single-vessel disease was found on coronary angiography in 63% of patients. Eight patients had concomitant coronary artery bypass grafting. Overall survival at 1, 5, and 10 years was 68%, 55%, and 42%, respectively. Event-free survival from subsequent angina, myocardial infarction, congestive heart failure, or percutaneous interventions at 1, 5, and 10 years was 66%, 43%, and 25%, respectively. Preoperative oliguria and postoperative sepsis were independent predictors of 30-days mortality on multivariate analysis ( p = 0.02). Preoperative left ventricular function was associated with long-term survival ( p = 0.048).

Conclusion:

We had good results of current postinfarction ventricular septal defect repair. Selected patients had concomitant coronary artery bypass grafting. Preoperative oliguria and postoperative sepsis were independent predictors of 30-day mortality, while left ventricular function was related to long-term survival.

Outcome and survival analysis of surgical repair of post-infarction ventricular septal rupture

Background

To review the experience of surgical repair of post-infarction ventricular septal rupture (VSR) and analyze the associated outcomes and prognostic factors.

Methods

Following approval from the Singhealth Centralised Institutional Review Board (reference: 2011/881/C), a retrospective review was performed on 38 consecutive patients who had undergone surgical repair of post-infarction VSR between 1999 and 2011. Continuous variables were expressed as either mean ± standard deviation or median with 25^th and 75^th percentiles. These were compared using two-tailed t-test or Mann–Whitney U test respectively. Categorical variables were compared using chi-square or Fisher’s exact test. To identify predictors of operative mortality, univariate analysis of perioperative variables followed by multivariate analysis of significant univariate risk factors was performed. A two-tailed p-value < 0.05 was used to indicate statistical significance.

Results

Mean age was 65.7 ± 9.4 years with 52.6% males. The VSR was anterior in 28 (73.7%) and posterior in 10 patients. Median interval from myocardial infarction to VSR was 1 day (1, 4). Pre-operative intra-aortic balloon pump was inserted in 37 patients (97.8%). Thirty-six patients (94.7%) underwent coronary angiography.

Thirty-five patients (92.1%) underwent patch repair. Mean aortic cross clamp time was 82 ± 40 minutes and mean cardiopulmonary bypass time was 152 ± 52 minutes. Coronary artery bypass grafting (CABG) was performed in 19 patients (50%), with a mean of 1.5 ± 0.7 distal anastomoses. Operative mortality within 30 days was 39.5%.

Univariate analysis identified emergency surgery, New York Heart Association (NYHA) class, inotropic support, right ventricular dysfunction, EuroSCORE II, intra-operative red cell transfusion, post-operative renal failure and renal replacement therapy (RRT) as predictors of operative mortality. Multivariate analysis identified NYHA class and post-operative RRT as predictors of operative mortality.

Ten year overall survival was 44.4 ± 8.4%. Right ventricular dysfunction, LVEF and NYHA class at presentation were independent factors affecting long-term survival. Concomitant CABG did not influence early or late survival.

Conclusions

Surgical repair of post-infarction VSR carries a high operative mortality. NYHA class at presentation and post-operative RRT are predictors of early mortality. Right ventricular dysfunction, LVEF and NYHA class at presentation affect long-term survival. Concomitant CABG does not improve survival.

Management and midterm outcomes of post-infarction ventricular septal defect

We assessed midterm outcomes, predictors of mortality, and residual defects after repair of post-infarction ventricular septal defect in 10 patients (mean age, 65.3 years; range, 50-78 years) who were operated on between 2000 and 2008. Mean time from onset of symptoms of myocardial infarction to diagnosis of ventricular septal defect was 3.5 days. Time from diagnosis to surgery ranged from 6 h to 84 days. The defects were located anteriorly in 4 patients and posteriorly in 6. Patch reconstruction of the septum was used in 6 patients and the infarct exclusion technique in 4. Hospital mortality was 60%. The only predictor of mortality was tricuspid valve competence (p = 0.048). There was no correlation between location of the defect or type of repair and operative mortality. Residual or recurrent ventricular septal defect was noted in 6 patients. Location of the defect and type of repair were not predictors of residual or recurrent defects. Residual ventricular septal defect was not associated with increased short-term mortality or reduction of functional status. Early mortality associated with post-infarction ventricular septal defect repair is significant. Discharged patients continue to have good functional capacity and quality of life, as well as favorable midterm survival.

Surgical repair of ventricular septal defect after myocardial infarction: outcomes from the Society of Thoracic Surgeons National Database

BACKGROUND

The development of a ventricular septal defect (VSD) after myocardial infarction (MI) is an uncommon but highly lethal complication. We examined The Society of Thoracic Surgeons database to characterize patients undergoing surgical repair of post-MI VSD and to identify risk factors for poor outcomes.

METHODS

This was a retrospective review of The Society of Thoracic Surgeons database to identify adults (aged≥18 years) who underwent post-MI VSD repair between 1999 and 2010. Patients with congenital heart disease were excluded. The primary outcome was operative death. The covariates in the current The Society of Thoracic Surgeons model for predicted coronary artery bypass grafting operative death were incorporated in a logistic regression model in this cohort.

RESULTS

The study included 2,876 patients (1,624 men [56.5%]), who were a mean age of 68±11 years. Of these, 215 (7.5%) had prior coronary artery bypass grafting operations, 950 (33%) had prior percutaneous intervention, and 1,869 (65.0%) were supported preoperatively with an intraaortic balloon pump. Surgical status was urgent in 1,007 (35.0%) and emergencies in 1,430 (49.7%). Concomitant coronary artery bypass grafting was performed in 1,837 (63.9%). Operative mortality was 54.1% (1,077 of 1,990) if repair was within 7 days from MI and 18.4% (158 of 856) if more than 7 days from MI. Multivariable analysis identified several factors associated with increased odds of operative death.

CONCLUSIONS

In the largest study to date to examine post-MI VSD repair, ventricular septal rupture remains a devastating complication. As alternative therapies emerge to treat this condition, these results will serve as a benchmark for future comparisons.

Determinants of in-hospital death in patients with postinfarction ventricular septal perforation

Ventricular septal perforation (VSP) is a serious complication associated with acute myocardial infarction (MI). The purpose of this study was to investigate the determinants of in-hospital death in patients with postinfarction VSP. Between January 1990 and April 2010, we identified 37 patients from our hospital records. Univariate analysis and multivariate logistic regression analysis were performed to find the determinants of in-hospital death. In-hospital mortality was 35% (13/37 patients). History of hypertension (P = 0.03), percutaneous coronary intervention (P = 0.04), and preoperative percutaneous cardiopulmonary support (P = 0.04) were associated with in-hospital death, whereas history of hyperlipidemia was associated with in-hospital survival. The interval from MI to VSP in survivors was significantly longer than that in nonsurvivors (P < 0.01). In multivariate logistic regression analysis, a shorter interval from MI to VSP (odds ratio 0.57, 95% confidence interval 0.34-0.95, P = 0.03) was found to be an independent predictor of in-hospital death. In conclusion, in-hospital mortality was high in patients with postinfarction VSP. A shorter interval from MI to VSP was a significant independent predictor of in-hospital death.

[Late postinfarction rupture of the interventricular septum]

Postinfarction ventricular septal rupture complicates 1 to 2% of cases of acute myocardial infarction and accounts for 5% of early mortality. This severe complication usually occurs within two weeks after acute myocardial infarction, and the elderly are more susceptible. We present a case of late rupture of the septum.

CASE REPORT

In a 75-year-old man, a ventricular septal defect developed more than two months after an extensive inferoseptal myocardial infarction due to occlusion of the right coronary artery. After more than two months of no symptoms he was referred to hospital due to symptoms of right ventricle failure. The diagnosis was made by echocardiography, pulmonary artery catheterization and ventriculography. Coronarography was also performed. Intraaortic balloon pump was introduced and the patient was transferred to the operating room. The defect was repaired using a circular polytetrafluoroethylene patch supported by buttressed interrupted sutures from both sides. Due to significant mitral valve regurgitation mechanical bileaflet mitral valve was implanted with preservation of the entire mitral apparatus and the left descending artery was revascularized using a saphenous graft.

CONCLUSION

This case is reported to emphasize that later postinfarction rupture of the ventricular septum may occur with symptoms of right ventricle failure dominating the clinical course.

Repeated successful surgical rescues of early and delayed multiple ruptures of ventricular septum, right ventricle and aneurysmal left ventricle following massive biventricular infarction

A 58 year old man underwent 6 surgical interventions for various complications of massive biventricular myocardial infarction over a period of 2 years following acute occlusion of a possibly "hyperdominant" left anterior descending coronary artery. These included concomitant repair of apicoanterior post-infarction VSD and right ventricular free wall rupture, repeat repair of recurrent VSD following inferoposterior extension of VSD in the infarcted septum 5 weeks later, repair of delayed right ventricular free wall rupture 4 weeks subsequently, repair of a bleeding left ventricular aneurysm eroding through left chest wall 16 months thereafter, repair of right upper lobe lung tear causing massive anterior mediastinal haemorrhage, mimicking yet another cardiac rupture, 2 months later, followed, at the same admission, 2 weeks later, by sternal reconstruction for dehisced and infected sternum using pedicled myocutaneous latissimus dorsi flap. 5 years after the latissimus myoplasty, the patient remains in NYHA class 1 and is leading a normal life.

Surgical repair of post-infarction ventricular septal defect: 19 years of experience

OBJECTIVES

To review our experience of surgical repair of post-infarction ventricular septal defect (VSD).

METHODS

In the period 1983-2002, 50 patients underwent repair of VSD. Mean age was 66 years, male sex 52%. Infarct location was anterior in 60% and posterior in 40% of cases. Median interval between rupture and surgery was 2 days. Preoperative intra-aortic balloon counterpulsation was employed in 56%; a coronary angiogram was performed in 98% of cases. A patch repair technique was used in 90% of cases. Coronary bypass grafting was associated in 50% of patients.

RESULTS

Mean aortic clamp time was 101+/-31 min. Global operative mortality was 36%, respectively 26.7% in anterior and 50% in posterior location (p=ns). Emergency operation and interval from rupture to surgery less than 3 days were univariate predictor of early mortality. Five years survival excluding operative deaths was 76%.

CONCLUSIONS

The surgical repair of post-infarction VSD entails a high operative mortality; different techniques were employed with similar results. Emergency operation is associated with a worse short-term prognosis; long-term survival is acceptable.

Surgical treatment for complications of acute myocardial infarction

OBJECTIVE

We report the results of surgical repair for postinfarction left ventricular free wall rupture (LVFR) and ventricular septal perforation (VSP) complicating acute myocardial infarction.

METHODS

We experienced 14 LVFRs and 10 VSPs from January 1991 to December 2002. The mean age of patients with LVFR was 74+/-8.1 years. There were 6 oozing cardiac ruptures and 8 blowout cardiac ruptures. An intraaortic balloon pump (IABP) was inserted in 8 patients, and percutaneous cardiopulmonary support (PCPS) was inserted in 5 patients. The mean age of patients with VSP was 72+/-5.1 years. The rupture was located within the anterior septum in 8 patients and within the posterior septum in 2 patients. All patients required IABP, and one of them needed PCPS. We employed a sutureless technique in 8 patients, direct closure in 5 patients, and infarct exclusion in 1 patient with LVFR. Infarct exclusion was conducted in 9 patients, and the da Silva technique was used in 1 patient with VSP.

RESULTS

The patient survival rate of LVFR was 36% (blowout 13%; oozing 67%). Residual shunt occurred in 4 patients with VSP postoperatively. The overall survival rate for VSP was 70%.

CONCLUSION

The operative prognosis of blowout cardiac rupture was poor. Good results were obtained with the infarct exclusion technique for patients with VSP. Although some patients had postoperative residual shunts, the infarct exclusion technique was generally a safe and excellent procedure.

Post infarction ventricular septal defect - can we do better?

OBJECTIVE

To identify predictors of early and late outcome among 117 consecutive patients who underwent postinfarction ventricular septal defect (VSD) repair over a period of 12 years.

METHODS

A retrospective analysis of clinical data was performed. Mean age was 65.5+/-7.8. There were 43 females. Full data were obtained in 110 patients. Of these, 76 patients presented with anterior and 34 with posterior VSD. Thirty-three patients were operated in cardiogenic shock. Mean time between myocardial infarction (MI) and VSD development was 5.6+/-7.8 days (median 4) and from VSD to surgery 9. 0+/-28.1 (median 2). Sixty-six patients had intraaortic balloon pump (IABP) inserted, and 15 were ventilated preoperatively. Logistic regression and Cox regression were used for multivariate analysis.

RESULTS

Thirty days mortality was 37%. Among 110 patients, in whom complete analysis was possible, 38 died within 30 days (35%). Mortality in the posterior VSD group was 35% and in the anterior VSD group 34% (NS). In 44 patients (40%) a residual shunt was found on postoperative echocardiography. This required reoperation in 13 patients (four deaths). Cardiogenic shock prior to surgery adversely influenced early survival - odds ratio (OR) 5.7 (confidence interval (CI) 2.1-16.0) (P=0.0008). Deterioration of haemodynamic status in between admission and surgery was stronger predictor of mortality than shock on admission - OR 6.0 (CI 1.6-22.6) (P=0.008) vs. 3.1 (CI 1.0-9.3) (P=0.049). A longer time between MI and surgery favoured survival - OR 0.1 (CI 0.03-0.4) (P=0.002). The time period from the infarct to the septal rupture, but not from the rupture to surgery, appeared to be a significant predictor of survival - OR 0.2 (CI 0. 05-0.6) (P=0.008). Five years survival was 46+/-5%. Preoperative cardiogenic shock affected late survival - OR 2.7 (CI 1.5-4.9) (P=0. 001). Of 72 patients who survived 30 postoperative days, 12 (17%) were in New York Heart Association (NYHA) class III or IV and five (6.9%) in Canadian Cardiovascular Soceity (CCS) class III or IV at the last follow-up.

CONCLUSIONS

Preoperative cardiogenic shock and early postinfarction septal rupture carry a grave prognosis. Achieving haemodynamic stability prior to surgery may be beneficial but prolonged attempts to improve patients' cardiovascular state are hazardous.

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.

Operative results of "repair" of ventricular septal rupture after acute myocardial infraction

Fifty-four consecutive patients with postinfarction ventricular septal defect were reviewed. The rupture was closed with a patch and the left ventricle remodeled in all patients. Coronary artery bypass surgery was performed in 28 patients (52%). Fourteen patients (26%) died after operation and 19 during follow-up (mean 42 months). Cumulative survival (including operative deaths) was 78%, 65%, and 40% at 1, 5, and 10 years, respectively. A short interval between septal rupture and operation was a risk factor for early mortality (p = 0.03). Treated associated coronary artery disease had no effect. A residual septal shunt, detected in 10 patients (18%), warranted reoperation in 7 and contributed to 2 early and 1 late death. The location and morphology of the septal rupture were not associated with increased risk of residual shunt. Thus, patch closure of the ventricular septal rupture, remodeling of the left ventricle to improve stroke volume and reduce wall stress, and selective myocardial revascularization provided acceptable results.

Postinfarction ventricular septal rupture

Postinfarction ventricular septal rupture is an uncommon but serious complication of acute myocardial infarction. Although I have tried various methods for repairing postinfarction septal defects, I recently began to use an exclusion technique, which is an extension of the intracavitary repair method that I use to treat ventricular aneurysms. This exclusion technique yields satisfactory results (early mortality rate, 36.4%), even in patients in severe cardiogenic shock.

Repair of postinfarction ventricular septal defects

Postinfarction ventricular septal defects complicate approximately 1% to 2% of cases of acute myocardial infarction and account for about 5% of early deaths after myocardial infarction. By differentiating the surgical treatment of these acquired lesions from the surgical approaches used to repair congenital ventricular septal defects and realizing the significance of differing anatomic locations of postinfarction ventricular septal defects, techniques have been developed that have improved salvage of patients suffering this catastrophic complication of myocardial infarction. The principles underlying these surgical techniques include (1) expeditious establishment of total cardiopulmonary bypass with moderate hypothermia and meticulous attention to myocardial protection; (2) transinfarct approach to ventricular septal defect with the site of ventriculotomy determined by the location of the transmural infarction; (3) thorough trimming of the left ventricular margins of the infarct back to viable muscle to prevent delayed rupture of the closure; (4) conservative trimming of the right ventricular muscle as required for complete visualization of the margins of the defect; (5) inspection of the left ventricular papillary muscles and concomitant replacement of the mitral valve only if there is frank papillary muscular rupture; (6) closure of the septal defect without tension, which in most instances will require the use of prosthetic material; (7) closure of the infarctectomy without tension with generous use of prosthetic material as indicated, and epicardial placement of the patch to the free wall to avoid strain on the friable endocardial tissue; and (8) buttressing of the suture lines with pledgets or strips of Teflon felt or similar material to prevent sutures from cutting through friable muscle.

Surgical repair of postinfarction ventricular septal defect by infarct exclusion

Repair of postinfarction ventricular septal defect (VSD) by infarct exclusion has been used for a decade in our unit. It involves securing a glutaraldehyde-preserved bovine pericardial patch to the endocardium of the left ventricle all around the necrotic myocardium to exclude the VSD and the infarct from the left ventricular cavity. Fifty-two patients with postinfarction VSD underwent this type of repair from 1987 to 1996. Thirty-four patients were in shock when undergoing operation; 26 had anterior VSD and 26 had posterior. Ten patients died perioperatively, for surgical mortality of 19%. Three patients developed recurrent VSD; one died and two survived. Preoperative cardiogenic shock and age older than 70 years were associated with an increased operative mortality. Operative survivors were followed up from 6 to 135 months, mean of 65 months. The actuarial survival at 8 years was 59% +/- 6%. Repair of postinfarction VSD by infarct exclusion is a relatively simple operative procedure and seems to have improved the results of surgery in patients with posterior VSD.

Postinfarction ventricular septal rupture: the Wessex experience

Surgical repair of a postinfarct ventricular septal defect (VSD) remains a difficult surgical challenge associated with a significant operative mortality. Between 1972 and 1995, 179 patients with a postinfarct VSD have undergone operation in this institution. There were 118 males and 61 females, with a mean age of 66 years (range 43 to 80). Operative mortality was 26.7%. Surgery was deferred until 1 month after the septal rupture in 29 patients, with these labeled as having a chronic VSD. The remaining 150 underwent operation on within 1 month of infarction and are described as having an acute VSD. For those with an acute VSD, factors significantly associated with an increased risk of 30-day mortality included preoperative New York Heart Association status (P = .04), site of myocardial infarction (inferior worse than anterior) (P = .004), cross-clamp time (P = .05) and cardiopulmonary bypass time (P = .0001) (logistic regression). On multiple logistic regression, only cardiopulmonary bypass time remained significant. Survival including in-hospital mortality at 5 and 10 years was 49% +/- 4% and 31% +/- 5% and excluding in-hospital mortality was 72% +/- 5% and 45% +/- 6%, respectively. Those patients who survived attained a good quality of life. No factors were significantly associated with prolonged survival.

Should coronary artery bypass grafting be performed at the same time as repair of a post-infarct ventricular septal defect?

OBJECTIVE

The value of coronary artery bypass grafting (CABG) at the time of repair of a post-infarct ventricular septal defect (VSD) remains controversial. The aim of this study was to analyse the effect of CABG on early mortality and survival following repair of an acquired VSD.

METHODS

Over 23 years, 179 patients, 118 male, 61 female, mean age 66 years (range 43-80), have undergone repair of a post-related VSD in our unit. A total of 29 patients, who predominantly form the earlier part of the series, were operated on greater than 1 month after the infarct and are, therefore, excluded. Coronary angiography was performed in 98 (65.3%) of the remaining 150 patients. Of these, 41 had coronary artery disease (CAD) limited to the infarct-related vessel and 57 had additional significant CAD. Those with CAD limited to the infarct-related vessel were not grafted (Group A). Of those, 40 with significant CAD underwent CABG at the time of VSD repair (Group B) and 17 did not (Group C). In 52 patients the coronary anatomy was not documented (Group D). Risk factors for early mortality were evaluated using logistic regression. Actuarial survival was compared using log rank and Wilcoxon tests. Cox's proportional hazards method was used to determine factors affecting survival.

RESULTS

Overall, 30 day mortality was 32%. CABG did not significantly decrease operative mortality (logistic regression). There was no statistically significant difference in early mortality or actuarial survival between the four groups. CABG was not associated with an increased survival (Cox's method).

CONCLUSIONS

Concomitant CABG at the time of VSD repair does not affect early mortality nor confer survival benefits. There seems to be no demonstrable benefit in revascularisation at the time of repair and, therefore, it may be unnecessary to perform CABG or coronary angiography in these patients.

[Double post-acute myocardial infarction complication: rupture of the interventricular septum and acute mitral insufficiency]

We present a case of double post acute myocardial infarction complication: ventricular septal defect and acute and severe mitral insufficiency. As a consequence of the delay in the diagnosis, the patient developed pulmonary hypertension with values at the systemic level. The patient underwent surgery in order to close the ventricular septal defect and aneurysmectomy, resulting in posterior regression of mitral insufficiency and pulmonary circuit values became normal. The ethology, diagnosis, evolution and treatment of this exceptional association of acute post myocardial infarction complications are discussed.

Early repair of postinfarction ventricular septal rupture

BACKGROUND

Postinfarction rupture of the interventricular septum is usually fatal without surgical intervention. The optimal timing and the most appropriate technique of surgical repair remain unsettled.

METHODS

The results of surgical closure of postinfarction ventricular septal defect in a consecutive series of patients seen over a 24-year period were reviewed and analyzed. Late follow-up was obtained in all patients who survived the operation.

RESULTS

Sixty of 76 patients treated surgically exhibited cardiogenic shock, low cardiac output syndrome, or both at the time of operation. A plan of early operative intervention was followed in these unstable patients, with 60% of them undergoing repair within 24 hours of septal rupture. For the entire series of patients, the hospital mortality rate was 40.8%; survival was 41.5% at 5 years and 25.6% at 10 years postoperatively.

CONCLUSIONS

Significant trends observed during the period of study were a more aggressive stance regarding surgical intervention in all patients who presented with hemodynamic instability and improved survival in those patients who presented with septal rupture complicating an inferior myocardial infarction.

Postinfarction ventricular septal rupture: repair by endocardial patch with infarct exclusion

A novel operative technique for postinfarction ventricular septal defect has been used in 44 consecutive patients. The operation consists of excluding rather than excising the infarcted septum and ventricular walls. This is accomplished by performance of a left ventriculotomy through the infarcted muscle and securing a glutaraldehyde-fixed bovine pericardium patch to the endocardium of the left ventricle all around the infarcted myocardium. The ventriculotomy is simply closed over the pericardial patch. There were 21 men and 23 women whose mean age was 69 +/- 7 years. Twenty-nine patients were in cardiogenic shock at the time of operation. All patients had Doppler echocardiography and coronary angiography before operation. All but two patients were operated on during the acute phase of the myocardial infarction. There were six operative deaths. Postoperative complications included renal failure in 10 patients and respiratory failure in 18. Severe right ventricular dysfunction was the only independent predictor of operative mortality. Patients have been followed up for a mean of 40 +/- 34 months. There have been six late deaths and three of these were because of cardiac problems. The actuarial survival at 6 years was 66% +/- 7%. Only one patient had a small residual ventricular septal defect. Late postoperative assessment of ventricular function by echocardiography revealed that most patients had normal or mild impairment of right ventricular function and mild or moderate impairment of left ventricular function. Repair of acute postinfarction ventricular septal defect by endocardial patch with infarct exclusion of the left ventricule probably avoids additional damage to the right ventricle, remodels the acutely infarcted left ventricle, and enhances survival.

Good long-term outcome following surgical repair of post-infarction ventricular septal defect

BACKGROUND

A post-infarction ventricular septal defect (VSD) is a serious complication of a myocardial infarction with 90% of patients dying by two months, in published series. Urgent surgical repair improves the prognosis.

AIMS

To assess the Green Lane Hospital experience over a ten year period, especially with regard to hospital mortality and long-term follow up.

METHODS

A retrospective case note review of all 35 consecutive patients undergoing post-infarct VSD repair from 1981 to 1990. Long-term follow up was obtained in all but one patient (97%).

RESULTS

Twenty-one male and 14 female patients presented with a mean age of 67 years (range 51-75). All were in NYHA class 3 or 4, 14 (40%) were in cardiogenic shock. Following urgent surgical repair, 30 day mortality was 31% (11 patients). A further three patients died at two, 33 and 39 months; one patient was lost to follow up. At a mean follow up of 61 months (range 16-111), 15 patients were in NYHA class 1 or 2, five in NYHA class 3 or 4. For the whole group (n = 35) the actuarial survival was 66% at one year, 62% at three years and 58% at nine years.

CONCLUSION

Post-infarct VSD surgery is of major prognostic benefit with patients obtaining a good long-term outcome.