Postinfarction ventricular septal rupture: early repair through the right atrial approach

Early surgical outcomes of a modified infarct exclusion technique in acute post-myocardial infarction ventricular septal rupture: a single-centre experience

Introduction

Operative mortality in an acute post-myocardial infarction (AMI) ventricular septal rupture (VSR) is high. In addition to ventricular dysfunction, friable myocardium adds to the technical difficulty of the operation. In a modified infarct exclusion technique, the right ventricle is left undisturbed and the free edge of the pericardial patch is incorporated in the sutures while closing the left ventriculotomy. This simplifies the procedure and decreases the chances of right ventricular dysfunction, any residual defect, and bleeding.

Methods

Study design

A retrospective analysis of patients with VSR following AMI operated in our institute from January 2018 to June 2021 was done.

Results

Over the last 3 years, 16 patients with AMI VSR were treated with a modified infarct exclusion technique. Eight patients presented in cardiogenic shock preoperatively and were put on intra-aortic balloon pump support. All patients could be weaned successfully from the cardiopulmonary bypass, no patient had any residual defect, and none of the patients required re-exploration for bleeding. Postoperatively, 5 patients died within the first week and 2 more patients subsequently died due to intractable arrhythmias over the next 30 days.

Conclusions

In our centre, the mortality following repair of VSR after AMI was 43%. The modified infarct exclusion technique is a good technique with less chances of postoperative re-exploration and residual defect.

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.

Extended sandwich technique via the right atrial approach for post-infarction posterior ventricular septal rupture

An 84-year-old man who underwent percutaneous coronary intervention for acute inferior myocardial infarction due to occlusion of the mid portion of the right coronary artery was transferred to our hospital because of post-infarction posterior ventricular septal rupture. We performed the extended sandwich technique via the right atrial approach as well as tricuspid and mitral valve replacement and permanent pacemaker implantation. Mild residual shunt was detected post-operatively, but the patient's condition was controlled well with diuretics.

A Modified Transatrial Approach for Repair of Postinfarction Ventricular Septal Defect

Ventricular septal defect (VSD) is a life-threatening complication of myocardial infarction. Surgical repair is generally performed through a left/right ventriculotomy. To avoid complications associated with ventriculotomy, a right transatrial approach has been proposed. We describe a modified transatrial approach through the left atrium for basal-inferior VSD. After left atriotomy, mitral valve is detached from the annulus to expose the defect, which is closed with a pericardial patch. Two patients were operated by this method. In both cases venoarterial extracorporeal membrane oxygenation with a ventricular vent was utilized to unload the left ventricle. Echocardiography revealed no residual shunt in both cases.

Right atrial approach for repairing a posterior ventricular septal rupture: a case report

BACKGROUND

Ventricular septal rupture (VSR) is a life-threatening complication following acute transmural myocardial infarction. Posteriorly located ruptures are one of the main predictors of poor prognoses because of the surgical difficulties associated with this location.

CASE PRESENTATION

A 72-year-old man with a posterior VSR underwent surgical repair via the right atrial approach. The patient's postoperative course was uneventful, and echocardiography showed no residual shunt flow. He was discharged on postoperative day 37.

CONCLUSION

By temporally detaching the tricuspid valve leaflet, this approach provides a better view and handling space within the posterior ventricular septum than the trans-ventricular approach. Additionally, avoiding a ventricular incision can better preserve postoperative ventricular function.

Tricuspid Septal Leaflet Detachment for Ventricular Septal Defect Repair in Adults

We report a 21-year-old patient with a ventricular septal defect (VSD) with an embolic vegetation on the tricuspid valve using a technique of septal leaflet detachment to facilitate the repair of the VSD. Although described in the pediatric patients, this technique has not been reported in adults. The technique of septal leaflet mobilization is described, along with other techniques of tricuspid leaflet mobilization that aid in VSD visualization and repair. Tricuspid leaflet detachment has application for adult surgeons repairing perimembranous, postinfarction, and iatrogenic VSD encountered in resection of subaortic stenosis.

Transatrial Approach for the Repair of the Posterior Post-Infarct Ventricular Septal Rupture

Ventricular septal rupture (VSR) is a disastrous mechanical complication of myocardial infarction. Although several surgical interventions have been developed, mortality due to surgical management remains high, especially in the case of posterior VSR. We report a successful case of repair of posterior VSR using an alternative transatrial approach to avoid the complications related to ventricular incision.

Surgical Outcomes of a Modified Infarct Exclusion Technique for Post-Infarction Ventricular Septal Defects

BACKGROUND

Postinfarction ventricular septal defects (pVSDs) are a serious complication of acute myocardial infarctions. The aim of this study was to analyze the clinical outcomes of the surgical treatment of pVSDs.

METHODS

The medical records of 23 patients who underwent operations (infarct exclusion in 21 patients and patch closure in two patients) to treat acute pVSDs from 2001 to 2011 were analyzed. Intra-aortic balloon counter-pulsation was performed in 19 patients (82.6%), one of whom required extracorporeal membrane support due to cardiogenic shock. The mean follow-up duration was 26.2±18.6 months.

RESULTS

The in-hospital mortality rate was 4.3% (1/23). Residual shunts were found in seven patients and three patients required reoperation. One patient needed reoperation due to the transformation of an intracardiac hematoma into an abscess. No patients required reoperation due to recurrence of a ventricular septal defect during the follow-up period. The cumulative survival rate was 95.5% at one year, 82.0% at five years, and 65.6% at seven years.

CONCLUSION

The use of a multiple-patch technique with sealants appears to be a reliable method of reducing early mortality and the risk of significant residual shunting in patients with pVSDs.

Technical modifications in the repair of acute ischemic posterior ventricular septal defect without ventriculotomy

OBJECTIVE

Transventricular repair for acute ischemic posterior ventricular septal defect is challenging and is associated with high operative morbidity and mortality. We have adopted the alternative technique of transatrial repair and recently have added technical modifications that result in less residual or recurrent septal shunt. This study reports those modifications and the related outcomes.

METHODS

Retrospective review of 10 patients with acute ischemic posterior ventricular septal defect operated from November 2006 through March 2013. The septal defect was repaired through the right atrium with a prosthetic patch. Interlocking sutures and an additional continuous suture line buttress around the perimeter of the patch were added to the repair in four (40%) patients.

RESULTS

Killip class IV heart failure was present in nine (90%) of the patients, and all received preoperative intra-aortic balloon pump therapy. No patient who received the recent technical modifications experienced a residual or recurrent shunt. However, three (50%) patients who did not undergo this modification developed either a residual septal shunt (n = 1), an early recurrent septal shunt (n = 1), or a ventricular rupture (n = 1). There was no 30-day or in-hospital mortality after surgery, but a single patient died two years after operation due to congestive heart failure. The remaining patients are alive after surgery at a median of 2.0 years.

CONCLUSIONS

The transatrial repair of an acute ischemic posterior ventricular septal defect is a safe technique. The addition of interlocking pledgetted sutures and a patch suture line buttress decreases the incidence of residual and recurrent septal shunt.

Repair of acute inferior wall myocardial infarction-related basal ventricular septal defect: transatrial versus transventricular approach

BACKGROUND

We describe our contemporary experience for the management of patients with an acute postinfarction basal ventricle septal defect (VSD) using the transatrial (TA) and transventricular (TV) approaches.

METHODS

Retrospective review of all patients diagnosed with an ischemic basal VSD since January 2000. There were 20 patients with a median age of 68 years (39 to 85); 13 (65%) were males. Median time from diagnosis of the ischemic basal VSD to operation was 22 hours (6 to 144).

RESULTS

All patients received standard patch closure of the septal defect with exposure of the VSD through the TA approach in eight patients (40%) and the TV approach in 12 (60%). All TA group patients received tricuspid valve replacement, while in the TV group, two had tricuspid valve replacement and two repair. Five patients (25%) had clinically insignificant (<0.5 mm) residual septal defects; three additional patients (15%) experienced patch dehiscence and two (10%) underwent re-exploration. There were five mortalities (25%): one in the TA group (right ventricular heart failure) and four in the TV group (one right ventricular heart failure, three ventriculotomy site hemorrhage or patch dehiscence). Preoperative right atrial pressure (p=0.0003) and right ventricular dysfunction (p=0.04) were predictors of hospital mortality. Follow-up of the hospital survivors was 4.3 years (40 days to 11.5 years) with one death at seven years.

CONCLUSION

Operative mortality associated with repair of postinfarction basal ventricular septal defect is high and is related to right ventricular failure and bleeding from the ventriculotomy. The TA approach avoids ventriculotomy-associated bleeding and provides excellent exposure but is associated with an increased incidence of tricuspid valve replacement.

Posterior ventricular septal perforation: sandwich technique via right ventriculotomy using BioGlue

We present a case in which the sandwich technique was successfully applied via right ventriculotomy for posterior infarction ventricular septal perforation 2 days after acute posterior myocardial infarction in a 73-year-old male patient. The sealant BioGlue was applied to the space between the two patches instead of gelatin-resorcinol-formaldehyde biological glue. The postoperative course was good, and the patient was discharged on day 24 after surgery with no recognized residual shunt.

Transtricuspid approach in redo surgery for post-infarction ventricular septal rupture

A 59-year-old man, who had been treated using the infarction exclusion technique for inferior post-infarction ventricular septal rupture (VSR) 4 months previously, was readmitted because of deterioration of mitral valve regurgitation, residual shunt, and progression of pulmonary hypertension. We performed mitral valve replacement via the transseptal approach, patch closure of the defect via the transtricuspid approach, and tricuspid valve annuloplasty. The post-operative course was uneventful. The transtricuspid approach is useful in redo surgery for post-infarction VSR.

Transatrial Repair of Post-infarction Posterior Ventricular Septal Rupture

Ventricular septal rupture (VSR) is a rare but lethal complication of myocardial infarction. The event occurs 2~8 days after an infarction and often precipitates cardiogenic shock. Post myocardial infarction VSR is known for difficult to repair. Especially, Transmural myocardial infarction involved in the posterior VSD area, exposure of the affected site is difficult and postoperative mortality rate is high. We have experienced a case of a 75-year-old female patient who suffered posterior VSD due to acute myocardial infarction, and attained good result by approaching the lesion through right atrial incision and repaired the defect by using patch closure technique.

A modified infarct exclusion repair of posterior postinfarction ventricular perforation: triple-patch technique for postinfarction ventricular septal perforation in 2 female patients

We describe a new technique for the early surgical repair of a posterior postinfarction ventricular septal perforation (VSP) in two consecutive female patients. The occurrence of a posterior VSP is rare, and its repair is technically difficult because the posteromedial papillary muscle is located adjacent to the intraventricular septum. This modification appears to prevent leaks to the right ventricle through the VPS with a single direct patch and the use of two equine pericardial patches to form a single endocardial pouch. The women were 77 and 62 years old, and the time between the onset of acute MI and surgery was 3 and 6 days. On preoperative catheterization, Qp/Qs was 4.18 and 4.01. Neither operative death nor residual shunting was observed.

Postinfarction inferior ventricular septal rupture: surgical repair through the right atrium

Operative mortality of inferior postinfarct ventricular septal rupture (VSR) remains high. Previous reports have described a transatrial approach to access the VSR avoiding a ventriculotomy, thereby reducing the potential risks of myocardial damage, hemorrhage, and ventricular arrhythmias. The transatrial right ventricular patch or direct suture repair, however, is exposed to the left-to-right pressure gradient and is at risk of residual shunting. In this report, a transatrial approach is used, with direct suture of the VSR, patch exclusion of the right ventricle, and biological glue instillation to protect the patch from left ventricular pressures.

A successful transatrial repair in redo surgery of postinfarction inferoposterior ventricular septal rupture

A successful transatrial repair in redo surgery of postinfarction posterior ventricular septal rupture (VSR) was performed after an infarct exclusion technique through left ventriculotomy incision of the infarcted area. For the infarct lesion, this approach provides excellent results with sufficient closure of the VSR and prevention of the ventricular remodeling for five years. A right atrial approach for postinfarction posterior VSR is very useful for avoiding any further ventriculotomy in an already impaired ventricle, securing a stable suture, and preserving the left ventricular geometry and function.

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.

Repair of acute postinfarct posterior ventricular septal rupture without left ventriculotomy: a stable suture preserving left ventricular geometry

The present article describes the case of a man operated upon for emergency closure of an acute postinfarction defect in the posterior septum. We used a novel technique. The rupture was approached by disconnection of the right ventricular posterior free wall with the exposure of the right side of the septum. First, the edges of the defect were joined together by a single purse-string pledgetted suture. Then an on-site tailored double-folded patch was applied with the aim of closing both the septal defect and the RV access. In our limited experience the technique proved to be safe and effective, allowed optimal exposure of the defect and placement of stable stitches, reducing postoperative complications.

Risk factors, echocardiographic patterns, and outcomes in patients with acute ventricular septal rupture during myocardial infarction

Ventricular septal rupture (VSR), which can complicate an acute myocardial infarction (MI), carries a high mortality rate. Because precordial and transesophageal echocardiography can identify the type of rupture and assess right ventricular (RV) function at the patient's bedside, we examined the prognostic significance of echocardiographic patterns in postinfarct VSR by postulating that complex rupture and RV involvement carry a worse prognosis. Seventeen patients (10 men; mean age 66 years) who had confirmed postinfarct VSR underwent precordial and transesophageal echocardiography followed by coronary angiography. Serial 12-lead and right precordial leads were also available. Type of septal rupture was classified as simple or complex based on autopsy-proved echocardiographic criteria. Three patients had inferior wall MI and 14 had anterior wall MI. ST-segment elevation persisted >72 hours in all 3 patients who had inferior wall MI and in 12 who had anterior wall MI. Segmental wall motion abnormalities helped in detecting the left ventricular entry site, and use of unconventional views superimposed with color flow Doppler provided the RV exit site. RV function was better appreciated with transesophageal echocardiography. Two patients who had inferior wall MI and 7 who had anterior wall MI had complex ruptures. All 3 patients who had inferior wall MI and 7 who had anterior wall MI had electrocardiographic and echocardiographic evidence of RV involvement. Mortality rate was higher in patients who had complex rupture (78% vs 38%, p <0.001) and in those who had RV extension (71% vs 29%, p <0.001). In conclusion, persistent ST elevation is a common finding in patients who have postinfarct VSR. Complex VSR and RV involvement are significant determinants of clinical outcome.

Transatrial approach of acquired posterior ventricular septal rupture and double orifice technique in tricuspid valve repair

We present a successful transatrial repair of ventricular septal rupture and tricuspid valve reconstruction, using the "edge-to-edge" technique, as a serious complication of a posterior myocardial infarction in an 83-year-old woman.