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

Ventricular septal defect complicating acute myocardial infarction: diagnosis and management. A Clinical Consensus Statement of the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the ESC Working Group on Cardiovascular Surgery

Ventricular septal defects are a rare complication after acute myocardial infarction with a mortality close to 100% if left untreated. However, even surgical or interventional closure is associated with a very high mortality and currently no randomized controlled trials are available addressing the optimal treatment strategy of this disease. This state-of-the-art review and clinical consensus statement will outline the diagnosis, hemodynamic consequences and treatment strategies of ventricular septal defects complicating acute myocardial infarction with a focus on current available evidence and a focus on major research questions to fill the gap in evidence.

Ventricular Septal Rupture After Myocardial Infarction: JACC Focus Seminar 3/5

Ventricular septal rupture remains a dreadful complication of acute myocardial infarction. Although less commonly observed than during the prethrombolytic era, the condition remains complex and is often associated with refractory cardiogenic shock and death. Corrective surgery, although superior to medical treatment, has been associated with high perioperative morbidity and mortality. Transcatheter closure techniques are less invasive to surgery and offer a valuable alternative, particularly in patients with cardiogenic shock. In these patients, percutaneous mechanical circulatory support represents a novel opportunity for immediate stabilization and preserved end-organ function. Multimodality imaging can identify favorable septal anatomy for the most appropriate type of repair. The heart team approach will define optimal timing for surgery vs percutaneous repair. Emerging concepts are proposed for a deferred treatment approach, including orthotropic heart transplantation in ideal candidates. Finally, for futile situations, palliative care experts and a medical ethics team will provide the best options for end-of-life clinical decision making.

Successful repair of recurrent ventricular septal perforation after myocardial infarction using double patch technique via right ventriculotomy: a case report

BACKGROUND

Post-myocardial infarction (MI) ventricular septal perforation (VSP) is a rare but life-threatening complication. Surgical repair is challenging and carries significant risks, particularly in the context of recurrent VSPs. This case study presents a patient with recurrent VSP after initial surgical repair following myocardial infarction.

CASE PRESENTATION

A 65-year-old male were re-administered to our hospital due to recurrent VSP. He was during follow up after undergone emergency VSP closure surgery 2 months earlier, utilizing the bovine double patch technique via left ventriculostomy. The initial VSP was located in the apical part of the interventricular septum, while the recurrent VSP appeared in the upper middle portion of the interventricular septum (Fig. 1). As the previous patch remained intact, the second surgery employed the bovine double patch technique via right ventriculostomy. The patient's condition remained stable without the development of heart failure symptoms.

CONCLUSION

Repairing recurrent VSPs remains a challenge, necessitating the mastery of appropriate approaches to achieve optimal outcomes. Further research and guidelines are required to refine management strategies for recurrent VSPs.

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.

Early and Late Surgical Outcomes after Geometrical Infarct Exclusion for Post-Infarct Ventricular Septal Perforation

PURPOSE

Ventricular septal perforation (VSP) is a critical complication of acute myocardial infarction. Various surgical procedures for it have been developed; however, surgical outcomes remain unsatisfactory. In 2010, we introduced geometrical infarct exclusion (GIE) as a modification of the Komeda-David technique. This retrospective study compared the surgical outcomes of our geometric infarct exclusion technique to those of other surgical procedures.

METHODS

This study included 38 patients who underwent surgery for VSP. They were divided into patients who underwent GIE (GIE group; n = 17) and those who underwent other procedures (non-GIE group; n = 21). The clinical outcomes of the two groups were compared.

RESULTS

Operation, cardiopulmonary bypass, and cardiac arrest times in the GIE group were significantly longer than those in the non-GIE group (p <0.001). A residual shunt was observed in one patient (5.8%) in the GIE group and eight (38.0%) in the non-GIE group (p = 0.026). No patients in the GIE group required a reoperation for the residual shut, while two patients required it in the non-GIE group (p = 0.492). Operative mortality was insignificantly different between the two groups.

CONCLUSION

Geometric infarct exclusion has a longer procedural time than does other surgical procedures but can reduce the rates of residual shunts and reoperations.

Infarct exclusion repair of postmyocardial infarction ventricular septal rupture with a hybrid patch and septal occluder device compared with patch only

Objective

We developed a hybrid technique for repairing post-myocardial infarction (MI) ventricular septal defect (VSD) that combines infarct exclusion with patch and a nitinol-mesh septal occluder device (SOD) to provide a scaffold to support the damaged septal wall. Here, we compare outcomes of patients with post-MI VSD repaired using patch only or hybrid patch/SOD.

Methods

Patients undergoing post-MI VSD repair at our institution from 2013 to 2022 who received patch alone or patch/SOD repair were analyzed. Primary outcome was survival to hospital discharge. Clinical outcomes and echocardiograms were also analyzed.

Results

Over a 9-year period, 24 patients had post-MI VSD repair at our institution with either hybrid patch/SOD (n = 10) or patch only repair (n = 14). VSD size was 18 ± 5.8 mm for patch/SOD and 17 ± 4.6 mm for patch only. In the patch/SOD repair cohort, average size of SOD implant was 23.6 ± 5.6 mm. Mild left ventricular dysfunction was present prerepair and was unchanged postrepair in both groups; however, moderate-to-severe right ventricular (RV) dysfunction was common in both groups before repair. RV function worsened or persisted as severe in 10% of hybrid versus 54% of patch-only patients postrepair. Tricuspid annular systolic excursion and RV:left ventricle diameter ratio, quantitative metrics of RV function, improved after patch/SOD repair. No intraoperative mortality occurred in either group. Postoperative renal, hepatic, and respiratory failure requiring tracheostomy was common in both groups. Survival to hospital discharge in both cohorts was 70%.

Conclusions

Post-MI VSD repair with patch/SOD has comparable short-term outcomes with patch alone. Addition of a SOD to patch repair provides a scaffold that may enhance the repair of post-MI VSD with patch exclusion.

Ventricular Septal Rupture Management in Patients With Acute Myocardial Infarction: A Review

Untreated myocardial infarction (MI) can potentially lead to many fatal complications which require immediate management. One of them is ventricular septal rupture (VSR) which necessitates the hemodynamic stabilization and closure of the septal rupture. Conventional treatment strategy involves surgical repair; however, percutaneous transcatheter repair using an occluder device is a promising upcoming approach. We conducted a detailed review of various published articles and examined the trends in incidence, risk factors, and pathophysiology of MI leading to VSR followed by an in-depth analysis of the various management strategies for the same. In the current clinical scenario, thrombolysis is an imperative management strategy that has been shown to decrease the occurrence of VSR by manifolds, more specifically in patients having ST-elevated MI. Delayed surgical closure remains the main treatment for post-infarction VSR. Other newer modalities, such as percutaneous closure devices and mechanical circulatory supports, are attractive alternative or complementary strategies to treat such patients, both postoperatively and perioperatively. However, earlier surgical repair in VSR increases the risk of mortality, and the optimal timing for VSR closure remains controversial. Despite surgical closure of VSR being the traditional treatment, it presents a considerably high operative risk. Although newer interventions such as percutaneous closure devices and mechanical circulatory supports provide impressive outcomes, their efficacy in high-risk patients remains inconclusive.

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.

Extracorporeal Membrane Oxygenation as a Bridge to Surgical Repair of Postinfarct Ventricular Septal Defect

Postinfarct ventricular septal defect (PIVSD) is associated with high mortality and the management of these patients has been a challenge with little improvement in outcomes. We commenced a protocol of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for those patients who present in cardiogenic shock with the aim to improve end-organ function before definitive surgical repair to reduce postoperative mortality. This study reviewed the results of this strategy. This was a single-center, retrospective review of all patients who were admitted to our institution with PIVSD in cardiogenic shock from September 2015 to November 2019. Clinical and investigative data were evaluated. Eight patients were referred with PIVSD during this period in cardiogenic shock. One patient had an anterior PIVSD and the other seven had inferior PIVSD. Six patients underwent surgical repair at a median (interquartile range, IQR) of 7 (5-8) days after initiation of VA ECMO. Two patients did not undergo surgical repair. Five patients survived after surgery and one patient died postoperatively due to multiorgan failure. Preoperative use of VA ECMO is a feasible strategy for PIVSD and may improve the results of repair.

Analysis of influencing factors for prognosis of patients with ventricular septal perforation: A single-center retrospective study

Background

Ventricular septal rupture (VSR) is a type of cardiac rupture, usually complicated by acute myocardial infarction (AMI), with a high mortality rate and often poor prognosis. The aim of our study was to investigate the factors influencing the long-term prognosis of patients with VSR from different aspects, comparing the evaluation performance of the Gensini score, Sequential Organ Failure Assessment (SOFA) score and European Heart Surgery Risk Assessment System II (EuroSCORE II) score systems.

Methods

This study retrospectively enrolled 188 patients with VSR between Dec 9, 2011 and Nov 21, 2021at the First Affiliated Hospital of Zhengzhou University. All patients were followed up until Jan 27, 2022 for clinical data, angiographic characteristics, echocardiogram outcomes, intraoperative, postoperative characteristics and major adverse cardiac events (MACEs) (30-day mortality, cardiac readmission). Cox proportional hazard regression analysis was used to explore the predictors of long-term mortality.

Results

The median age of 188 VSR patients was 66.2 ± 9.1 years and 97 (51.6%) were males, and there were 103 (54.8%) patients in the medication group, 34 (18.1%) patients in the percutaneous transcatheter closure (TCC) group, and 51 (27.1%) patients in the surgical repair group. The average follow-up time was 857.4 days. The long-term mortality of the medically managed group, the percutaneous TCC group, and the surgical repair group was 94.2, 32.4, and 35.3%, respectively. Whether combined with cardiogenic shock (OR 0.023, 95% CI 0.001–0.054, P = 0.019), NT-pro BNP level (OR 0.027, 95% CI 0.002–0.34, P = 0.005), EuroSCORE II (OR 0.530, 95% CI 0.305–0.918, P = 0.024) and therapy group (OR 3.518, 95% CI 1.079–11.463, P = 0.037) were independently associated with long-term mortality in patients with VSR, and this seems to be independent of the therapy group. The mortality rate of surgical repair after 2 weeks of VSR was much lower than within 2 weeks (P = 0.025). The cut-off point of EuroSCORE II was determined to be 14, and there were statistically significant differences between the EuroSCORE II &lt; 14 group and EuroSCORE II≥14 group (HR = 0.2596, 95%CI: 0.1800–0.3744, Logrank P &lt; 0.001).

Conclusion

Patients with AMI combined with VSR have a poor prognosis if not treated surgically, surgical repair after 2 weeks of VSR is a better time. In addition, EuroSCORE II can be used as a scoring system to assess the prognosis of patients with VSR.

Mechanical Circulatory Support in Delayed Surgery of Post-Infarction Ventricular Septal Rupture in Patients in Cardiogenic Shock-A Review

Post-infarction ventricular septal rupture (VSR) is a serious complication of myocardial infarction, which, in its natural course or treated medically, is related to high mortality rate. Surgical intervention remains the treatment of choice. Recent studies have shown that delayed surgery is related to better outcomes in comparison with urgent surgery; however, in many studies the impact of the patients' initial hemodynamic status on the treatment outcomes often remains unclear. In this review, we analyze the outcomes of delayed surgical treatment of patients in cardiogenic shock in the course of post-infarction ventricular septal defect stabilized with preoperative use of mechanical circulatory support. We evaluate the importance of various types of mechanical circulatory devices (MCD), such as extracorporeal membrane oxygenation, Tandem Heart, Impella, and intra-aortic baloon pump (IABP) in preoperative stabilization of patients, and the most suitable time for surgery, and we also present the features of ideal MCD for patients with VSR. A search of Pubmed to identify studies concerning the use of MCD in patients in cardiogenic shock in the course of VSR qualified for delayed surgery was conducted in January 2022. A total of 16 articles with three or more patients described were analyzed in this study. The preoperative use of MCD in patients in cardiogenic shock and delayed surgery as a main part of treatment seems to be a promising direction, however, it requires further research.

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 &gt;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 &gt;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.

Transesophageal Echocardiographic Illustration of Postinfarction Ventricular Septal Rupture

Postinfarction ventricular septal rupture (VSR) is a rare but dreaded mechanical complication of myocardial infarction. Moreover, patient develops cardiogenic shock or congestive heart failure requiring early surgical intervention. To optimize surgical repair, perioperative confirmation, determining location of VSR and adequacy of repair, is mandatory. Assessment can be obtained by the transesophageal echocardiography (TEE). Use of two- and three-dimensional TEE techniques clearly delineate size and shape of septal rupture and involvement of other cardiac structures. We report a patient presenting with postinfarction VSR for elective VSR repair and surgical revascularization and implication of TEE in perioperative management.

Benefits and Risks of Delayed Surgery for Ventricular Septal Rupture after Acute Myocardial Infarction

The timing of surgery for ventricular septal rupture (VSR) after acute myocardial infarction (AMI) remains controversial. This study investigated the benefits and risks of delayed surgery for post-AMI VSR and examined differences in echocardiographic findings between early and delay groups.A total of 38 consecutive patients with post-AMI VSR who underwent surgery at our hospital between May 2003 and November 2020 were retrospectively analyzed. Our strategy was to delay surgery until 2 weeks after AMI. If patients demonstrated organ dysfunction, we considered early surgery. Patients were divided into early (n = 20; 53%) and delay (n = 18; 47%) groups. Risks and benefits were investigated based on echocardiographic findings during the waiting period. The delay group had more preoperative intravenous catheter infections (P = 0.008) but fewer reoperations (P = 0.02) and lower operative mortality (P = 0.04) than the early group. The VSR defect diameter and total pulmonary blood flow to total systemic blood flow (Qp/Qs) increased in both groups while waiting. Nevertheless, the early group had a significantly higher Qp/Qs change rate than the delay group (P = 0.05). The 30 day and hospital mortality rates were 5.3% and 13.2%, respectively.The VSR defect diameter and Qp/Qs in both groups increased with time and can therefore become risk factors. Nonetheless, the benefit of waiting exceeded the risk because our outcomes were better than those previously reported.

The evaluation of levosimendan in patients with acute myocardial infarction related ventricular septal rupture undergoing cardiac surgery: a prospective observational cohort study with propensity score analysis

STUDY OBJECTIVE

The purpose of the present study was to evaluate the efficacy of levosimendan in patients with acute myocardial infarction related ventricular septal rupture (AMI-VSR) underwent cardiac surgery.

DESIGN

Prospective observational cohort study with propensity score analysis.

PATIENTS

There were 261 patients with AMI-VSR in our study. After 1:1 propensity matching, 106 patients (53 levosimendan and 53 control) were selected in the matched cohort.

INTERVENTIONS

None.

MEASUREMENTS

Patients who received levosimendan were assigned to the levosimendan group (n = 164). The patients who were not received were levosimendan assigned to the control group (n = 97). The levosimendan was initiated immediately after cardiopulmonary bypass. Then, it has been maintained during the postoperative 3 days. The poor outcomes were identified as follows: death and postoperative complications (postoperative stroke, low cardiac output syndromeneeded mechanical circulatory support after surgery, acute kidney injury (≥ stage III), postoperative infection or septic shock, new developed atrial fibrillation or ventricular arrhythmias).

MAIN RESULTS

Before matching, the control group had more length of ICU stay (6.69 ± 3.90 d vs. 5.20 ± 2.24 d, p < 0.001) and longer mechanical ventilation time (23 h, IQR: 16-53 h vs. 16 h, IQR: 11-23 h, p < 0.001). Other postoperative outcomes have not shown significant differences between two groups. After matching, no significant difference was found between both groups for all postoperative outcomes. The Kaplan-Meier survivul estimate and log-rank test showed that the 90-day survival had no significant differences between two groups before and after matching.

CONCLUSION

Our study found that a low-dose infusion of levosimendan in AMI-VSR patients underwent surgical repair did not associated with positively affect to postoperative outcomes.

Post-infarction ventricular septal rupture

Coronary reperfusion therapies have led to a reduction in the incidence of mechanical complications of acute myocardial infarction (AMI), but the associated mortality of these complications has remained high. Ventricular septal rupture is the most common mechanical complication after myocardial infarction and occurs in approximately 0.21% with ST-segment elevation myocardial infarction and in 0.04% with non-ST-segment elevation myocardial infarction. Surgery is the only definitive treatment but it is associated with high operative mortality and morbidity and, in some centers, alternative treatment with mechanical support of circulation and trans-catheter closure of the defect is being used. We continue to believe that immediate surgery offers the best opportunity for long-term survival. Patients should be taken directly to the operating room or via the heart catheterization laboratory if the coronary artery anatomy is unknown. This should be done as soon as the diagnosis is made, as acute rupture of the interventricular septum is a surgical emergency. The operative technique of infarct exclusion has been our preferred method and when performed in hemodynamically stable patients, the operative mortality is around 10%, although much higher in patients in cardiogenic shock. Patch dehiscence and persistent shunts are uncommon after closure of the defect using this technique. Delaying operative intervention in hemodynamically stable patients frequently leads to cardiogenic shock and multi-organ failure. Transcatheter closure of these acute septal lesions is complex, not necessarily feasible in all patients, and there is no evidence that the results are superior to surgery.

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.

Treatment Strategies for Ventricular Septal Rupture After Myocardial Infarction: A Single-Center Experience

Objective

To analyze treatment strategies, prognosis, and related risk factors of patients with postinfarction ventricular septal rupture, as well as the impact of timing of surgical intervention.

Methods

A total of 23 patients diagnosed with postinfarction ventricular septal rupture who were non-selectively admitted to Shanxi Provincial Cardiovascular Hospital between October 2017 and August 2021 were included in this study. The relevant clinical data, operation-related conditions, and follow-up data were summarized for all patients. The Kaplan-Meier method and log-rank test were used for the cumulative incidence of unadjusted mortality in patients with different treatment methods. Multivariate logistic regression was used to evaluate the independent risk factors for in-hospital patient mortality.

Results

The mean age of the study patients was 64.43 ± 7.54 years, 12(52.2%) were females. There was a significant difference in terms of postoperative residual shunt between the surgical and interventional closure groups (5.9 vs. 100%, respectively; P < 0.001). The overall in-hospital mortality rate was 21.7%; however, even though the surgical group had a lower mortality rate than the interventional closure group (17.6 vs. 33%, respectively), this difference was not statistically significant (P = 0.576). Univariate analysis showed that in-hospital survival group patients were significantly younger than in-hospital death group patients (62.50 ± 6.53 vs. 71.40 ± 7.37 years, respectively; P = 0.016), and that women had a significantly higher in-hospital mortality rate than men (P = 0.037). The average postoperative follow-up time was 18.11 ± 13.92 months; as of the end of the study all 14 patients in the surgical group were alive, Two out of four patients survived and two patients died after interventional closure. Univariate analysis showed that interventional closure was a risk factor for long-term death (P < 0.05).

Conclusion

Surgical operation is the most effective treatment for patients with postinfarction ventricular septal rupture; however, the best timing of the operation should be based on the patient's condition and comprehensively determined through real-time evaluation and monitoring. We believe that delaying the operation time as much as possible when the patient's condition permits can reduce postoperative mortality. Interventional closure can be used as a supplementary or bridge treatment for surgical procedures.

Surgical Treatment of Postinfarction Ventricular Septal Rupture

IMPORTANCE

Ventricular septal rupture (VSR) is a rare but life-threatening mechanical complication of acute myocardial infarction associated with high mortality despite prompt treatment. Surgery represents the standard of care; however, only small single-center series or national registries are usually available in literature, whereas international multicenter investigations have been poorly carried out, therefore limiting the evidence on this topic.

OBJECTIVES

To assess the clinical characteristics and early outcomes for patients who received surgery for postinfarction VSR and to identify factors independently associated with mortality.

DESIGN, SETTING, AND PARTICIPANTS

The Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort (CAUTION) Study is a retrospective multicenter international cohort study that includes patients who were treated surgically for mechanical complications of acute myocardial infarction. The study was conducted from January 2001 to December 2019 at 26 different centers worldwide among 475 consecutive patients who underwent surgery for postinfarction VSR.

EXPOSURES

Surgical treatment of postinfarction VSR, independent of the technique, alone or combined with other procedures (eg, coronary artery bypass grafting).

MAIN OUTCOMES AND MEASURES

The primary outcome was early mortality; secondary outcomes were postoperative complications.

RESULTS

Of the 475 patients included in the study, 290 (61.1%) were men, with a mean (SD) age of 68.5 (10.1) years. Cardiogenic shock was present in 213 patients (44.8%). Emergent or salvage surgery was performed in 212 cases (44.6%). The early mortality rate was 40.4% (192 patients), and it did not improve during the nearly 20 years considered for the study (median [IQR] yearly mortality, 41.7% [32.6%-50.0%]). Low cardiac output syndrome and multiorgan failure were the most common causes of death (low cardiac output syndrome, 70 [36.5%]; multiorgan failure, 53 [27.6%]). Recurrent VSR occurred in 59 participants (12.4%) but was not associated with mortality. Cardiogenic shock (survived: 95 [33.6%]; died, 118 [61.5%]; P < .001) and early surgery (time to surgery ≥7 days, survived: 105 [57.4%]; died, 47 [35.1%]; P < .001) were associated with lower survival. At multivariate analysis, older age (odds ratio [OR], 1.05; 95% CI, 1.02-1.08; P = .001), preoperative cardiac arrest (OR, 2.71; 95% CI, 1.18-6.27; P = .02) and percutaneous revascularization (OR, 1.63; 95% CI, 1.003-2.65; P = .048), and postoperative need for intra-aortic balloon pump (OR, 2.98; 95% CI, 1.46-6.09; P = .003) and extracorporeal membrane oxygenation (OR, 3.19; 95% CI, 1.30-7.38; P = .01) were independently associated with mortality.

CONCLUSIONS AND RELEVANCE

In this study, surgical repair of postinfarction VSR was associated with a high risk of early mortality; this risk has remained unchanged during the last 2 decades. Delayed surgery seemed associated with better survival. Age, preoperative cardiac arrest and percutaneous revascularization, and postoperative need for intra-aortic balloon pump and extracorporeal membrane oxygenation were independently associated with early mortality. Further prospective studies addressing preoperative and perioperative patient management are warranted to hopefully improve the currently suboptimal outcome.

Clinical Characteristics and Contemporary Prognosis of Ventricular Septal Rupture Complicating Acute Myocardial Infarction: A Single-Center Experience

Objectives: Ventricular septal rupture (VSR) is a rare but lethal complication of acute myocardial infarction (AMI). We conducted a retrospective analysis of the clinical characteristics of VSR patients and explored the risk factors for long-term mortality. Methods: In this single-center cohort study, 127 patients diagnosed with post-AMI VSR between May 2012 and April 2019 were included. Demographic, clinical, operative, and outcome data were collected. The 30-day and long-term mortality were outcomes of interest. Cox proportional hazard regression analysis was used to explore the predictors of long-term mortality. Results: The mean age of the VSR cohort was 66.6 ± 8.7 years, 67 (52.8%) were males. Among the 127 patients, 78 patients (61.4%) were medically managed, 31 (24.4%) patients underwent percutaneous transcatheter closure (TCC), and 18 (14.2%) patients received surgical repair. The median follow-up time was 1129 days [interquartile range: 802-2019 days]. The 30-day mortality of the medically managed group, percutaneous TCC group, and surgical management group was 93.6, 22.6, and 11.1%, respectively; and the long-term mortality was 96.2, 25.8, and 22.2%, respectively. VSR repair treatment including surgical management (HR 0.01, 95% CI 0.001-0.09, p < 0.001) and percutaneous TCC (HR 0.09, 95% CI 0.03-0.26, p < 0.001) was associated with a better prognosis, and cardiogenic shock (CS) (HR 9.30, 95% CI 3.38-25.62, p < 0.001) was an independent risk factor of long-term mortality. Conclusions: The prognosis of VSR patients without operative management remains poor, especially in those complicated with CS. Timely and improved surgery treatment is needed for better outcomes in VSR patients.

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.

Sutureless patch repair with a novel adhesive for postinfarction ventricular septal rupture

Ventricular septal rupture after acute myocardial infarction is a fatal complication with a very high in-hospital mortality. Herein, we describe a new repair technique using a 1st patch for exclusion of the infarcted myocardium and a 2nd sutureless patch for rupture site closure with a novel tissue adhesive (Hydrofit®). Follow-up of over 2 years revealed a good clinical course and no residual interventricular shunt on echocardiography. This modified infarct exclusion technique with a 2nd sutureless patch has a benefit of avoiding stitches to the fragile infarcted myocardium and might be effective in preventing interventricular shunt recurrence after ventricular septal rupture.

Mechanical Complications of Acute Myocardial Infarction: A Review

Importance

Mechanical complications of acute myocardial infarction include left ventricular free-wall rupture, ventricular septal rupture, papillary muscle rupture, pseudoaneurysm, and true aneurysm. With the introduction of early reperfusion therapies, these complications now occur in fewer than 0.1% of patients following an acute myocardial infarction. However, mortality rates have not decreased in parallel, and mechanical complications remain an important determinant of outcomes after myocardial infarction. Early diagnosis and management are crucial to improving outcomes and require an understanding of the clinical findings that should raise suspicion of mechanical complications and the evolving surgical and percutaneous treatment options.

Observations

Mechanical complications most commonly occur within the first week after myocardial infarction. Cardiogenic shock or acute pulmonary edema are frequent presentations. Echocardiography is usually the first test used to identify the type, location, and hemodynamic consequences of the mechanical complication. Hemodynamic stabilization often requires a combination of medical therapy and mechanical circulatory support. Surgery is the definitive treatment, but the optimal timing remains unclear. Percutaneous therapies are emerging as an alternative treatment option for patients at prohibitive surgical risk.

Conclusions and Relevance

Mechanical complications present with acute and dramatic hemodynamic deterioration requiring rapid stabilization. Heart team involvement is required to determine appropriate management strategies for patients with mechanical complications after acute myocardial infarction.

Long-Term Survival and Risk Factors for Post-Infarction Ventricular Septal Rupture

BACKGROUND

This study was performed to assess long-term survival and identify risk factors for acute myocardial infarction in patients complicated with ventricular septal rupture (VSR).

METHOD

A retrospective analysis of 116 patients with post-infarction VSR (PI-VSR) hospitalised in Beijing Anzhen Hospital from January 2008 to February 2019 was performed. The independent risk factors for in-hospital mortality were assessed using multivariate analysis with a logistic regression model. The Kaplan-Meier method and log-rank test were carried out for long-term survival in the surgery group.

RESULTS

The overall in-hospital mortality rate was 47.4%. Logistic regression analysis revealed that age (p<0.05), female sex (p<0.05), no surgical repair (p<0.05), liver dysfunction (p<0.05), high heart rate (p<0.05), and low platelet count (PLT; p<0.05) were independent risk factors for in-hospital mortality. The 1-year mortality rate was lower in the surgery group than in the medical treatment group (18.3% vs 84.5%; p<0.005). During the mean follow-up of 5.2±5.1 years (median, 1.3 years), the actuarial survival rates of these patients at 5 and 10 years were 72.3% and 43.2%, respectively.

CONCLUSIONS

The overall in-hospital mortality rate remained high. The independent risk factors for in-hospital mortality associated with PI-VSR were age, female sex, no surgical repair, liver dysfunction, tachycardia, and low PLT level. The 1-year mortality and long-term outcomes of patients treated with surgery were significantly better than those of patients who were treated conservatively.

Recurrent ventricular septal defect following closure CorMatrix: A case report

Ventricular septal ruptures are an uncommon complication following acute myocardial infarction. Operative repair, utilizing a patch for closure of the defect, is the primary treatment modality to achieve hemodynamic stability. The use of an extracellular matrix derived from small intestinal submucosa as a scaffold for tissue repair is becoming increasingly common. Here, we present the case of a 58-year-old female found to have a ventricular septal rupture and posterior left ventricular aneurysm following late presentation after a myocardial infarction that required operative repair with a CorMatrix patch. Upon readmission for dyspnea and poor exercise tolerance several months later, the patch was subsequently found to have near-completely reabsorbed. There is a paucity of long-term outcomes data following the use of CorMatrix for septal defects, with rare reports of such reabsorption. Further study is required to identify the incidence and implications of such findings.

Optimal Time Repair of Ventricular Septal Rupture Post Myocardial Infarction

Ventricular septal rupture (VSR) is an uncommon complication of myocardial infarction (MI). The mortality rate of VSR is high. The management of VSR is including the stabilization of the hemodynamic status and surgical closure of the rupture. In spite of the agreement of experts on the necessity of surgical repair, the timing of VSR repair management remains unclear. In this review article, we evaluate the optimal time repair of VSR. To collect the data, Pubmed, EMBASE, and Cochrane Central Registry databases were searched for potentially suitable studies. Search terms were including “Ventricular Septal Rupture”, “Myocardial Infarction”, “Timing”, and “MI”. According to the result of the studies, it seems that the time between VSR detection and its repair is a determining factor in the survival or mortality of patients in post-myocardial infraction VSR. Studies showed that earlier surgical repair in VSR increases the risk of mortality, because in the early phase after MI, infarcted myocardium is very fragile, and it is very difficult surgical repair and increases the risk of recurrent septal defects. The longer time is needed for the heart and different body systems to adapt to the hemodynamic results of the abrupt left to right shunt. It seems that the best time for the operation is after the maturation of VSR with scarring at the edges of the defect. Moreover, in a large number of patients, it is not possible to delay the operation since they are at risk of severe heart failure and organ dysfunction. In these cases operation immediately after diagnosis of VSR is recommended to prevent further hemodynamic deterioration. In hemodynamically compromised patients, it may be considered to use a ventricular assist device, requiring an intra-aortic balloon pump (IABP), or extracorporeal membrane oxygenation (ECMO) preoperative to postpone the operation which leads to higher survival in post-MI-VSD.

Decision making, management, and midterm outcomes of postinfarction ventricular septal rupture: Our experience with 21 patients

Context:

Ventricular septal rupture (VSR) is a dreaded complication following myocardial infarction. Surgical repair of VSR is associated with significant early mortality. Variable outcomes in terms of early mortality and midterm functional status have been reported from different centers.

Aims:

In our study, we attempt to review the experience of decision making and surgical repair of postinfarction VSR, and to analyze the factors contributing to the early mortality and midterm outcome after repair.

Materials and Methods:

It is a retrospective study. Data were summarized retrospectively by frequencies and percentages for categorical factors, and means and standard deviations for continuous factors. Multivariate logistic regression, odds ratios, 95% confidence intervals, and P value were calculated for different variables to determine their independent effect on operative mortality. All surviving patients answered the EQ-5D Health Questionnaire.

Results:

Preoperative renal failure, left ventricular dysfunction (moderate and severe), and Killip class (III and IV) were significantly associated with early mortality after surgery. Small residual ventricular septal defect (VSD) was not found to affect the midterm quality of life.

Conclusions:

Early surgical repair benefits the patient by preventing early end-organ damage. The renal failure left ventricular dysfunction (moderate and severe) and Killip class (III and IV) adversely affect early outcomes after surgery. Small residual ventricular septal defect (VSD) does not affect the midterm quality of life.

Mechanical circulatory support for early surgical repair of postinfarction ventricular septal defect with cardiogenic shock

Postinfarction ventricular septal defect (pVSD) due to acute myocardial infarction complicated by cardiogenic shock (CS) is associated with high mortality. The aim of this study was to determine the outcome of primary surgical repair of pVSD in patients with CS and examine whether it is influenced by the use of mechanical circulatory support (MCS) devices. Between October 1994 and April 2016, primary surgical repair of pVSD complicated by CS was performed in 53 patients. Thirty-six (68%) were implanted pre-operatively with an intra-aortic balloon pump (IABP), 4 (8%) with extracorporeal life support (ECLS), and 13 (24%) received no MCS device. Prospectively collected demographic and perioperative data were analyzed retrospectively. All-cause, 30-day mortality rates were analyzed and multivariate analysis was performed to differentiate independent risk factors. No pre-operatively implanted MCS device was able to improve 30-day survival, whereas pre-operatively implanted ECLS tended to have a positive effect (P = .106). The post-operative need for a MCS device or escalation of MCS invasiveness (IABP upgrade to ECLS) was associated with a higher 30-day mortality (P = .001) compared with patients without any MCS device or those with pre-operatively implanted MCS devices. An independent risk factor for 30-day mortality was the interval between acute myocardial infarction and surgery <7 days (OR 5.895, CI 1.615-21.515; P = .007). Pre-operative implantation of ECLS for CS tends to improve the outcome of early primary surgical pVSD repair. The need for a post-operative MCS device is associated with a worse 30-day survival after early primary surgical pVSD repair.

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.

The evaluation of a tissue-engineered cardiac patch seeded with hips derived cardiac progenitor cells in a rat left ventricular model

BACKGROUND

Ventricular septal perforation and left ventricular aneurysm are examples of potentially fatal complications of myocardial infarction. While various artificial materials are used in the repair of these issues, the possibility of associated infection and calcification is non-negligible. Cell-seeded biodegradable tissue-engineered patches may be a potential solution. This study evaluated the feasibility of a new left ventricular patch rat model to study neotissue formation in biodegradable cardiac patches.

METHODS

Human induced pluripotent stem cell-derived cardiac progenitor cells (hiPS-CPCs) were cultured onto biodegradable patches composed of polyglycolic acid and a 50:50 poly (l-lactide-co-ε-caprolactone) copolymer for one week. After culturing, patches were implanted into left ventricular walls of male athymic rats. Unseeded controls were also used (n = 10/group). Heart conditions were followed by echocardiography and patches were subsequently explanted at 1, 2, 6, and 9 months post-implantation for histological evaluation.

RESULT

Throughout the study, no patches ruptured demonstrating the ability to withstand the high pressure left ventricular system. One month after transplantation, the seeded patch did not stain positive for human nuclei. However, many new blood vessels formed within patches with significantly greater vessels in the seeded group at the 6 month time point. Echocardiography showed no significant difference in left ventricular contraction rate between the two groups. Calcification was found inside patches after 6 months, but there was no significant difference between groups.

CONCLUSION

We have developed a surgical method to implant a bioabsorbable scaffold into the left ventricular environment of rats with a high survival rate. Seeded hiPS-CPCs did not differentiate into cardiomyocytes, but the greater number of new blood vessels in seeded patches suggests the presence of cell seeding early in the remodeling process might provide a prolonged effect on neotissue formation. This experiment will contribute to the development of a treatment model for left ventricular failure using iPS cells in the future.

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.

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.

Profile and Outcomes of Surgical Treatment for Ventricular Septal Rupture in Patients With Shock

BACKGROUND

The outcomes of surgical treatment of ventricular septal rupture (VSR) complicating acute myocardial infarction are worse in patients with cardiogenic shock. This study aimed to identify clinical characteristics and outcomes in patients with VSR presenting with cardiogenic shock.

METHODS

A retrospective analysis was performed in 105 consecutive VSR patients, 71 with cardiogenic shock (67.6%) and 34 without cardiogenic shock (32.4%), who underwent surgical treatment in the Department of Adult Cardiac Surgery of Fuwai Hospital between January 2002 and December 2017. Baseline characteristics and outcomes in patients with VSR with and without cardiogenic shock were assessed.

RESULTS

There were no differences in hypertension, diabetes, history of myocardial infarction, body mass index, or location of VSR between patients with and without cardiogenic shock. The size of VSR was larger in patients with cardiogenic shock than in those without (18.2 ± 8.1 mm vs 14.0 ± 7.8 mm; P = .013). Intraaortic balloon pump was required more in patients with cardiogenic shock before operation (39 [68.4%] vs 1 [5.0%]; P < .001]. More emergency surgeries were performed in the cardiogenic shock group (21 [29.6%] vs 3 [8.8%]; P = .018). There were 3 in-hospital deaths among patients with VSR with cardiogenic shock. After 76.56 ± 47.78 months of follow-up, only 2 noncardiac deaths were documented.

CONCLUSIONS

The larger the ventricular septal rupture is, the more prone patients are to develop cardiogenic shock. Surgical treatment outcomes for VSR with cardiogenic shock are satisfactory.

In-hospital outcome of patients with post-MI VSD: a single-center study

Introduction

Ventricular septal defect (VSD) is a rare but life-threatening complication of acute myocardial infarction (AMI). There is a paucity of data regarding the natural history of this devastating complication of myocardial infarction in the Middle East region with restricted financial resources and unsolved major health problems.

Aim

To evaluate the clinical presentation and in-hospital outcome of patients with post-infarction VSD over a 10-year period in a tertiary center in northwest Iran.

Material and methods

Data from 64 consecutive patients with VSD complicating AMI were retrospectively analyzed from March 2005 to May 2015.

Results

The mean age of the patients was 71.62 ±9.38 years with 57.8% of them being female. The VSDs were anterior in 52 (82%) patients. More than half of patients were in cardiogenic shock during the initial presentation. Multivessel coronary artery disease was found on coronary angiography in 70.3% of patients. In-hospital mortality was 82.8%. Multivariate analysis revealed cardiogenic shock (HR = 12.5, p = 0.001) as the only independent predictor of in-hospital mortality and surgical treatment as the only predictor of in-hospital survival (HR = 0.2, p = 0.02).

Conclusions

Our study demonstrated that VSD complicating myocardial infarction had an extremely high in-hospital mortality rate. Cardiogenic shock was the only independent predictor of in-hospital mortality and surgical treatment was the only predictor of in-hospital survival.

Post-Myocardial Infarction Ventricular Septal Defect: A Comprehensive Review

Post-myocardial infarction (MI) ventricular septal defect (VSD) is a rare but potentially catastrophic mechanical complication that occurs in <1% of patients following a myocardial infarction and it is associated with a high morbidity and mortality despite improvements in medical and surgical therapies. Post-MI VSD is a medical emergency and outcome is very poor in medically treated patients. Treatment of choice remains surgical closure of defect and transcatheter defect closure less so. We performed a comprehensive review of the clinical presentation and management options of post-MI VSD.

Modified Infarct Exclusion Technique for Repair of Postinfarction Ventricular Septal Rupture

Repair of ventricular septal rupture after acute myocardial infarction remains a surgical challenge. Several techniques for the closure of these defects have been described. This report discusses an infarct exclusion technique modified from the one described by Tirone David and associates. In this technique two separate pericardial patches are used. The first patch excludes the rupture. The second patch is sutured to the margins of the first patch and thus provides strength to the margins of the first patch. The repair is simple and durable and has reduced the incidence of residual ventricular septal defects and patch dehiscence.

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.

Echocardiographic Assessment of Ventricular Septal Rupture and Left Ventricular Aneurysm after Inferior and Posterior Myocardial Infarction

We present a case of posterior ventricular septal rupture associated to left ventricular aneurysm manged, during peri-operative period, by transthoracic and transesophageal echocardiography. Three-dimensional transesophageal echocardiography findings add adjunctive and more accurate information regarding morphological details of the ventricular septal rupture rather than two-dimensional echocardiography, allowing, meanwhile, the detection of the outcome of the surgical repair.

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.