Repair of postinfarction ventricular septal defects

Lower extremity artery thromboembolism during removal of Impella after repair for ventricular septal rupture: A case report

Although the anticoagulant complications of Impella are well known, the timing of heparin administration when using Impella immediately after open heart surgery has not been established. We report a case of a 59-year-old man with Impella-assisted repair of a ventricular septal perforation after acute myocardial infarction who developed thromboembolism of the lower extremity arteries after removal of Impella.

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.

Percutaneous repair of post-myocardial infarction ventricular septal defect: current approaches and future perspectives

Post-myocardial infarction ventricular septal defect is a devastating complication of ST-elevation myocardial infarction. Although surgical intervention is considered the gold standard for treatment, it carries high morbidity and mortality rates. We present 2 cases that illustrate the application of percutaneous closure of a post-myocardial infarction ventricular septal defect: the first in a patient who had undergone prior surgical closure and then developed a new shunt, and the second as a bridge to definitive surgery in a critically ill patient.

[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.

Delayed closure of postinfarction ventricular septum defect in a patient with single vessel disease

A 65-year-old patient with a systolic murmur that developed five days after acute anteroseptal myocardial infarction was referred to our Institution. He had previously been treated with fibrinolytic therapy. The patient was in a stable hemodynamic condition when admitted, with sustained diuresis. Blood gas analysis revealed normal parameters, whereas a chest X-ray showed signs of pulmonary congestion. Transthoracic echocardiography revealed a 1.5×1.2 cm post-infarction ventricular septum defect (VSD) in the apical part of the septum. Because the patient’s hemodynamic conditions were stable, we decided to postpone the operative treatment to allow scarring of the infarcted area to make VSD repair feasible, thereby increasing the chance for success. Operative treatment was performed three weeks after admission. We performed closure of the VSD with a bovine pericardial patch. The patient was discharged in good condition and remained well three months after the surgery.

Percutaneous closure of post-infarction ventricular septal defect using an Amplatzer septal occluder

A 77-year-old woman underwent percutaneous closure of post-infarction ventricular septal defect. The defect was successfully closed with a 20-mm Amplatzer septal occluder with a small residual shunt and Qp/Qs improved from 3.38 to 1.48. She was discharged 30 days after procedure. To our knowledge, this is the first case reported in Japan.

Severe mitral regurgitation in patients with postinfarction interventricular septal defect: a simple way of simultaneous valve repair

Ventricular septal defect, a potentially deadly complication of transmural myocardial infarction, is often accompanied by ischaemic mitral regurgitation. It has been recognized that the presence and persistence of the latter negatively affect survival rates in patients after myocardial infarction. We present a simple endoventricular edge-to-edge technique of mitral repair using a single U-shaped stitch of polytetrafluoroethylene and a refined double-patch 'exclusion' technique of postinfarction interventricular septal defect (PVSD) closure in the treatment of two consecutive cases of PVSD and concomitant ischaemic mitral regurgitation. This technique is effective and reproducible to address mitral incompetence in patients undergoing surgical correction of PVSD.

"The non-ischemic repair" as a safe alternative method for repair of anterior post-infarction VSD

Patient's myocardium with post-infarction ventricular septum defect (VSD) is characterized by severe dysfunction. The "additive ischemia" caused by the operating process of cross-clamp ischemia and reperfusion injury, has a significant aggravation to the myocardium and overall negative impact to patient's outcome. We present a useful, safe and advantageous methodology in order to abolish "the toxic phase" of ischemia-reperfusion which is adopted by most as the "classic repair method" of myocardial protection. This abolition is in our opinion, particularly beneficial in order to reverse postoperatively the Low Cardiac Output Syndrome (LOS) and achieve better short and long term results. By using this method we avoid the aortic occlusion, the use of systematic hypothermia and any cardioplegic arrest. Furthermore, the total cardio-pulmonary bypass (CPB) time is significantly reduced, tissue debridement and stitching is much easier and safer. We think the method is applicable for every anterior and apical case of post-infarction septum rupture. After application of method in 3 patients with anterior post-myocardial infarction VSD, we are convinced that the patient will have a better postoperative haemodynamic condition and therefore a better outcome.

On-pump coronary artery bypass surgery in high-risk patients aged over 65 years (EuroSCORE 6 or more): impact on early outcomes

The results of on-pump coronary artery bypass graft (CABG) surgery in 166 high-risk elderly patients (EuroSCORE 6 or more; over age 65 years [mean 71.8 years]) were compared with 176 low-risk elderly patients (EuroSCORE below 6; over age 65 years [mean 68.8 years]). There was no significant difference in hospital mortality or number of grafts between the two groups. Rates of inotropic agent use, intra-aortic balloon pump insertion and atrial fibrillation, and the duration of intensive care unit and hospital stay were significantly higher in high-risk than low-risk patients. There were no significant differences in the incidence of major complications between the two groups. The results suggest that, in selected patients, on-pump CABG can be safely performed in high-risk patients over 65 years old with no effect on mortality.

Experiences with surgical treatment of ventricle septal defect as a post infarction complication

BACKGROUND

Complications of acute myocardial infarction (AMI) with mechanical defects are associated with poor prognosis. Surgical intervention is indicated for a majority of these patients. The goal of surgical intervention is to improve the systolic cardiac function and to achieve a hemodynamic stability. In this present study we reviewed the outcome of patients with post infarction ventricular septal defect (PVSD) who underwent cardiac surgery.

METHODS

We analysed retrospectively the hospital records of 41 patients, whose ages range from 48 to 81, and underwent a surgical treatment between 1990 and 2005 because of PVSD.

RESULTS

In 22 patients concomitant coronary artery bypass grafting (CAGB) was performed. In 15 patients a residual shunt was found, this required re-op in seven of them. The time interval from infarct to rupture was 8.7 days and from rupture to surgery was 23.1 days. Hospital mortality in PVSD group was 32%. The mortality of urgent repair within 3 days of intractable cardiogenic shock was 100%. The mortality of patients with an anterior VSD and a posterior VSD was 29.6% vs 42.8%, respectively. All patients who underwent the surgical repair later than day 36 survived.

CONCLUSION

Surgical intervention is indicated for a majority of patients with mechanical complications. Cardiogenic shock remains the most important factor that affects the early results. The surgical repair of PVSD should be performed 4-5 weeks after AMI. To improve surgical outcome and hemodynamics the choice of surgical technique and surgical timing as well as preoperative management should be tailored for each patient individually.

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.

Feasibility study of the use of the TandemHeart® percutaneous ventricular assist device for treatment of cardiogenic shock

BACKGROUND

The mortality of cardiogenic shock (CGS) remains high despite currently available pharmacological and mechanical treatment options. The standard of care in medically refractory situations has been the insertion of an intra-aortic balloon pump. The purpose of this study was to investigate the feasibility, safety, and hemodynamic impact of the TandemHeart percutaneous left ventricular assist device (pVAD) in CGS.

METHODS

Thirteen patients from five centers in the US with the diagnosis of CGS were enrolled in the study. Hemodynamic measurements, including cardiac index (CI), mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP), and central venous pressure (CVP) were performed presupport, during support and after device removal. Patients were monitored for 6 months.

RESULTS

The pVAD was successfully implanted in all 13 patients, with duration of support averaging 60 +/- 44 hr. During support, CI increased from 2.09 +/- 0.64 at baseline to 2.53 +/- 0.65 (P = 0.02), MAP increased from 70.6 +/- 11.1 to 81.7 +/- 14.6 (P = 0.01), PCWP decreased from 27.2 +/- 12.2 to 16.5 +/- 4.8 (P = 0.01), and CVP from 12.9 +/- 3.7 to 12.6 +/- 3.6 (P = NS). Ten patients survived to device explant, 6 of whom were bridged to another therapy. Seven patients survived to hospital discharge and were all alive at 6 months. The two most common adverse events were distal leg ischemia (n = 3) and bleeding from the cannulation site (n = 4).

CONCLUSION

The TandemHeart PTVA System may be a useful complementary treatment for patients with CGS, especially as a bridge to another treatment. Further study is needed to definitively establish safety and efficacy.

Transcatheter repair of recurrent postinfarct ventricular septal defects

Surgical repair of recurrent postmyocardial infarction septal defect is associated with a high mortality rate. We present 2 patients whose recurrent defects were closed percutaneously using an Amplatzer device.

Transcatheter closure of a ruptured ventricular septum after myocardial infarction using a venous approach

A 65-year old patient was admitted after having sustained a ventricular septum rupture 18 days after an anterior myocardial infarction. He developed acute heart failure. Given the extremely high perioperative risk in surgical approaches in this setting, we decided for a transcatheter closure of the defect with an exclusively venous approach. After a complete recovery, the patient underwent open heart surgery with aorto coronary bypass, aneurysmectomy, and removal of the closure device. This case demonstrates that transcatheter closure of a post infarction ventricular septum rupture is a technically feasible and suitable method.

Surgical Repair of Mechanical Complications of Myocardial Infarction

Mechanical complications of acute myocardial infarction are estimated to account for 25,000 fatalities yearly in the United States. The diagnosis necessitates a high degree of clinical suspicion. Once recognized, prompt surgical intervention is necessary because if left untreated the condition frequently causes a fatal outcome. The main determinants of survival are the preoperative hemodynamic status of the patient, the presence of multisystem failure at presentation, and concomitant revascularization during repair of the defect. Because ischemic heart disease remains the leading cause of death in such patients following repair, coronary artery bypass should be considered and, whenever possible, performed in conjunction with repair of the postinfarct mechanical complication.

Transcatheter closure of recurrent postmyocardial infarction ventricular septal defects utilizing the Amplatzer postinfarction VSD device: a case series

The initial therapy for postmyocardial infarction ventricular septal defects is surgical repair of the defect. Unfortunately, a significant number of patients develop recurrent ventricular septal defects (VSDs) following operative repair. Transcatheter closure offers an alternative to reoperation in these critically ill patients. We present a series of four patients in whom recurrent ventricular septal defects were closed using an Amplatzer VSD device.

Review of ventricular rupture: key concepts and diagnostic tools for success

Although a rare complication of acute myocardial infarction (AMI), ventricular rupture is a serious event associated with significant mortality and morbidity. Patients normally present with hemodynamic instability, often in cardiogenic shock. Despite improvements in surgical techniques and diagnostic tools, post-myocardial infarction ventricular rupture remains a difficult therapeutic challenge. There are three categories of ventricular rupture: free wall rupture (FWR), ventricular septal rupture (VSR), and papillary muscle rupture (PWR). The incidence of FWR occurs following up to 10% of myocardial infarctions. VSR and PWR have a lower incidence of 1-2% and 0.5-5%, respectively. Patients often present with single-vessel coronary artery disease and usually do not have a positive history for a previous myocardial infarction. The incidence of post infarction angina in these patients is significantly greater than in patients without ventricular rupture. Delay in treatment and continued physical activity post infarction increases the risk of ventricular rupture. Diagnostic tools such as two-dimensional echocardiography and cardiac catheterization confirm the diagnosis of ventricular rupture in only 45-88% of cases. Knowledge of the disease progression is necessary to insure accurate and timely diagnosis. Due to the rapid deterioration of these patients, there is a 50-80% mortality rate within the first week if untreated. With surgical correction, patients can extend their 5-year survival rates to 65%. A good example of the complex course of ventricular rupture is the case of a 71-year-old patient at our institution. The patient presented in cardiogenic shock following an AMI. Preoperative diagnosis was unsuccessful in determining the extent of the ventricular rupture. The correct diagnosis was determined in the operating room, and both a mitral valve replacement and closure of a ventricular septal defect were completed. The patient was successfully treated with this difficult pathology.

Percutaneous extracorporeal life support for treatment of fatal mechanical complications associated with acute myocardial infarction

Mechanical complications of acute myocardial infarction (AMI), such as free wall rupture, ventricular septal perforation (VSP), and mitral regurgitation due to papillary muscle rupture, are associated with high mortality rates. These complications result in extreme deterioration and increased risk of death in patients who do not receive timely resuscitation and surgical treatment. We studied the effectiveness of percutaneous extracorporeal life support (ECLS) for fatal mechanical AMI complications. Nine patients (7 men and 2 women, mean age 69 +/- 6 years) who suffered circulatory collapse refractory to conventional resuscitation were treated with ECLS. Circulatory collapse was caused by free wall rupture in 4 patients, VSP in 4, and mitral regurgitation due to papillary muscle rupture in 1. All patients were successfully resuscitated by ECLS and underwent surgical repair with conventional cardiopulmonary bypass. Eight patients required ECLS after surgery. Four of the 9 patients (2 with free wall rupture, 1 with VSP, and 1 with papillary muscle rupture) were successfully weaned from ECLS and were discharged. Three of the 4 survivors had no major complications, but the remaining survivor suffered neurological deficit. Four patients died while on devices. The duration of ECLS was from 13 to 167 h (mean 76 +/- 57 h) with a maximum bypass flow of 2.0 to 3.9 L/min (mean 2.9 +/- 0.6 L/min). There were no device-related complications during the support period. Total weaning rate was 56% (5/9), and survival was 44% (4/9). We conclude that ECLS can provide appropriate circulatory support during resuscitation and subsequent postoperative circulatory support for cardiovascular collapse associated with AMI complications.

[The practical clinical guidelines of the Sociedad Española de Cardiología on coronary surgery]

Surgery in coronary disease, including myocardial revascularization and the surgery of mechanical complications of acute myocardial infarction, has shown to improve the symptoms, quality of life and/or prognosis in certain groups of patients. The expected benefit in each patient depend on many well-known factors among which the appropriateness of the indication for surgery is fundamental. The objective of these guidelines is to review current indications for cardiac surgery in patients with coronary heart disease through an evaluation of the degree of evidence of effectiveness in the light of current knowledge (systematic review of bibliography) and expert opinion gathered from various reports. Indications and the degree of recommendation for conventional coronary artery bypass grafting have been established for each of the most frequent anatomo-clinical situations defined by clinical symptoms (stable angina, unstable angina and acute myocardial infarction) as well as by left ventricular function and extend of coronary disease. Furthermore, the subgroups with the greatest surgical risk and stratification models are described to aid the decision making process. Also we analyse the rational basis and indication for the new surgical techniques such as minimally invasive coronary surgery and total arterial revascularization. Finally, the indication and timing of surgery in patients with mechanical complications of acute myocardial infarction are considered.

A right atrial approach in redo postinfarction ventricular septal defect

Despite improvements in surgical techniques, post-infarction ventricular septal defect remains a surgical challenge that is associated with significant early and late mortality. Furthermore, the recurrence of the defect after primary correction occurs in approximately 10-25% of patients, and the operative risk increases because of a difficult dissection that is often complicated by previous patent grafts. The repair of recurrent ventricular septal defect has generally been performed by ventriculotomy in the infarcted zone. The authors propose an alternative approach that, when the rupture is posterior, allows its complete visualization, and avoids any further ventriculotomy in an already impaired ventricle.