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

Surgical management for mechanical complications of acute myocardial infarction: a systematic review of long-term outcomes

BACKGROUND

Mechanical complications following acute myocardial infarction (AMI), though rare, are associated with significant morbidity and mortality. Surgical management remains a mainstay of therapy for these complications. The purpose of this review is to evaluate long-term outcomes data of surgical management for postinfarction free wall rupture, ventricular septal defect, papillary muscle rupture, and pseudoaneurysm.

METHODS

An electronic literature search was performed to identify original studies reporting long-term outcomes data of surgical management of one of the four mechanical complications following AMI. Studies were considered to have long-term outcomes if they at minimum included survival or mortality data up to one year.

RESULTS

A total of 285 studies were identified from the literature search. Of these, 29 studies with long-term survival data on surgically managed mechanical complications of AMI are included in the review. The majority of these are retrospective cohort studies or single-center case series. Five studies are included on free wall rupture, 18 on ventricular septal defect, 4 on papillary muscle rupture, and 2 on pseudoaneurysm. Detailed results are tabulated according to complication.

CONCLUSIONS

Long-term surgical outcomes of postinfarction mechanical complications remain understudied. Outcomes for ventricular septal defect repair are better represented in the literature than are outcomes for other mechanical complications, though available studies are still limited by small sample sizes and retrospective design. Further research is warranted, particularly for outcomes of acute pseudoaneurysm repair.

Post-infarction ventricular septal defect with cardiogenic shock: peripheral veno-arterial extracorporeal membrane oxygenator as a bridge to surgery

We present a patient with post-infarction posterior ventricular septal defect complicated by cardiogenic shock who was transferred after percutaneous coronary revascularization. A peripheral venoarterial extracorporeal membrane oxygenator was placed as a bridge to definite treatment to stabilize his condition. Patch closure of the ventricular septal defect and tricuspid valve replacement were performed successfully with right atrial approach 3 days after the extracorporeal membrane oxygenation (ECMO) placement and 11 days after the myocardial infarction. The extracorporeal membrane oxygenator was successfully weaned off intraoperatively and the patient was discharged without complications.

Transaortic approach for the repair of the basal ventricular septal rupture

A 53-year-old man who suffered acute inferior myocardial infarction was recently transferred to our hospital due to occlusion of the right coronary artery. The results of the echocardiogram revealed a basal ventricular septal rupture (VSR). Since hemodynamic instability had been observed, we performed emergency surgery 5 days after the myocardial infarction began. We used a recently developed novel technique to treat this case: a patent ductus arteriosus occluder placed on the left ventricular side of the septum to close the VSR site, placed directly via the transaortic approach. Simple intermittent mattress sutures with gaskets were used for further fixation. The mild residual shunt was detected postoperatively. The patient was discharged 3 weeks after surgery.

Emergency sandwich patch repair via right ventricular incision for postinfarction ventricular septal defects: a case series

Background

The surgical treatment for postinfarction ventricular septal defect (VSD) remains challenging, especially in emergency cases. Several authors have reported the efficacy of a sandwich patch VSD repair via a right ventricular (RV) incision. However, this procedure remains uncommon, and its efficacy is still unknown, especially when performed under an emergency.

Case summary

We were able to perform sandwich patch VSD repair via an RV incision on seven consecutive patients with VSD following an ST-segment elevation myocardial infarction (STEMI) from March 2017 to December 2019. Bovine pericardial patches were used for sandwich patches. Two patients developed inferior STEMI, and the other patients developed anterior STEMI. Six patients received intra-aortic balloon pump prior to surgery, and the other received extracorporeal membrane oxygenation with Impella. The interval between the diagnosis of VSD and surgery was within 1 day in all patients except one (5 days). All seven patients underwent VSD repair in the emergency status. Four patients underwent concomitant coronary artery bypass grafting. The hospital mortality rate was 14.3% (1/7). Early postoperative transthoracic echocardiography revealed that only one patient developed more than trace residual shunt. The postoperative right atrial pressure was not significantly elevated at ≤12 mmHg in all patients. No patient developed early postoperative prolonged low cardiac output syndrome.

Discussion

In patients with postinfarction VSD, a sandwich patch VSD repair via an RV incision is a promising procedure with a low incidence of residual shunt development and hospital mortality, even in emergency cases.

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.

IABP: history-evolution-pathophysiology-indications: what we need to know

Treatment with the intraaortic balloon pump (IABP) is the most common form of mechanical support for the failing heart. Augmentation of diastolic pressure during balloon inflation contributes to the coronary circulation and the presystolic deflation of the balloon reduces the resistance to systolic output. Consequently, the myocardial work is reduced. The overall effect of the IABP therapy is an increase in the myocardial oxygen supply/demand ratio and thus in endocardial viability.

This is an overall synopsis of what we need to know regarding IABP. Furthermore, this review article attempts to systematically delineate the pathophysiology linked with the hemodynamic consequences of IABP therapy. The authors also look at the future of the use of the balloon pump and conclude that the positive multi-systemic hemodynamic regulation during IABP treatment should further justify its use.

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.

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.