Ventricular apical wall rupture and ventricular aneurysm formation concurrent with ventricular septal dissection and rupture due to ST-segment elevation myocardial infarction: a case report

The most common mechanical complications of acute myocardial infarction include free-wall rupture, ventricular septal rupture (VSR), papillary muscle rupture and pseudoaneurysm. It is rare for a patient to experience more than one mechanical complication simultaneously. Here, we present a case of ST-segment elevation myocardial infarction (STEMI) complicated with three mechanical complications, including ventricular apical wall rupture, ventricular aneurysm formation and ventricular septal dissection (VSD) with VSR. Cardiac auscultation revealed rhythmic S1 and S2 with a grade 3 holosystolic murmur at the left sternal border. Electrocardiogram indicated anterior ventricular STEMI. Serological tests showed a significant elevated troponin I. Bedside echocardiography revealed ventricular apical wall rupture, apical left ventricle aneurysm and VSD with VSR near the apex. This case demonstrates that several rare mechanical complications can occur simultaneously secondary to STEMI and highlights the importance of bedside echocardiography in the early diagnosis of mechanical complications.

Mechanical complications in patients with ST-segment elevation myocardial infarction: A single centre experience

Background

The study aims to assess characteristics and outcomes of patients suffering a mechanical complication (MC) after ST-segment elevation myocardial infarction (STEMI) in a contemporary cohort of patients in the percutaneous coronary intervention era.

Methods and results

This retrospective single-center cohort study encompasses 2508 patients admitted with STEMI between March 9, 2009 and June 30, 2014. A total of 26 patients (1.1%) suffered a mechanical complication: ventricular septal rupture (VSR) in 17, ventricular free wall rupture (VFWR) in 2, a combination of VSD and VFWR in 2, and papillary muscle rupture (PMR) in 5 patients. Older age (74.5 ± 10.4 years versus 63.9 ± 13.1 years, p < 0.001), female sex (42.3% versus 23.3%, p = 0.034), and a longer latency period between symptom onset and angiography (> 24h: 42.3% versus 16.2%, p = 0.002) were more frequent among patients with MC as compared to patients without MC. The majority of MC patients had multivessel disease (77%) and presented in cardiogenic shock (Killip class IV: 73.1%). Nine patients (7 VSR, 2 VFWR & VSR) were treated conservatively and died. Out of the remaining 10 VSR patients, four underwent surgery, three underwent implantation of an occluder device, and another three patients had surgical repair following occluder device implantation. All patients with isolated VFWR and PMR underwent emergency surgery. At 30 days, mortality for VSR, VFWR, VFWR & VSR and PMR amounted to 71%, 50%, 100% and 0%, respectively.

Conclusions

Despite advances in the management of STEMI patients, mortality of mechanical complications stays considerable in this contemporary cohort. Older age, female sex, and a prolonged latency period between symptom onset and angiography are associated with the occurrence of these complications.

Risk factors and outcome analysis after surgical management of ventricular septal rupture complicating acute myocardial infarction: a retrospective analysis

BACKGROUND

Ventricular septal rupture (VSR) is an uncommon but well-recognized mechanical complication of acute myocardial infarction (AMI). The outcome of VSR remains poor even in the era of reperfusion therapy. We reviewed our experience with surgical repair of post-infarction VSR and analyzed outcomes in an attempt to identify prognostic factors.

METHODS

From October 1995 to December 2013, data from 47 consecutive patients (mean age, 68 ± 9.5 years) with post-infarction VSR who underwent surgical repair at our institute were retrospectively reviewed. The preoperative conditions, morbidity and surgical mortality were analyzed. Multivariate analysis was subsequently carried out by constructing a logistic regression model in order to identify independent predictors of postoperative mortality. Long term survival function were estimated using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

Percutaneous coronary intervention was performed in 17 (36.2%) patients, intra-aortic balloon pump (IABP) was used in 34 (72.3%), and six (12.8%) were supported with extracorporeal membrane oxygenation (ECMO) preoperatively. Forty-one (87.2%) patients received emergent surgical treatment. Concomitant coronary artery bypass grafting was performed in 27 (57.4%) patients. Operative mortality was 36.2% (17 of 47). The survival rate was 59.3% with concomitant CABG and 70% without concomitant CABG (p = 14). Multivariate analysis revealed that the survivors had higher preoperative left ventricular ejection fractions (LVEFs) compared with those who died (51 ± 13.7% vs. 36.6 ± 6.4% , respectively; p < 0.001) and lower European system for cardiac operative risk evaluation II (EuroSCORE II) (22.9 ± 14.9 vs. 38.3 ± 13.9, respectively; p < 0.001). The patients receiving total revascularization has long term survival benefit (p = 0.028).

CONCLUSIONS

Post-infarction VSR remains a serious and challenging complication of AMI in the modern surgical era. The EuroSCORE II can be used for an approximate prediction of operative mortality. Preserved LVEF was associated with better prognosis, while the need for postoperative RRT was associated with higher early and late mortality. Besides, the strategy of total revascularization should be applied to ensure long-term survival benefit.

Closure of post-myocardial infarction ventricular septal defect with use of intracardiac echocardiographic imaging and percutaneous left ventricular assistance

WEBSITE FEATURE

Posterior ventricular septal defect in presence of cardiogenic shock: early implantation of the impella recover LP 5.0 as a bridge to surgery

Urgent repair (within 48 hr after diagnosis) of posterior ventricular septal defect in the presence of cardiogenic shock, consequent to acute myocardial infarction, is associated with a very high mortality rate. The use of left ventricular mechanical support devices has the potential to impart hemodynamic stability and to delay surgical treatment until such time as scar tissue forms around the defect, sufficient to hold a suture patch.From May 2004 through July 2007, 5 patients who were in cardiogenic shock as a consequence of acute posterior ventricular septal defect underwent early implantation of a transfemoral microaxial Impella® Recover® LP 5.0 Support System as mechanical support (bridge to surgery).The mean duration of support by the left ventricular assist device was 14.4 ± 6 days. No one died during assistance. The device reduced left-to-right shunting, systolic pulmonary artery pressure, central venous pressure, and pulmonary capillary wedge pressure. Liver, kidney, and lung function improved, and the 30-day mortality rate was 40%.Although this is a retrospective study of a very small patient population, without benefit of a control group, it is the first report of its kind. This initial experience using the Impella Recover 5.0 in cases of cardiogenic shock due to posterior ventricular septal defect suggests that this conservative approach is a feasible and safe way to improve hemodynamic conditions and delay surgery. Further clinical experience is needed to confirm these early results.

[Outcomes of surgical management of elderly and aged patients with complicated forms of coronary artery disease]

The article is dedicated to comparative analysis of surgical management of elderly and aged patients presenting with complicated forms of coronary artery disease (CAD). Suggested herein is an algorithm of concerning the choice of methods aimed at surgical correction of postinfarction aneurysms of the right ventricle of the heart and postinfarction ruptures of the interventricular septum in these patients, depending on the morphological structure of the right-ventricular postinfarction aneurysms and postinfarction ruptures of the interventricular septum, followed by determining the incidence rate of using "complete" and "incomplete" myocardial revascularization in elderly and aged patients with complicated forms of CAD depending on peculiarities of the coronary blood flow. Also considered herein is efficacy of preventing rethrombosis following correction of right-ventricular postinfarction aneurysms and thrombectomy. The article is based on studying a total of forty-two 60-to-78-year-old patients with CAD. The measures taken made it possible to decrease postoperative lethality and postoperative complications rate in the patients concerned.

Measurement of cardiac output in ventricular rupture following acute myocardial infarction--pulmonary artery catheter vs transpulmonary thermodilution--a case report

We compared the cardiac output measured by the transpulmonary aortic single indicator thermodilution method with that by the pulmonary artery catheterization in a patient with ventricular septal rupture after acute myocardial infarction. Though the former cardiac output was lower than the latter, in the presence of the ventricular septal rupture, the cardiac outputs were equal after the rupture was closed. This indicates that, while the cardiac output measured by the pulmonary artery catheter is influenced by the ventricular left-to-right shunt, transpulmonary aortic thermodilution method measures the true cardiac output of the left heart, which is responsible for organ perfusion.

Percutaneous ventricular assist device support in a patient with a postinfarction ventricular septal defect

Complications of acute myocardial infarction have decreased in number and severity due to the application of early thrombolytic coronary revascularization techniques. Nonetheless, the mortality rate associated with these complications remains high. Ventricular septal rupture is one of the complications that can occur after myocardial infarction. In the treatment of postinfarction ventricular septal rupture, the need for immediate closure to avoid acute hemodynamic compromise must be weighed against the need for delayed repair to enable the acutely necrotic myocardium to organize and to develop fibrotic tissue. We report the use of a minimally invasive TandemHeart percutaneous ventricular assist device for 18 days in a 58-year-old man who experienced postinfarction ventricular rupture. The hemodynamic support provided by the device allowed time for left ventricular recovery before attempted percutaneous closure of the ventricular septal rupture and after definitive surgical repair of the septal defect. To our knowledge, this is the 1st reported use of the TandemHeart for support before and after repair of a postinfarction ventricular septal rupture.

Increased pericardial fluid level of matrix metalloproteinase-9 activity in patients with acute myocardial infarction: possible role in the development of cardiac rupture

BACKGROUND

In an animal model of acute myocardial infarction (AMI), deletion of matrix metalloproteinase (MMP)-9 results in suppression of the development of cardiac rupture. The present study sought to clarify how myocardial MMP-9 activity is related to the pathophysiologies of AMI and cardiac rupture in humans.

METHODS AND RESULTS

Levels of interleukin-8 (IL-8), polymorphonuclear leukocyte (PMN) elastase, monocyte chemotactic protein-1 (MCP-1) and MMP activity were measured in the pericardial fluid obtained from 28 patients with angina pectoris (AP group) and 16 patients with AMI (AMI group) undergoing cardiac surgery. In the AMI group, 5 were complicated with ventricular septal perforation (VSP) and the remaining 11 were not (non-VSP). Levels of IL-8, PMN elastase, MMP-2 and MMP-9 activity were all higher in the AMI group than in the AP group. In the AMI group, all levels other than MMP-2 activity were further elevated in cases with VSP compared with those in the non-VSP group. There was no significant difference in MCP-1 among the groups

CONCLUSIONS

Markers of neutrophil activation in the infarcted cardiac tissue seem to be elevated in AMI. Highly elevated levels of MMP-9 activity, which may be derived from neutrophils, and PMN elastase may be related to the pathophysiology of VSP or cardiac rupture in AMI.

Ventricular septal rupture following myocardial infarction. Long-term survival of patients who did not undergo surgery. Single-centre experience

Long-term survival is rare in patients not undergoing surgery after post-myocardial infarction ventricular septal rupture. We report our experience of seven patients out of 27, who did not undergo surgery and were followed up for a mean period of 2.8 years. They were evaluated after a mean period of 2.2 months after infarction in our centre. The septal defects measured 9.8 mms on average and the mean left-to-right shunt ratio was 1.98: 1. The mean pulmonary artery, right atrial and left ventricular end diastolic pressures were 28.3 +/- 10.6, 4 +/- 3 and 15.8 +/- 4.8 mm Hg, respectively. Only three out of seven patients had LV aneurysm and all patients had single-vessel disease. Smaller defect size, minimal left-to-right shunt and preserved right ventricular function may be the factors responsible for long-term survival.

[Risk factors for the surgical repair of ventricular septal perforation; an 8-year multiinstitutional analysis]

OBJECTIVE

The purpose of this study was to determine the surgical outcomes and risk factors for surgical repair of the ventricular septal perforation (VSP).

METHOD

From 1995 to 2003, 41 patients with VSP underwent surgical repair. There were 18 males and 23 females, with the mean age of 71.7 +/- 9.2. Sixteen patients (39.0%) had the preoperative shock, while 30 patients received intraaortic balloon pumping (IABP) assistance and 1 of those required percutaneous cardiopulmonary support (PCPS). Mean durations from onset of myocardial infarction and VSP to operation were 5.8 +/- 9.4 and 2.4 +/- 8.1 days, respectively. Twenty-six patients underwent infarct exclusion technique, 11 underwent patch closure, and 4 Daggett operation. Mean cardiopulmonary and aortic cross-clamp time were 211 +/- 85 and 105 +/- 43 minutes, respectively.

RESULTS

Thirty days mortality was 11 (26.8%). Nine patients (22%) required PCPS after repair, however, 2 weaned off the support and only 1 discharged the hospital. Residual shunt was found in 12 patients (29.3%), and 4 underwent the reclosure of the residual shunt 13 +/- 8.6 days after the initial operation, whereas none of patients with PCPS had residual shunt. Univariate analysis revealed the preoperative shock (p = 0.03), longer cardiopulmonary bypass time (p < 0.01), and the need for PCPS after repair (p < 0.01) were the risk factors for the early mortality. Multivariate analysis indicated the cardiopulmonary time over 210 minutes and the need for PCPS to be the significant risk factors.

CONCLUSION

The long cardiopulmonary bypass support after repair and the subsequent need for PCPS imply the poor left ventricular function. Since the residual shunt was not the cause of PCPS, the surgical outcome for VSP may be limited in patients with poor left ventricular function. In these patients, other therapeutic strategies may be required, such as ventricular assisting devices, transplantation, or regenerative therapy.

Hemodynamic complications of ventricular septal rupture after acute myocardial infarction

Ventricular septal rupture (VSR) is a rare but serious complication following acute myocardial infarction (MI). Patients may present with a new murmur associated with a thrill. Right heart catheterization will demonstrate elevated right atrial and pulmonary artery pressures as well as an oxygen step-up at the right ventricular level. Patients with a right ventricular infarction or cardiogenic shock and a ventricular septal rupture have high in-hospital mortality rates. Prompt diagnosis followed by surgical repair is essential for patients with VSR following MI.

An unusual cause of diastolic mitral regurgitation as a result of sterile perforation of the mitral valve

We report the case of a 50-year-old man in whom a supracristal ventricular septal defect led to aortic regurgitation and, thus, to consecutive sterile perforation of the anterior mitral leaflet, culminating in the development of severe systolic and diastolic mitral regurgitation. Aortic regurgitation as a result of valve prolapse caused by a supracristal (conal) ventricular septal defect is a well-known phenomenon. The same is true for the origin of mitral jet lesions in patients with infective endocarditis of the aortic valve. As of yet, there have been no reports about the acquisition of mitral valve perforations in patients without the history of vegetations. Moreover, the occurrence of diastolic mitral regurgitation is usually associated with atrioventricular pressure reversal, a phenomenon that was not present in our patient. The unique comorbidity was easy to detect with Doppler echocardiography, supported by transesophageal 2-dimensional and dynamic 3-dimensional echocardiography for preoperative surgical treatment.

Spontaneous closure of an acquired ventricular septal defect

Ventricular septal defect (VSD) is a rare but serious complication of acute myocardial infarction requiring early surgical intervention. A patient with acquired VSD that spontaneously closed over three months is presented. The literature on spontaneous closure of acquired VSDs is also reviewed.

Long-term usefulness of percutaneous intrapericardial fibrin-glue fixation therapy for oozing type of left ventricular free wall rupture: a case report

This report describes a long-term survival case of left ventricular free wall rupture treated with percutaneous intrapericardial fibrin-glue fixation therapy. A 82-year-old woman was admitted to the emergency room because of vomiting and syncope diagnosed as acute posterolateral myocardial infarction complicated by cardiac tamponade. After her hemodynamic condition was stabilized by drawing off the bloody pericardial effusion, fibrin-glue was injected into pericardial space with the expectation that the glue would cover the oozing site of the left ventricular epicardium. After this therapy, the patient recovered and did not have any no recurrent cardiac events for 1 year. Serial echocardiographic studies revealed a preserved left ventricular function and no development of left ventricular restriction. This case suggests that percutaneous intrapericardial fibrin-glue fixation therapy is an effective treatment for the oozing type of left ventricular free wall rupture and that there is no risk of left ventricular restriction during long-term follow-up.

Primary angioplasty reduces the risk of left ventricular free wall rupture compared with thrombolysis in patients with acute myocardial infarction

OBJECTIVES

This study aimed to evaluate the effect of primary angioplasty (PA) over the risk of free wall rupture (FWR) in reperfused acute myocardial infarction (AMI).

BACKGROUND

It has been suggested that PA reduces the risk of FWR compared with thrombolysis. However, few studies have evaluated this issue, and there are no data demonstrating this hypothesis.

METHODS

A total of 1,375 patients with AMI treated with PA (n = 762, 55.4%) or thrombolysis (n = 613, 44.6%) within 12 h after symptoms onset were included. The diagnosis of FWR was made either in the presence of sudden death due to electromechanical dissociation with large pericardial effusion on an echocardiogram or when demonstrated post mortem or at surgery. A multivariable analysis was performed including type of reperfusion strategy.

RESULTS

The overall incidence of FWR was 2.5% (n = 34): 1.8% and 3.3% in patients treated with PA and with thrombolysis, respectively (p = 0.686). The following characteristics were associated with a higher rate of FWR in the univariable analysis: age >70 (5.2% vs. 1.2%, p < 0.001), female gender (5.1% vs. 1.8%, p = 0.006), anterior location (3.3% vs. 1.4%, p = 0.020) and treatment >2 h after symptoms onset (3.6% vs. 1.7%, p = 0.043). In the multivariable analysis, age >70 (odds ratio [OR]: 4.12, 95% confidence interval [CI]: 2.04 to 8.62, p < 0.001) and anterior location (OR: 2.91, 95% CI: 1.36 to 6.63, p = 0.008) were independent risk factors of FWR, whereas treatment with PA was an independent protective factor (OR: 0.46, 95% CI: 0.22 to 0.96, p = 0.0371).

CONCLUSIONS

In patients with AMI, PA reduces the risk of FWR in comparison with thrombolysis.

Assessment of perioperative predictive factors influencing survival in patients with postinfarction ventricular septal perforation. Classified by the site of myocardial infarction

BACKGROUND

The present study was designed to identify the perioperative factors and to consider a counterplan for the improvement of surgical results, based on the site of myocardial infarction.

METHODS

Sixteen patients with postinfarction ventricular septal perforation underwent surgical repair. The operation was performed 5+/-3 days after the onset of ventricular septal perforation using the same method, an infarctectomy and reconstruction of the septum and right and left ventricular walls with a single Dacron patch. The ventricular septal perforation was anterior in 11 patients and posterior in 5. Preoperative hemodynamics between survivors and non-survivors were compared. Left ventricular wall motion was estimated using echocardiography by wall motion score (divided into 17 segments and each segment was graded on a fourpoint scale: normal, 0; hypokinetic, 1; severe hypokinetic, 2; a- or dyskinetic, 3) and summed up.

RESULTS

The operative mortality was 36% in 11 patients with anterior ventricular septal perforation. In non-survivors compared to survivors, wall motion score was greater (25+/-4 vs 18+/-4, p<0.01) and all values were over 20. The value of the cardiac index divided by Qp/Qs was lower (0.98+/-0.09 vs 1.44+/-0.31, p<0.02) and all were under 1.1. In 5 patients with inferior ventricular septal perforation, the operative mortality was 40%. In non-survivors compared to survivors, wall motion score was greater (18, 18 vs 7, 2, 12) and the right atrial pressure was greater (18, 19 vs 10, 9, 9 mmHg) due to a right ventricular infarction.

CONCLUSIONS

The patients with poor left ventricular wall motion were lost for reasons unrelated to the site of myocardial infarction. Moreover, a cardiac index over Qp/Qs in anterior ventricular septal perforation and the existence of a right ventricular infarction in inferior ventricular septal perforation was predictive of operative mortality.

Frequency of collateral blood flow in the infarct-related coronary artery in rupture of the ventricular septum after acute myocardial infarction

Patients with postinfarction ventricular septal rupture have poor residual or collateral blood flow in the infarct artery and do not benefit from ischemic preconditioning. This suggests that rupture of the ventricular septum occurs on an unprotected and unprepared myocardium.

Double cardiac rupture after direct infarct coronary angioplasty: report of a case

The occurrence of double cardiac rupture (DCR) after a successful direct infarct coronary angioplasty (DICA) is extremely uncommon. We describe herein the case of a patient who underwent delayed DICA and despite successful recanalization, subsequently suffered DCR, as a postinfarction ventricular septal defect (PIVSD) with left ventricular free wall rupture (LVFWR). Emergency surgery was performed, and the patient is now doing well more than 2 years after his operation. The possible mechanisms of DCR after delayed DICA are discussed following the presentation of this unusual case.

Urgent surgical repair of postinfarction ventricular septal rupture: early and late outcome

AIM

This retrospective analysis focuses on predictive factors of operative mortality and long-term survival after surgical repair of postinfarction ventricular septal rupture (VSR).

METHODS

Sixty-seven patients (43 males, 24 females) with VSR underwent surgical repair between December 1977 and December 1995. The site of the rupture was anterior in 44 patients and posterior in 23. The mean interval between myocardial infarction (MI) and VSR was 3.6+/-4.1 days. Clinical condition on admission was critical in 63 patients (49 in cardiogenic shock). An intra-aortic balloon pump was inserted preoperatively in 54 patients.

RESULTS

Operative mortality was 25% (17 patients). The main cause of death was cardiac failure. Factors influencing early deaths in univariate analysis were preoperative hemodynamic status (cardiogenic shock present in 30%; absent in 8%; p = 0.001), the location of the MI (anterior in 11.6%, posterior in 45.4%), the interval between infarction and surgery (<1 week was 33%, >1 week was 6.2%), and the response to initial active therapy. All patients were available for follow-up. The actuarial survival rates at 1 and 5 years are 74.6%+/-5.3% and 66.2%+/-6.2%, respectively. There were 12 late deaths and 40% were cardiac related. Two patients presented residual VSD (one reoperation). The left ventricular ejection fraction (LVEF) was mildly impaired in 9 patients. Three patients had moderate mitral insufficiency and two had moderate tricuspid insufficiency.

CONCLUSION

Repair of the postinfarction VSR remains a challenge. Improvement should be rendered possible by optimizing techniques. Postoperative morbidity is high, and these patients require intensive hospital resources. The late results have been satisfactory.

Rupture recurrence after surgical repair of postinfarction ventricular septal rupture. Influence of early thrombolysis

OBJECTIVES

The aim of this study was to identify factors causing rupture recurrence after surgical repair of postinfarction ventricular septal rupture and to evaluate the indication for reoperation.

PATIENTS

Recurrence of rupture was analysed in 25 out of a series of 109 patients who underwent surgical repair for postinfarction ventricular septal rupture between 1980 and 1992 in our institution.

RESULTS

The mean interval between initial operation and recurrence was 3.6 days with a median of 2 days. Multivariate logistic regression analysis identified early thrombolysis after infarction (P = 0.0085) as a risk factor for recurrence of the rupture. Rupture recurrence occurred more in the anterior then in the posterior infarction site, although non-significant. Reoperation was indicated in 15 patients, in 13 for postrecurrent cardiac failure. The main determinant of cardiac failure was a large postrecurrent shunt (P = 0.05). The mean interval between initial operation and reoperation was 136 days with a median of 101 days. In 6 patients a combined apical ventricular septal rupture recurrence and anterior ventricular aneurysm was found, in 9 patients the recurrent rupture was proximally located, without concomitant aneurysm formation. Of 15 patients who were reoperated, one died in hospital and three after the in-hospital period. Of 10 patients treated conservatively, one died in hospital and two after the in-hospital period. One residual ventricular septal rupture closed spontaneously.

CONCLUSIONS

Rupture recurrence is mainly determined by early thrombolysis. Postrecurrent cardiac failure, as the main indication for reoperation, is dependent on postrecurrent shunt size.

Emergent use of echocardiography in a post-myocardial infarction patient with acute dyspnea

Acute dyspnea in a post-myocardial infarction patient may prompt the physician to use further diagnostic testing to evaluate apparent worsening left ventricular function, ischemia, mitral valve dysfunction, chordae or valvular rupture, or a ventricular septal defect producing a left to right shunt. We present a case of a 62-year-old woman with an unrecognized myocardial infarction at home who presented to the emergency department (ED) acutely dyspneic and free of chest pain. Prompt evaluation in the ED with echocardiography and Doppler imaging proved time-efficient and allowed early lifesaving surgery to be performed. We propose that access to emergent echocardiography in select cases should be a standard service in every ED.

[Surgical repair of post-infarction ventricular septal defects--reconstruction with pericardial patch]

Despite improvements in the pre- and postoperative management of patients with post-infarction ventricular septal defects, the results after surgery have been variable. This is in part due to advanced patient age, multi-vessel coronary disease. In addition, resection of the infarcted ventricular septum results in significant compromise in left ventricular function. Since January of 1993, we have used a new technique for the reconstruction of the left ventricle using a single pericardial patch. In this method, which was introduced by Komeda and David in 1990, a single patch is sutured to the interventricular septum and the lateral ventricular wall, excluding the infarcted muscle from the left ventricular cavity. This method was used in the treatment of four patients. There was no bleeding along the suture lines at operation, all of the patients survived. Postoperatively, all four were functional New York Heart Association Class 1. One patient underwent re-operation on the 12th day using the same technique because of a residual shunt. Another two patients had small residual shunts, which spontaneously resolved in 2 to 7 months. Left ventricular function evaluated 1 month after the operation utilizing cardiac catheterization revealed a mean stroke volume index of 40 (range: 32-45 ml/m2, and a mean left ventricular ejection fraction of 71 (range: 70-73%). An excellent functional outcome has thus been achieved with the reconstruction of post-infarction ventricular septal defects using a single pericardial patch.