Post-infarct VSD

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1. Morphological Features

Location: 60% anterior, 40% posterior

Associated with total occlusion coronary artery, few collaterals

Large loss of myocardium

My be multiple; staged appearance

Posterior VSD- can have MR

Late complication- aneurysm

2. Clinical Features & Diagnosis

Murmur, pansystolic, LLSB

(Also consider acute MR murmur)

Chest X-Ray- pulmonary venous hypertension, large pulmonary blood flow

ECHO- site, size, ?MR

Swan-Ganz- Qp:Qs >/= 2, hemodynamics

Cardiac catheterization (optional??)

Coronary angiography

Left ventriculography (only if condition permits)

3. Natural History

Occurence- 1-2% of MI

(Decreased since thrombolytics)

Timing- 2-3 days post MI up to 2 weeks

Early death is common

4. Indications for Operation

Indication = presence of VSD

Timing

Urgent- for hemodynamic or end-organ decline

Delayed (2-3 weeks) - if stable

5. Operative Considerations

Urgency, IABP

Approached through LV

Patch technique

2 patches unless apical

Concomittant procedures

CABG

MV replacement

Aneurysm resection

Free wall perforation (especially posterior)

6. Results or Repair

Survival: 35% early mortality

Functional status: good

Modes of death

50% CHF, acute

10% sudden death

5% CHF, chronic, intractable

CVA

Risk factors

Hemodynamic status & RV function preoperatively

Extent of myocardial necrosis

Posterior VSD >> anterior VSD