Concomitant Surgical Management of Postinfarctual Ventricular Septal Rupture and Left Anterior Ventricular Aneurysm

Ventricular septal defect (VSD) occurs in less than 1 percent of patients suffering from myocardial infarction (1), but anterior or apical VSD provides more than 60 percent of all postischemic VSD (2,3).

Left ventricular aneurysm (LVA) is a more frequent mechanical complication of myocardial infarction, yet later in the clinical course of infarction (4). The association of VSD and LVA in the same patient is extremely rare (5).

Several techniques have been described for the treatment of these two complex ventricular diseases (6,7,8,9,10).

The Patient

This video presents a sixty-six-year-old woman with a history of unstable angina two months before an acute clinical presentation of anteroseptal myocardial infarction. The echocardiography imaging showed an anteroapical left ventricular aneurysm with an anterior postinfarction VSD and a depressed left ventricular ejection function (EF 30%), as well as right ventricular dysfunction with pulmonary hypertension. The coronary angiogram revealed a left anterior descending artery (LAD) occlusion and a chronic right coronary artery occlusion. 

The patient manifested unstable hemodynamic, oliguria, bilateral pleural effusion, and clinical evidence of poor perfusion. A preoperative intra-aortic balloon pump (IABP) was implanted. Furthermore, inotropic drugs and vasodilators were used to support hemodynamics. After standard median sternotomy, an oval-shaped autologous pericardial patch was tailored. A large hemorrhagic infarcted area along the LAD coronary artery course was detected, in addition to a left anteroapical ventricular aneurysm. 

The Surgery

First, the ascending aorta was cannulated with standard bicaval venous cannulation. Cardiopulmonary bypass was initiated with systemic mild hypothermia (30 °C) and the left ventricle was vented through the right superior pulmonary vein. After the aorta was cross-clamped, cold (4°C) antegrade and retrograde crystalloid (Bretschneider’s solution) and cardioplegia, respectively, were administered. The aneurysmatic anterior wall of the left ventricle was incised through the infarction area, approximately 2 cm leftward of the LAD coronary artery. 

After exposing the defect and debriding the interventricular septum in order to find a viable myocardial muscle, the oversized autologous pericardial patch was trimmed to the rough VSD and positioned on the left ventricular side of the septum by passing felt-reinforced mattress sutures of 3-0 polypropylene from the right site, through the septum, and through the pericardial patch, then tied with care. Anteriorly, the patch was trimmed to the appropriate height and sutured with felt-reinforced sutures to the superior ventricular edge, closing the defect. The ventriculostomy was closed with a running “eight-figure” 2-0 polypropylene suture from inside to inside of the edges and reinforced by two parallel surgical felts. 

Then the suture was placed at the junction between the endocardial scar and the normal myocardium of the lateral free wall and medially at the level of the new septum. This procedure excludes the aneurismatic area and surrounds the left ventricle with viable muscle, except for a rim of scar at the repair. The third strip of felt was then placed over the ventriculostomy and sewn in place with a hemostatic running 2-0 polypropylene suture. The aortic cross-clamp was removed and the heart restarted beating sinus rhythm.

References

1. Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation. 2000;101(1):27-32.
2. Birnbaum Y, Fishbein MC, Blanche C, Siegel RJ. Ventricular septal rupture after acute myocardial infarction. N Engl J Med 2002;347:1426-1432
3. Visser CA, Kan G, Meltzer RS, Koolen JJ, Dunning AJ. Incidence, timing and prognostic value of left ventricular aneurysm formation after myocardial infarction: A prospective, serial echocardiographic study of 158 patients. Am J Cardiol 1986;57: 729-32
4. DePace NL, Dowinsky S, Untereker W, LeMole GM, Spagna PM, Meister SG: Giant inferior wall left ventricular aneurysm. Am Heart J. 1990, 119:400-402
5. Shafi I, Oviedo C, Reddy V, Abu-Mahfouz, Omar AE, Baciewicz FA, Alonso L: Ventricular Septal Rupture (VSR) and Ventricular Wall Aneurysm (VWA) Complicating Acute Myocardial Infarction. J Cardiovasc Dis Diagn. 2019,7:2
6. Daggett WM, Guyton RA, Mundth ED, Buckley MJ, McEnany MT, Gold HK, Leinbach RC, Austen WG. Surgery for post-myocardial infarct ventricular septal defect. Ann Surg 1977;186:260–271.
7. David TE, Dale L, Sun Z. Postinfarction ventricular septal rupture: repair by endocardial patch with infarct exclusion. J Thoracic Cardiovasc Surg 1995;110:1315–1322.
8. Jatene AD. Left ventricular aneurysmectomy. J Thorac Cardiovasc Surg 1985; 89: 321 – 325.
9. Dor V, Kreitmann P, Jourdan J. Interest of physiological closure (circumferential plasty on contractile areas) of the left ventricle after resection and endocardiectomy for aneurysm or akinetic zone: Comparison with a classical technique about a series of 209 left ventricular resections. J Cardiovasc Surg 1985; 26: 73.
10. Schlotter F, de Waha S, Eitel I, Desch S, Fuernau G, Thiele H.: Interventional post myocardial infarction ventricular septal defect closure: a systematic review of current evidence. Eurointervention.2016 May 17;12 (1): 94-102.

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