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Postinfarction ventricular septal defect is a rare complication of myocardial infarction with a high mortality rate (1).
Standard repair techniques—infarcectomy and infarct exclusion—are performed through a left ventriculotomy. These methods are surgically challenging and have a high risk of operative mortality (2–4).
This video describes the case of a sixty-six-year-old patient with a 1.4 cm ventricular septal rupture developed after a subacute myocardial infarction because of complete occlusion of the proximal right coronary artery. Surgeons performed a modified closure using two handmade patches parachuted through the aortic valve and the tricuspid valve, and without left ventriculotomy.
The Procedure
First, the patches were made before cardiopulmonary bypass. The measures were echocardiographically-based—the patch should be 2–3 cm larger than the maximum measured diameter of the defect. The left-side patch should be bigger than the right-side patch because of different pressures and to avoid any interference with the septal leaflet of the tricuspid valve.
The patch was made with an autologous or bovine pericardial disk reinforced with two Teflon layers and sewn together with a 5-0 Prolene running suture. Two or three Ethibon 2-0 mattress single stiches were passed through the central part of the larger left-side patch. The needles were then cut off.
After cardiopulmonary bypass institution, transversal aortotomy and right atriotomy were performed. Right angle forceps were passed through the septal rupture to grab a surgical loop placed as a marker through the aortic valve, the septal defect, and the tricuspid valve.
The Ethibon sutures of the left-side patch were then knotted to the aortic extremity of the loop. Then, pulling out the tricuspid extremity of the loop, the patch was parachuted down in the left ventricle with the Teflon layer against the septum. The Ethibon sutures were passed across the septum, out of the right atrium and—, using a hollow need—, , were passed through the central part of the smaller right-side patch. The right-side patch was finally parachuted down in the right ventr,icle and the Ethibon stiches were knotted, tightening together the two patches. Intraoperative echocardiography was crucial to assess valve function and any residual shunt.
The patient was discharged from the intensive care unit after five days. He had an almost normal ejection fraction, preserved mitral and tricuspid valve function, and no residual shunt. The good surgical result was confirmed also by angiograph CT scan.
Conclusions
This case demonstrates a surgical approach technically simpler than standard techniques. It only requires an aortotomy and a right atriotomy and, in case of failure, it can be repeated or quickly converted into a classical approach. It is timesaving, with shorter cardiopulmonary bypass and cross-clamping time. It is also myocardial-saving, with no ventriculotomy or infarcectomy performed, and cross-clamping is shorter. It eases bleeding control and, compared with percutaneous closure, patch size can be more tailored on each side of the septum so surgeons can use the biggest patch possible. The absence of a waist between the discs allows a perfect location across the septum with no pressure on friable necrotic tissues due to Nitinol expanding radial force. Because ventricular septal ruptures are complex, hybrid approaches may be a good strategy.
References
- Elbadawi A, Elgendy IY, Mahmoud K, et al. Temporal trends and outcomes of mechanical complications in patients with acute myocardial infarction. JACC Cardiovasc Interv. 2019; 12: 1825-1836.
- David T. Post-infarction ventricular septal rupture. Ann Thorac Surg. 2022; 11: 261-267.
- Madsen JC, Daggett WM Jr. Repair of postinfarction ventricular septal defects. Semin Thorac Cardiovasc Surg. 1998; 10: 117-27.
- Jeppsson A, Liden H, Johnsson P, Hartford M, Rådegran K. Surgical repair of post infarction ventricular septal defects: a national experience. Eur J Cardiothorac Surg. 2005; 27: 216-21.
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14 Comments
Very interesting idea and procedure. I think the central Ethibond sutures, should be a little peripheral on discs to completely obstruct the flow of blood.
Nice operation.
Thanks. You are right: not too central, but neither too peripheral!
Nice operation, clever and smart idea, congratulation. Few things intrigate me:
– the preop measures you implemented followed the guide lines: was there any sign of acute heart failure or impending to go to surgery?
– how long is the follow up of this patient and, besides the rarity of this specific pathology, did you perform more of such procedures using the same tecnique?
Again, congratulations.
Thanks Dr. Triumbari!
The heart team decided to do urgent surgery because the shunt was increasing and patient’s hemodynamic stability was only achieved with high dosage of intravenous diuretics and inotrops. And despite this he was very symptomatic.
Regarding the follow-up, is almost one year (with an impressive improvement of clinical and hemodynamic status).
We did not had the chance to perform it again in an adult with acute myocardial infarction, but we are going to reported larger numbers and longer follow-up in a group of younger patients with congenital SVD repaired successfully with the same technique.
Thank you for that great idea. I have done one case of post-infarction septal rupture due to acute occlusion of right coronary artery using your technique, with 30 minutes of ACC, easy weaning from CPB, and discharge from the hospital at 9-th postoperative day. I had some troubles with right sided patch placement due to tricuspid chords and papillary muscles, but with good result without tricuspid insufficiency. I’ll see what will happen in a future (residual VSD…), but in any case, i think that your technique can be used even for the temporary occlusion of the VSD, and later you can make total repair if necessary.
We are all really happy you found it useful and that you use it for VSD repair. That’s great! Your ACC times and weaning conditions are consistent with ours. Regarding any interference with septal leaflets and chordae of the tricuspid valve, it might be useful to place two-three 5/0 Prolene single stitches to fix the patch to the Sept or the right ventricle wall to try to reduce such interference. And absolutely, the idea was to use this patch technique also in acute situations to avoid repairing on a frail necrotic myocardial tissue, buying time for eventually Redo surgical repairing or for completing the repair with a percutaneus septal occluder device.
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Hi, any selection criteria?
Hi, potentially we thought this technique might me useful in all types of VSD, in all anatomical locations (but in apical VSD it may be less useful), for almost all dimensions (just remember that the pact has to be at least 1.5/2 times bigger than the largest VSD diameter. We imagine to place even more than one patch if necessary or, in case of residual shunt, a percutaneus device can be delivered in a second moment.
Two months after repair (in August 2023), 3D echocardiographic reconstruction with the multi-slice CT scan will be done, and I will inform You about results. Anyway, the patient is doing well, without any important problem.
Considering apical VSDs, I think that one can use transapical approach together with right atrial approach, and use “old” repair techniques (David…) if the muscle is not so friable, but use your technique if it is.
I will present this case in Valencia, (18.09.2023) on Cardiology World Conference, and I hope that will be followed by interesting discussion.
VSD is a quite rare complication nowadays, therefore it is quite difficult to collect data in a single hospital institution. So, if anyone who uses this technique is pleased to share the experience and participate to a multi-centre register to collect data about the efficacy of this procedure, please email me at mario.torre0@gmail.com. Thanks!
Congrats to the hole team!! Great idea, post infarction vsd can be very challenging! great out of the box thinking!
I’d like to congratulate and to thank you for coming up and sharing this method.
Yesterday we had to operate on a patient with postinfarction VSD and MR due to rutupre of the pappialry muscle and eventhogh he was on ECMO it was not going well. So I performed your method and MVReplacement along with 2 CABG. As i opened the atrial septum to replace the mitral valle, we were abre to look directly on the ventricular patch and check that the 1,5 cm VSD was totaly covered. I had no problem with the tricuspid valve and the patches were 5 and 3 cm diameter. No VSD or valve regiegitation but the patient continues on ECMO and IABP as before the surgery.
I encourage my colleagues to try this novel method as it is very reproducible and resolutive and avoid ventriculotomy and its consecuences.
Truly thankfull.