Infarct Exclusion Technique for Posterior Ischemic Ventricular Septal Defect in a Patient With Impella 5.5 Support

The case involved a 69-year-old patient who presented with acute myocardial infarction. Catheterization showed triple vessel disease with an occluded right coronary artery (RCA). An intra-aortic balloon pump was placed. Emergent percutaneous coronary intervention (PCI) was performed, and drug-eluting stents were successfully placed. 

Echocardiography showed reduced heart function with a large ischemic ventricular septal defect (VSD) in the posterior septum. His kidney function worsened, and escalation of support to Impella 5.5 was indicated. Although his kidney function improved, the patient was not extubated, likely due to a large shunt. The decision was made to proceed with surgical repair of the ischemic VSD and coronary artery bypass grafting five days after admission.  

A median sternotomy was performed, and the ascending aorta was cannulated for arterial return, with both cavae cannulated for venous drainage. The distal anastomosis of the vein graft was performed to the obtuse marginal (OM) artery. The heart was lifted, and a parallel incision was made along the posterior descending artery (PDA). A large VSD was noted. In cases of posterior ischemic VSD, the posteromedial papillary muscle is often involved in infarction; however, in this case, the papillary muscle was intact.  

A 5 cm x 8 cm bovine pericardial patch was brought into the field and trimmed as necessary. The patch was sutured to the base of the left ventricle with a continuous 3-0 polypropylene suture, starting at the ventricle close to the mitral valve. It is important to sew the patch to the noninfarcted myocardium (yellow dots). After parachuting the patch, a separate suture was used to tighten the suture, and the patch was sutured to the endocardium of the healthy septum toward the apex, placed in an onlay fashion. The opposite side of the patch was then secured to the free wall of the left ventricle using a separate 3-0 polypropylene suture, which was initiated at the apex.  

This followed the original Tirone David technique, where a horizontal mattress stitch went through:  

1. Teflon felt (outside in)  
2. Myocardium (outside in)  
3. Patch (a rough surface to smooth surface)  
4. Patch (a smooth surface to rough surface)  
5. Myocardium (inside out)  
6. Teflon felt (inside out) 

Supplemental stitches (transmural, full thickness) were placed as necessary. In this case, the left ventricular ventriculotomy was closed using a Dacron patch. This technique is useful for posterior VSDs, as direct closure can reduce left ventricular size.  

Proximal anastomosis of the vein graft and left internal mammary artery to the left anterior descending (LIMA-LAD) anastomosis were performed. Cardiopulmonary bypass was weaned with Impella support. Impella 5.5 was removed on postoperative day three, and the patient was discharged without any major complications. 

References

1. David TE, Dale L, Sun Z. Postinfarction ventricular septal rupture: repair by endocardial patch with infarct exclusion. J Thorac Cardiovasc Surg. 1995 Nov;110(5):1315-22. ]

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