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Post MI VSD Intracardiac Double Patch Repair

Monday, November 14, 2016

A 64-year-old man was admitted to the emergency room with acute inferior wall infarction, which was confirmed by echocardiogram and ECG. The patient was immediately taken for primary percutaneous transluminal coronary angioplasty (PTCA) of the right coronary artery (RCA). He was discharged but continued to have breathlessness and was readmitted in 2008. The patient was found to have a basal aneurysm and a left to right shunt with posterior post-myocardial infarction (MI) ventricular septal defect (VSD). He was optimized on medical management and discharged. The patient was admitted again in 2010 with the same symptoms. Echocardiogram, angiography, and stress thallium confirmed previous findings, and he was advised to continue with medical management. During this period, his symptoms worsened from NYHA class II to NYHA class IV. In 2014, echocardiogram confirmed post-MI posterior VSD, increased left ventricle volume, and worsening of left ventricular and right ventricular function.

In 2016, the patient was admitted to the emergency room in cardiogenic shock and ventricular tachycardia. He was optimized and taken for coronary angiography, which confirmed double vessel disease and posterior VSD. He was stabilized with an intra-aortic balloon pump and taken for PCABG with LIMA to D1 and LAD, and posterior post-MI VSD double patch repair. The surgery was uneventful and an automatic implantable cardioverter defibrillator (AICD) was subsequently put in place. The patient was discharged and is now leading a normal life.


We have recently published a case. A 52-year-old patient was admitted in our hospital for postinfarction ventricular septal defect (VSD), left ventricular aneurysm and coronary artery disease. He was investigated by echocardiography and coronary angiography and proposed for operation. In the light of the patient’s stable hemodynamic condition, surgical intervention was delayed. 3 weeks following the acute myocardial infarction open heart surgery was performed and had been managed just pre-operatively with an intra-aortic balloon pumping. The patient underwent successful VSD closure with a patch. The repair involves VSD closure and infarct exclusion technique. The patient discharged 10 days postoperatively. We consider that this modification is a simple and effective way to decrease the surgical risk of postinfarction VSD. Due to of necrotic myocardium and friable endocardial tissue, the suture of the Dacron patch is difficult with a high risk of recurrence of the VSD and subsequent mortality. The single Dacron patch placed on the left side of the intraventricular septum, which covers the anterior VSD and ventriculotomy from the inside in a double layer, sticks to the endocardium tightly due to the high blood pressure of the left ventricle. Furthermore, the curve of the patch reinforce the fragile wall of the intraventricular septum. We consider that this modification is a simple and effective way to decrease the surgical risk of postinfarction VSD. In patients without cardiogenic shock urgent operation becomes unnecessary and the choice of surgical technique and surgical timing as well as pre-operative management should be tailored for each patient individually.
I would like to comliment the surgical team for the nice operation and video. I also would like to point out that despite the long unexplained delay of the operation (since the patient was severely breathless NYHA grade VI) the outcome was good. I appreciate it if the authors explain the reasons behined the long delay of surgical intervention.

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