Repair of Post-Infarction Ventricular Septal Defect Using a Double Patch Sandwich Technique

This video submission is from the 2025 CTSNet Instructional Video Competition. Watch all entries from the competition, including the winning videos.  

In this video, the authors discuss the surgical repair of post-infarction ventricular septal defects (VSD) using a double patch sandwich technique with simultaneous left ventricular (LV) aneurysmal repair. 

Patient 1 was a 60-year-old male with longstanding diabetes and frequent cocaine use who presented with new-onset heart failure after eight days of chest pressure. He was found to have a 3.7 cm x 2.2 cm VSD, a 3.3:1 left-to-right shunt, a basal infero-posterior left ventricular aneurysm, and no significant coronary disease. 
 
Patient 2 was a 66-year-old male who presented with anginal symptoms two and a half weeks prior to presentation. He was found to have a 1.9 cm midinferoseptal VSD, a 1.8:1 left-to-right shunt, and 40 percent diagonal, 50 percent left anterior descending artery (LAD), and 60 percent ostial obtuse marginal stenoses. Both patients were medically optimized for several days prior to surgery, and neither required mechanical support. 
 
Femoral catheters for possible intra-aortic balloon pump or extracorporeal membrane oxygenation (ECMO) were placed at the beginning of the case. A median sternotomy was performed, followed by cannulation of the distal ascending aorta and bicaval venous cannulation. LV and root vents were placed. Cardiopulmonary bypass was initiated with cooling to 32 degrees Celcius. The aorta was cross-clamped, and antegrade cardioplegia was administered. 
 
An oblique right atriotomy was performed parallel to the atrioventricular (AV) groove and extended toward the right atrial appendage and posteriorly toward the inferior vena cava (IVC). Stay sutures were placed for the atriotomy. The VSD, apical myocardial infarction (MI), and left ventricular aneurysm were identified through the tricuspid valve. The LV aneurysm was palpated. The LV apex was retracted cranially with a retraction device, and the intraventricular septal location was determined by palpation anteriorly and inferiorly. A 6–7-centimeter ventriculotomy was performed on the inferior wall of the left ventricle through the LV aneurysm and pledgetted 4-0 Prolene stay sutures were placed along the edges of the ventriculotomy. The VSD was again identified. Patient 1 was found to have two VSDs measuring 3.5 x 2.5 cm and 1.0 x 1.2 cm, while in Patient 2, a 3.0 x 2.5 cm VSD was identified. A bovine pericardial patch was fashioned. Circumferential sutures were placed on the first patch and through the VSD, securing it to the right side of the intraventricular septum. Sutures were passed through the intraventricular septum from right to left, ensuring  bites of healthy, viable myocardium. The patch was lowered through the defect to the right side, and the first patch was secured in position. A second bovine pericardial patch was then fashioned for the left side of the intraventricular septum. The sutures were organized, and the second patch for the sandwich repair was passed through the needles of the previously placed pledgetted sutures. By using the sandwich technique, the authors were able to create a tension-free repair, which they believe is superior to a running technique due to a decreased risk of suture pulling through damaged myocardium. The sutures were tied and divided. Attention was then directed toward the left ventricular aneurysm repair. Using the ventriculotomy performed through the left ventricular aneurysmal free wall, two strips of Teflon felt were secured using 3-0 Prolene suture on an MH needle in horizontal mattress fashion along the viable edges of the inferior wall of the LV. Next, the LV vent was pulled back, allowing the LV to fill, and bioglue sealant was applied over the suture line. The aortic cross-clamp was removed, and ventricular pacing wires were placed. The right atriotomy was then closed using running 4-0 Prolene. Both patients were weaned from cardiopulmonary bypass without complication. 
 
Patient 1 did not have a mechanical support device, was extubated on postoperative day one, and was off inotropes by postoperative day two. He was downgraded to step-down care on postoperative day four and discharged without complications on postoperative day 11, with no residual shunt on transthoracic echocardiogram (TTE) and an ejection fraction (EF) of 45 percent. At the most recent follow-up, two months postoperatively, he was doing well but had no additional imaging. 
 
Patient 2 had his intra-aortic balloon pump removed and was extubated on postoperative day one, off inotropic support by postoperative day two, downgraded from ICU on postoperative day three, and discharged on postoperative day seven with no residual shunt on TTE and an EF of 40 percent. The patient underwent a carotid endarterectomy at postoperative year three. At that time, his EF was 57 percent and there was still no visible shunt on TTE. He is doing well five years postoperatively. 
 
The authors conclude that the repair of ischemic VSD with a double sandwich patch technique is a durable and effective method for treating this devastating complication of MI. They believe this technique can help to minimize residual shunt and provide a tension-free repair to potentially increase durability. 

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.