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Ventricular Septal Defect Closure and Dor Procedure

Tuesday, October 25, 2016

The treatment of left ventricular aneurysm has been a matter of study for many years, and several techniques have been described. The endoventricular circular patch plasty repair was reported in 1984 by Vincent Dor (1, 2, and 3). The aim of this method is to rebuild the left ventricular geometry after myocardial infarction (akinetic/dyskinetic zone aneurysm), making the cavity helical again. In the presented case, this technique allows the authors to exclude the ventricular septal defect in the apex.

This video shows an interesting combination of two mechanical complications of myocardial infarction in the same patient. The Dor technique allowed the authors to exclude the septal defect, while using a patch to seal the interventricular defect. The ventricular septal defect remained outside the left ventricular cavity. The surgical resolution of these types of complications remains a challenge for cardiac surgeons.

Surgical Technique

  • Cardiopulmonary bypass of the ascending aorta, with double cava cannulation, was started. Anterograde and retrograde cold blood cardioplegia were used.
  • The left ventricle aneurysm was opened and care was taken not to damage the coronary vessels.
  • 3.0 polypropylene (Prolene®, Ethicon, New Jersey, USA) purse string sutures were placed in the transition zone between the aneurysm and the normal ventricular wall. The sutures were performed according to a ventricular volume of at least 60cc/m2 of body surface.
  • The ventricular septal defect on the apex was closed with a glutaraldehyde-treated bovine pericardial patch, 4.0 polypropylene, and Teflon pledgets.
  • Before closing the ventricular aneurysm, a plastic bag with saline was used to measure the volume of the left ventricular cavity. In the case presented, the volume was 110 ml.
  • The purse string was tightened, reducing the aneurysmal defect in the left ventricle wall.
  • An oval pericardial patch was used to close the ventricular aneurysm. It was sutured to the edges of the contractile area in the left ventricle hole by continuous 3.0 polypropylene sutures. Special care was taken not to leave the ventricle restrictive.
  • The aortic clamp was removed for better hemostatis of the two patches.
  • The left ventricular wall closure was performed with a double line suture, reinforced with Teflon.

References

  1. Dor V, Kreitmann P, Jourdan J, et al: Interest of physiological closure (circunferential plasty on contractile areas) of the left ventricle after resection and endocardectomy for aneurysm of akinetic one comparison with classical technique about a series of 209 left ventricular resections. J Cardiovasc Surg 26:73, 1985.
  2. Dor V, Saab M, Coste P, Kornaszewska M, Montiglio F. Left ventricular Aneurysm: A new Surgical Approach. Thorac Cardiovasc Surg 37 (1989) 11-19.
  3. Dor V. Surgery for left ventricular aneurysm. Current Opinion in Cardiology 1990, 5:773-780.

Comments

This is a nice video. It is important to point out that this was a chronic post-infarction VSD and ventricular aneurysm. This is a much easier operation than an acute VSD where the quality of the tissues surrounding the defect is poor and more perilous to sew to.
Congratulation,for doing double procedure. Can I inlight you with some information about the Modified Dor repair you nicely did? I was trained in Canada and I practice now in Saudi Arabia,I used to do this Dor repair for the LV aneurysm using saline filled glove and even steralized party balloons,Then I visited Prof.Manacanty in Milano-Italy , He developed a technique called ventricular restoration tech. in wich he uses a plastic maniqane pear shaped crosspond to patient matched strok volume.He first takes a 2-0 prolene stitch near apex and septum to narrow the neck of the aneurysm, then but his eliptiacal plastic balloon insid and put a pursstring surure ,tie it ,remove the balloon then put the patch.According to his published series he proofed that this tech restors the normal elipital shape of the LV and not the squarish shape we create with classic Dor. He claims ,by echo studies give better improvement of LV function. The plastic single use balloons are comm available in the USA ,Italy, Saudi Arabia. I hope this is helpful. Forgive my long comment.
Would you comment on the need of VSD closure prolonging the X-Clamp time, since the area of VSD remains in the excluded part of the left ventricle??? Sincerely

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