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Repair of a Post-Infarction VSD

Monday, December 15, 2025

By

Vincent Gaudiani

Gaudiani V, Tsau P, Rammohan C. Repair of a Post-Infarction VSD. December 2025. doi:10.25373/ctsnet.30885719

This video demonstrates the repair of a post-infarction ventricular septal defect (VSD). Initially, attempts were made at closure in the catheterization lab, but this was unsuccessful, and there was also severe tricuspid regurgitation, so the patient was brought to the operating room. A femoral venous cannula was placed to allow the inferior vena cava (IVC) to be cross-clamped with a Chitwood clamp, providing more operative space. A superior vena cava (SVC) cannula was also placed and snared. The right atrium was opened, and the VSD was inspected from the right atrium. A view was also obtained through the aortic valve, but it was not adequate. An incision was made into the right ventricle, and very large zero Ethibond pledgeted sutures were placed around the defect, and a patch was placed. The tricuspid valve was then repaired, and both the right ventricle and right atrium were closed.  

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Comments

Submitted by Edward Bender on
I really enjoy watching all your videos and have learned a lot. I usually (3 times) repair post-MI VSD's through the RV, but I put the patch on the left side as you alluded that you would like to do in the video. Pledgeted suture from "back" to "front" of patch and then thru septum. Then a second patch goes on the right side of the septum using same suture. Perhaps belt and suspenders. The second patch can be used in the RV closure as you also mentioned. I've used a softer patch (Sauvage dacron patch if available or even the dreaded bovine pericardium - maybe I get away with that because of 2 patches). In any case it's hard to argue strongly since your technique was certainly successful.
Submitted by Vincent Gaudiani on
The double patch technique sounds great to me, and there is no shame in belt and suspenders in a dangerous situation. We don’t have the Sauvage patch, but he was a great pioneer of graft material. When i reviewed this video, i realized that I didn’t discuss how to decide when to operate. Perhaps we should organize an online discussion.
Submitted by Jan Coveliers on
Thank you for sharing this interesting and challenging case. One question that came to mind while watching the video concerns timing of repair in the setting of very friable post-infarction tissue. Have you or your group had experience using VA-ECMO (with or without additional LV unloading) as a bridge to allow some infarct demarcation and improved tissue quality prior to definitive VSD repair? I would be very interested to hear whether this strategy has been feasible in your hands, and how you balance the risks of ongoing shunt physiology against the potential benefit of delayed repair. I have some cases where the ecmo was helpful and the shunt was manageable.
Submitted by Vincent Gaudiani on
I have not had experience with ECMO, and as I mentioned above, I did't do a good job of discussing when to operate. The heart will form good scar material that is fairly easy to sew in three weeks. So if the patient survives at home for a week before coming to the hospital, and is stable, it is reasonable to discuss with structural cardiology colleagues and decide whether a cath lab intervention or operation if preferable. Of course that will be a minority of these difficult cases. Most will be very ill, and perhaps ECMO could help them to a more chronic and easier to fix state. In general operating early is best, especially if the pati ent has any instability. also don't be fooled by an echo that shows reasonable ventricular function. The VSD unloads the LV!

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