Modified Infarct Exclusion Technique for Repair of Postinfarction Ventricular Septal Rupture
2018; Elsevier BV; Volume: 107; Issue: 3 Linguagem: Inglês
10.1016/j.athoracsur.2018.09.045
ISSN1552-6259
AutoresV Rao Parachuri, Amit Kumar Tripathy, Namdeo Mahadeo Gaikwad, Akshaya Pratap Singh, Vineet Mahajan, S. Niranjan,
Tópico(s)Cardiac Valve Diseases and Treatments
ResumoRepair of ventricular septal rupture after acute myocardial infarction remains a surgical challenge. Several techniques for the closure of these defects have been described. This report discusses an infarct exclusion technique modified from the one described by Tirone David and associates. In this technique two separate pericardial patches are used. The first patch excludes the rupture. The second patch is sutured to the margins of the first patch and thus provides strength to the margins of the first patch. The repair is simple and durable and has reduced the incidence of residual ventricular septal defects and patch dehiscence. Repair of ventricular septal rupture after acute myocardial infarction remains a surgical challenge. Several techniques for the closure of these defects have been described. This report discusses an infarct exclusion technique modified from the one described by Tirone David and associates. In this technique two separate pericardial patches are used. The first patch excludes the rupture. The second patch is sutured to the margins of the first patch and thus provides strength to the margins of the first patch. The repair is simple and durable and has reduced the incidence of residual ventricular septal defects and patch dehiscence. The Video and Supplemental Figures can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2018.09.045] on http://www.annalsthoracicsurgery.org. The Video and Supplemental Figures can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2018.09.045] on http://www.annalsthoracicsurgery.org. Ventricular septal rupture (VSR) after acute myocardial infarction (MI) remains a cardiac surgical emergency. Perioperative mortality still remains high despite the evolution of techniques for closure. These techniques include infarctectomy, described by Daggett and colleagues [1Daggett W.M. Guyton R.A. Mundth E.D. et al.Surgery for post-myocardial infarct ventricular septal defect.Ann Surg. 1977; 186: 260-271Crossref PubMed Scopus (185) Google Scholar], and infarct exclusion, described by David and associates [2David T.E. Dale L. Sun Z. Postinfarction ventricular septal rupture: repair by endocardial patch with infarct exclusion.J Thorac Cardiovasc Surg. 1995; 110: 1315-1322Abstract Full Text Full Text PDF PubMed Scopus (176) Google Scholar]. We report a technique in which two separate patches are used to repair the VSR. The second patch reinforces the first patch and provides an effective seal, thereby preventing postoperative residual ventricular septal defects (VSDs) and patch dehiscence. It is a simple, reproducible, and durable technique. Cardiopulmonary bypass is established using bicaval cannulation. Moderate hypothermia and antegrade cold blood cardioplegia are used for myocardial protection. The heart is vented through the right superior pulmonary vein. Distal anastomoses of the coronary arteries are performed if needed. The infarcted territory is identified, and left ventriculotomy is performed through the infarct, 2 to 3 cm away from the culprit coronary artery. The extent of the infarcted territory is noted, and the ventriculotomy is extended to include the full extent of the infarct. The ventriculotomy margins are retracted with two pledgetted 3-0 polypropylene sutures, and the VSD is located. A 10 × 5 cm patch of bovine pericardium is taken and sutured to the healthy area of myocardium surrounding the VSD by using 3-0 polypropylene sutures. The suturing is begun beyond the VSD margin, farthest away from the ventriculotomy into the healthy area of the septum. Suturing is performed in both clockwise and anticlockwise manner and is brought up to the ventriculotomy edge closer to the culprit coronary artery. The patch is then fashioned and sutured to this edge (Fig 1A ). This patch effectively excludes the right ventricular cavity, the VSD, and the infarcted portion of the septum. A second patch of similar dimension is taken and sutured to reinforce the previous suture line to the adjacent healthy margin of the left ventricle (LV) (Fig 1B). It is then brought up, the patch is tailored, and it is sutured to the opposite edge of the ventriculotomy (Figs 1C, 2, and 3). The ventriculotomy is closed in a linear fashion buttressed by two strips of soft Teflon (DuPont, Wilmington, DE) in two layers using 2-0 polypropylene suture (Fig 3B). Deeper interrupted horizontal mattress suturing is followed by over-and-over running sutures (Supplemental Figs 1–6, Video 1). Coronary revascularization is then completed if distal anastomosis was performed initially.Fig 2Second pericardial patch being sutured. (IVS = interventricular septum; VSR = ventricular septal rupture.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3(A) Two patches for closure of ventricular septal rupture (VSR). (B) Linear closure of the ventriculotomy in two layers. (IVS = interventricular septum; LV = left ventricle.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) A total of 32 patients underwent operation with this technique between January 2013 and March 2018. One patient had residual VSD that was detected on the operating table, and the patch was reinforced. All patients came off bypass successfully. There were no incidences of residual VSDs in the immediate postoperative period. VSR is a surgical emergency. Various techniques have developed over time. The presence of residual VSDs, LV geometry, septal dyskinesia, tension on suture margins, length of cardiopulmonary bypass time, and cross-clamp times are important considerations that have been addressed with the evolving techniques. With the advent of therapeutic interventions such as thrombolytic therapy and acute percutaneous coronary interventions, the incidence of postinfarction VSD has been reduced to less than 0.5% [3Yip H.K. Fang C.Y. Tsai K.T. et al.The potential impact of primary percutaneous coronary intervention on ventricular septal rupture complicating acute myocardial infarction.Chest. 2004; 125: 1622-1628Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar]. Evidence from the SHOCK (SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?) trial suggested a median time for presentation of VSD after MI to be 16 hours. Less than 30% patients survive to 2 weeks without surgical treatment, and only 10% to 20% survive beyond 4 weeks. It also reported that the risk of death is greatest immediately after myocardial rupture and decreases gradually [4Menon V. Webb J.G. Hillis L.D. et al.Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK trial registry. Should we emergently revascularize occluded coronaries in cardiogenic shock?.J Am Coll Cardiol. 2000; 36: 1110-1116Crossref PubMed Scopus (273) Google Scholar]. Latham [5Latham P.M. Lectures on Subjects Connected with Clinical Medicine Comparing Diseases of the Heart. 2. Longmans, Brown, Green, and Longmans, London, United Kingdom1845: 168Google Scholar] described postinfarction VSD for the first time in 1845. Cooley and associates [6Cooley D.A. Belmonte B.A. Zevis L.B. Schnur S. Surgical repair of ruptured intraventricular septum following acute myocardial infarction.Surgery. 1957; 41: 930PubMed Google Scholar] in 1957 used a polyvinyl sponge to plug a posterior VSR in the first reported successful repair of post-MI VSR. The defect was approached through a right ventriculotomy. The trabeculated nature of the septum with poor delineation of margins and potential risks for sacrificing healthy septum were potential disadvantages with this approach. Subsequently, the left ventriculotomy approach came into vogue. Daggett and colleagues [1Daggett W.M. Guyton R.A. Mundth E.D. et al.Surgery for post-myocardial infarct ventricular septal defect.Ann Surg. 1977; 186: 260-271Crossref PubMed Scopus (185) Google Scholar] proposed a technique of infarctectomy and closure of the VSD directly or with a patch. It has the advantages of being simple and reproducible, with a shorter operative time because of a smaller patch and shorter suture line. The potential disadvantages are the high incidences of postoperative residual VSDs, higher 30-day mortality, and poor long-term survival [6Cooley D.A. Belmonte B.A. Zevis L.B. Schnur S. Surgical repair of ruptured intraventricular septum following acute myocardial infarction.Surgery. 1957; 41: 930PubMed Google Scholar]. David and colleagues [2David T.E. Dale L. Sun Z. Postinfarction ventricular septal rupture: repair by endocardial patch with infarct exclusion.J Thorac Cardiovasc Surg. 1995; 110: 1315-1322Abstract Full Text Full Text PDF PubMed Scopus (176) Google Scholar] introduced a technique of endocardial patch repair with infarct exclusion. It revolutionised and simplified the approach to post-MI VSR. This technique has been adopted by most centers around the world and is being used currently either in its original form or with some modifications. Maintenance of ventricular geometry and consequent sustained or improved ventricular performance, absence of myocardial resection, and reduced chances of pseudoaneurysms are potential merits with this technique. A study conducted by Lundblad and colleagues [7Lundblad R. Abdelnoor M. Surgery of postinfarction ventricular septal rupture: the effect of David infarct exclusion versus Daggett direct septal closure on early and late outcomes.J Thorac Cardiovasc Surg. 2014; 148: 2736-2742Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar] found that the 30-day mortality and long-term survival were better with this technique than with the Daggett technique. Recurrence of VSD remains a major disadvantage. Caimmi and associates [8Caimmi P.P. Grossini E. Kapetanakis E.I. et al.Double patch repair through a single ventriculotomy for ischemic ventricular septal defects.Ann Thorac Surg. 2010; 89: 1679-1681Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar] reported a two-patch technique for repair of this condition in which, through a left ventriculotomy, one patch is used on either side of septum, and the suture lines are reinforced with glue. This technique appears promising, but longer cross-clamp time, accuracy of the suture line on either side, and reproducibility are important concerns. This double-patch technique for VSR has been in use at our center (Narayana Hrudayalaya, Bangalore, India) from 2013. Before that, we used the David technique for repair of VSR. Two cases had complete patch dehiscence, and there was postoperative residual leak in nearly 30% of the patients. This high incidence could reflect vulnerability of the single suture line with one patch in the David technique. We believe that reinforcing the first patch with another suture line using the second patch reduces the incidence of residual VSDs and patch dehiscence. It obviates the complex procedure of inlaying the large pericardial patch under the ventriculotomy margin. Moreover, because of the use of two patches, right ventricularization of the LV is minimized, and LV geometry is better restored. This technique is applicable to both anterior and inferior wall VSR and is simpler in terms of suturing and reproducibility than other procedures. Supplemental Figure 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)Supplemental Figure 3View Large Image Figure ViewerDownload Hi-res image Download (PPT)Supplemental Figure 4View Large Image Figure ViewerDownload Hi-res image Download (PPT)Supplemental Figure 5View Large Image Figure ViewerDownload Hi-res image Download (PPT)Supplemental Figure 6View Large Image Figure ViewerDownload Hi-res image Download (PPT)eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI5YThiOWFkNmEwZTFjNTc5ZDdkMTJjZGFhZGVjMzk5YSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NjU2MzcxfQ.SnIVZ9ZX7kMqwKYUPNHUfkKOU1i4gXovrAcOzOL9RgpunQYlaPri5kheRwTitb9RjJgmtccY5dFn14HMw30k_UVMv_ciyqK8BrpkkSVZpMkRfYileU4LNA2PShI2jHeuJt7vyzVPRMhHow7V367pSLYLKcA9NLc-Tn1cbcfVpwvgPDEVn6ncO86Y9gZidiNG5tSWMB85hNWetSLlN_29lzSmroGPscC7HsdEEjtd1UjAohdj84PN1FzF394vjJaVLAXvBIr_GA-qSm-3sF9_7US7DXzjzVtfNP99jmH-bZu2g7Ve-963HMph4dfVPCJgXfQKYGpKxn2Aly4U0c3W0w Download .mp4 (34.55 MB) Help with .mp4 files Video
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