Delayed repair of an acquired posterior septal defect through a right atrial approach

A Modified Transatrial Approach for Repair of Postinfarction Ventricular Septal Defect

Ventricular septal defect (VSD) is a life-threatening complication of myocardial infarction. Surgical repair is generally performed through a left/right ventriculotomy. To avoid complications associated with ventriculotomy, a right transatrial approach has been proposed. We describe a modified transatrial approach through the left atrium for basal-inferior VSD. After left atriotomy, mitral valve is detached from the annulus to expose the defect, which is closed with a pericardial patch. Two patients were operated by this method. In both cases venoarterial extracorporeal membrane oxygenation with a ventricular vent was utilized to unload the left ventricle. Echocardiography revealed no residual shunt in both cases.

Right atrial approach for repairing a posterior ventricular septal rupture: a case report

BACKGROUND

Ventricular septal rupture (VSR) is a life-threatening complication following acute transmural myocardial infarction. Posteriorly located ruptures are one of the main predictors of poor prognoses because of the surgical difficulties associated with this location.

CASE PRESENTATION

A 72-year-old man with a posterior VSR underwent surgical repair via the right atrial approach. The patient's postoperative course was uneventful, and echocardiography showed no residual shunt flow. He was discharged on postoperative day 37.

CONCLUSION

By temporally detaching the tricuspid valve leaflet, this approach provides a better view and handling space within the posterior ventricular septum than the trans-ventricular approach. Additionally, avoiding a ventricular incision can better preserve postoperative ventricular function.

Transatrial Approach for the Repair of the Posterior Post-Infarct Ventricular Septal Rupture

Ventricular septal rupture (VSR) is a disastrous mechanical complication of myocardial infarction. Although several surgical interventions have been developed, mortality due to surgical management remains high, especially in the case of posterior VSR. We report a successful case of repair of posterior VSR using an alternative transatrial approach to avoid the complications related to ventricular incision.

Repair of acute inferior wall myocardial infarction-related basal ventricular septal defect: transatrial versus transventricular approach

BACKGROUND

We describe our contemporary experience for the management of patients with an acute postinfarction basal ventricle septal defect (VSD) using the transatrial (TA) and transventricular (TV) approaches.

METHODS

Retrospective review of all patients diagnosed with an ischemic basal VSD since January 2000. There were 20 patients with a median age of 68 years (39 to 85); 13 (65%) were males. Median time from diagnosis of the ischemic basal VSD to operation was 22 hours (6 to 144).

RESULTS

All patients received standard patch closure of the septal defect with exposure of the VSD through the TA approach in eight patients (40%) and the TV approach in 12 (60%). All TA group patients received tricuspid valve replacement, while in the TV group, two had tricuspid valve replacement and two repair. Five patients (25%) had clinically insignificant (<0.5 mm) residual septal defects; three additional patients (15%) experienced patch dehiscence and two (10%) underwent re-exploration. There were five mortalities (25%): one in the TA group (right ventricular heart failure) and four in the TV group (one right ventricular heart failure, three ventriculotomy site hemorrhage or patch dehiscence). Preoperative right atrial pressure (p=0.0003) and right ventricular dysfunction (p=0.04) were predictors of hospital mortality. Follow-up of the hospital survivors was 4.3 years (40 days to 11.5 years) with one death at seven years.

CONCLUSION

Operative mortality associated with repair of postinfarction basal ventricular septal defect is high and is related to right ventricular failure and bleeding from the ventriculotomy. The TA approach avoids ventriculotomy-associated bleeding and provides excellent exposure but is associated with an increased incidence of tricuspid valve replacement.

Transatrial Repair of Post-infarction Posterior Ventricular Septal Rupture

Ventricular septal rupture (VSR) is a rare but lethal complication of myocardial infarction. The event occurs 2~8 days after an infarction and often precipitates cardiogenic shock. Post myocardial infarction VSR is known for difficult to repair. Especially, Transmural myocardial infarction involved in the posterior VSD area, exposure of the affected site is difficult and postoperative mortality rate is high. We have experienced a case of a 75-year-old female patient who suffered posterior VSD due to acute myocardial infarction, and attained good result by approaching the lesion through right atrial incision and repaired the defect by using patch closure technique.

A new double patch technique for early repair of postinfarct posterior ventricular septal rupture: Avoiding ventriculotomies

Our new double patch technique for repairing posteroinferior ventricular septal ruptures (VSRs) offers placement of patches in both the left and right ventricle, avoids ventriculotomies and gives good access and complete control of both AV-valves during implantation. We have treated two patients with this technique. Both survived with unremarkable status upon leaving the hospital.

Residual postmyocardial infarction ventricular septal defect repair through right atrium with right thoracotomy on beating heart technique

BACKGROUND AND AIM

The incidence of residual opening after repair of postmyocardial infarction ventricular septal defect (VSD) was reported to be 10% to 25%. Redo surgery with remedial sternotomy is more complex than primary surgery and is consequently associated with higher mortality and morbidity due to the myocardial and patent coronary grafts injury during pericardial dissection.

METHODS

A 59-year-old female patient had coronary artery bypass grafting and closure of post myocardial infarction ventricular septal defect with patch 10 months earlier in a different cardiac center. She was admitted to the hospital for severe congestive heart failure.

RESULTS

She was operated because of the residual opening after repair of post myocardial infarction ventricular septal defect. Post myocardial infarction ventricular septal defect closure was performed through the right atrium by on-pump beating heart technique via the right thoracotomy.

CONCLUSIONS

Closure of post myocardial infarction ventricular septal defect with this technique offers an alternative and safe approach to repair of the residual VSD when the coronary bypass grafts are patent.

Repeated successful surgical rescues of early and delayed multiple ruptures of ventricular septum, right ventricle and aneurysmal left ventricle following massive biventricular infarction

A 58 year old man underwent 6 surgical interventions for various complications of massive biventricular myocardial infarction over a period of 2 years following acute occlusion of a possibly "hyperdominant" left anterior descending coronary artery. These included concomitant repair of apicoanterior post-infarction VSD and right ventricular free wall rupture, repeat repair of recurrent VSD following inferoposterior extension of VSD in the infarcted septum 5 weeks later, repair of delayed right ventricular free wall rupture 4 weeks subsequently, repair of a bleeding left ventricular aneurysm eroding through left chest wall 16 months thereafter, repair of right upper lobe lung tear causing massive anterior mediastinal haemorrhage, mimicking yet another cardiac rupture, 2 months later, followed, at the same admission, 2 weeks later, by sternal reconstruction for dehisced and infected sternum using pedicled myocutaneous latissimus dorsi flap. 5 years after the latissimus myoplasty, the patient remains in NYHA class 1 and is leading a normal life.

Postinfarction ventricular septal rupture: early repair through the right atrial approach

OBJECTIVE

Early repair of posterior ventricular septal rupture associated with myocardial infarction by means of transinfarct ventriculotomy is technically challenging and can be associated with significant mortality and morbidity. An alternative route of exposing the septum is through the right atrium. This technique, which avoids direct incision of the ventricle in select patients, reduces postrepair bleeding and impairment of ventricular contractile function.

METHODS

The results of 12 patients operated on over a 20-year period were reviewed and analyzed. Late follow-up was obtained in all patients who survived the operation. There were 9 men and 3 women, with a mean age of 69.9 years. The mean time between acute myocardial infarction and surgery was 7.3 days (range, 2-16 days). Six patients were in New York Heart Association class IV, and 3 patients presented for surgery in cardiogenic shock. One patient had previously undergone a coronary artery bypass. The surgical technique included a standard sternotomy approach with a transatrial approach to the septal rupture. In all patients the septal rupture was repaired with a Dacron patch.

RESULTS

There were 3 early deaths and 1 late death; one patient was reoperated on for a residual shunt. Postoperative complications included low cardiac output, acute renal tubular necrosis, and supraventricular arrhythmia. Eight patients are alive and undergoing echocardiographic investigation, and only 1 patient had a small residual shunt.

CONCLUSION

Our experience shows that a posterior ventricular septal rupture can be safely repaired through a transatrial approach. Avoiding additional damage to the ventricle, it reduces the risks of the postoperative bleeding and enhances survival.

A right atrial approach in redo postinfarction ventricular septal defect

Despite improvements in surgical techniques, post-infarction ventricular septal defect remains a surgical challenge that is associated with significant early and late mortality. Furthermore, the recurrence of the defect after primary correction occurs in approximately 10-25% of patients, and the operative risk increases because of a difficult dissection that is often complicated by previous patent grafts. The repair of recurrent ventricular septal defect has generally been performed by ventriculotomy in the infarcted zone. The authors propose an alternative approach that, when the rupture is posterior, allows its complete visualization, and avoids any further ventriculotomy in an already impaired ventricle.

Transatrial repair of ventricular septal defect subsequent to myocardial infarction

We describe successful transatrial repair of a ventricular septal defect occurring secondary to myocardial infarction. This approach avoids the need for ventriculotomy and may be technically simpler and safer than repair across the zone of infarction in a subset of patients with posterior defects and right ventricular dysfunction who survive the early period subsequent to their infarct.