Early repair of postinfarction ventricular septal rupture

Massive post-infarction ventricular septal rupture complicaing cardiogenic shock with long term veno-arterial extracorporeal membrane oxygenation support

INTRODUCTION

Ventricular septal rupture (VSR) following acute myocardial infarction (AMI) is a rare but serious complication often causing cardiogenic shock (CS). The timing of surgery is a difficult problem for surgeons because of high mortality and surgical complexity. We present a case of successful use of extracorporeal membrane oxygenation (ECMO) for maintaining haemodynamic stability preoperative and delaying surgical repair of VSR patient in severe CS.

CASE REPORT

A 57-year-old man with AMI complicated by severe CS due to an massive VSR. Emergency surgery was considered a too high mortality risk. The patient was implanted with a percutaneous veno-arterial ECMO (VA-ECMO) system as a bridge to surgery for stabilizing general condition. On the 31th day after ECMO implantation, the ventricular septal defect was successfully repaired and weaning from the ECMO.

DISCUSSION

This case study illustrates that it may be considered to use long term ECMO preoperative to delayed surgery which leads to higher survival in cases of massive VSR patient after AMI in hemodynamically compromised patients. Still the optimal duration of mechanical circulatory support and the optimal timing for surgery need more research to define.

CONCLUSION

This case indicates the feasibility of preoperative using of a long term VA-ECMO as a bridge to surgical repair of VSR patient after AMI in severe CS. The optimal duration of mechanical circulatory support and the optimal timing for surgery still require further investigation.

Optimal Time Repair of Ventricular Septal Rupture Post Myocardial Infarction

Ventricular septal rupture (VSR) is an uncommon complication of myocardial infarction (MI). The mortality rate of VSR is high. The management of VSR is including the stabilization of the hemodynamic status and surgical closure of the rupture. In spite of the agreement of experts on the necessity of surgical repair, the timing of VSR repair management remains unclear. In this review article, we evaluate the optimal time repair of VSR. To collect the data, Pubmed, EMBASE, and Cochrane Central Registry databases were searched for potentially suitable studies. Search terms were including “Ventricular Septal Rupture”, “Myocardial Infarction”, “Timing”, and “MI”. According to the result of the studies, it seems that the time between VSR detection and its repair is a determining factor in the survival or mortality of patients in post-myocardial infraction VSR. Studies showed that earlier surgical repair in VSR increases the risk of mortality, because in the early phase after MI, infarcted myocardium is very fragile, and it is very difficult surgical repair and increases the risk of recurrent septal defects. The longer time is needed for the heart and different body systems to adapt to the hemodynamic results of the abrupt left to right shunt. It seems that the best time for the operation is after the maturation of VSR with scarring at the edges of the defect. Moreover, in a large number of patients, it is not possible to delay the operation since they are at risk of severe heart failure and organ dysfunction. In these cases operation immediately after diagnosis of VSR is recommended to prevent further hemodynamic deterioration. In hemodynamically compromised patients, it may be considered to use a ventricular assist device, requiring an intra-aortic balloon pump (IABP), or extracorporeal membrane oxygenation (ECMO) preoperative to postpone the operation which leads to higher survival in post-MI-VSD.

Decision making, management, and midterm outcomes of postinfarction ventricular septal rupture: Our experience with 21 patients

Context:

Ventricular septal rupture (VSR) is a dreaded complication following myocardial infarction. Surgical repair of VSR is associated with significant early mortality. Variable outcomes in terms of early mortality and midterm functional status have been reported from different centers.

Aims:

In our study, we attempt to review the experience of decision making and surgical repair of postinfarction VSR, and to analyze the factors contributing to the early mortality and midterm outcome after repair.

Materials and Methods:

It is a retrospective study. Data were summarized retrospectively by frequencies and percentages for categorical factors, and means and standard deviations for continuous factors. Multivariate logistic regression, odds ratios, 95% confidence intervals, and P value were calculated for different variables to determine their independent effect on operative mortality. All surviving patients answered the EQ-5D Health Questionnaire.

Results:

Preoperative renal failure, left ventricular dysfunction (moderate and severe), and Killip class (III and IV) were significantly associated with early mortality after surgery. Small residual ventricular septal defect (VSD) was not found to affect the midterm quality of life.

Conclusions:

Early surgical repair benefits the patient by preventing early end-organ damage. The renal failure left ventricular dysfunction (moderate and severe) and Killip class (III and IV) adversely affect early outcomes after surgery. Small residual ventricular septal defect (VSD) does not affect the midterm quality of life.

Flail Tricuspid Leaflet During the Percutaneous Closure of Post-Myocardial Infarction Ventricular Septal Defect

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A post-MI ventricular septal defect is a complication of ST-elevation MI.

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Iatrogenic tricuspid regurgitations have not been reported after percutaneous closure.

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Care should be taken with the degree of tricuspid regurgitation to prevent iatrogenic tricuspid injury.

Ventricular septal rupture: successful delayed repair

Ventricular septal rupture (VSR) occurs in approximately 1% of the patients who experience an acute myocardial infarction. The operative mortality of VSR repair decreases if surgery can be delayed until the infarct has healed and tissue strength improved. Because of heart failure or impending cardiogenic shock, surgical treatment can often not be delayed. We present a case in which a delayed repair of a VSR was possible. The patient was initially stabilized with an intra-aortic balloon pump. She was discharged and readmitted 5 weeks later for definitive repair. Repair was performed, according to the Daggett technique, using a bovine pericardial patch and a mitral annuloplasty was carried out to correct for the regurgitation. Recovery was uneventful. Cardiac ultrasound examination at discharge showed no residual defect.

Using extracorporeal membrane oxygenation support preoperatively and postoperatively as a successful bridge to recovery in a patient with a large infarct-induced ventricular septal defect

Rupture of the ventricular septum during acute myocardial infarction usually occurs within the first week. The event is usually followed by low cardiac output, heart failure, and multiorgan failure. Despite the many advances in the nonoperative treatment of heart failure and cardiogenic shock, including the intra-aortic balloon pump and a multitude of new inotropic agents and vasodilators, these do not supplant the need for operative intervention in these critically ill patients. This article describes the successful use of extracorporeal membrane oxygenation support as a bridge to recovery postoperatively in a patient with a large infarct-produced ventricular septal defect.

Surgical Repair of Ventricular Septal Defect after Myocardial Infarction: A Single Center Experience during 22 Years

BACKGROUND

Surgical repair of post-infarct ventricular septal defect (VSD) is considered one of the most challenging procedures having high surgical mortality. This study aimed to evaluate the outcomes of the surgical repair of post-infarct VSD.

METHODS

From May 1991 to July 2012, 34 patients (mean age, 67.1±7.9 years) underwent surgical repair of post-infarct VSD. A retrospective review of clinical and surgical data was performed.

RESULTS

VSD repair involved the infarct exclusion technique using a patch in all patients. For coronary revascularization, 12 patients (35.3%) underwent concomitant coronary artery bypass graft, 3 patients (8.8%) underwent preoperative percutaneous coronary intervention, and 9 patients (26.5%) underwent both of these procedures. The early mortality rate was 20.6%. Six patients (17.6%) required reoperation due to residual shunt or newly developed VSD. During follow-up (median, 4.8 years; range, 0 to 18.4 years), late death occurred in nine patients. Overall, the 5-year and 10-year survival rates were 54.4%±8.8% and 44.3%±8.9%, respectively. According to a Cox regression analysis, preoperative cardiogenic shock (p=0.069) and prolonged cardiopulmonary bypass time (p=0.008) were independent predictors of mortality.

CONCLUSION

The early surgical outcome of post-infarct VSD was acceptable considering the high-risk nature of the disease. The long-term outcome, however, was still dismal, necessitating comprehensive optimal management through close follow-up.

Device closure of post-myocardial infarction ventricular septal defect three weeks after coronary angioplasty

Percutaneus device closure appears to be safe and effective in patients treated for a residual shunt after initial surgical closure, as well as after two to three weeks of index myocardial infarction. The index case presented with a ventricular septal defect on second of acute myocardial infarction thrombolysed with streptokinase. The general condition of the patient was fairly stable. Cardiac catheterization and coronary angiography showed significant left to right shunt and there was 90 % proximal stenosis of left anterior descending coronary artery. Other coronary arteries were normal. Angioplasty and stenting to the coronary artery lesion was done using drug eluting stent (DES) with very good angiographic result. Patient was discharged after four days in stable condtion. After 3 weeks his ventricular septal defect was closed percutaneusly using cardio -O-fix device with tiny residual shunt. The procedure was uneventful and of brief duration. He was discharged after 5 days of the post procedure in very stable condition with minimal residual shunt. A staged procedure is a better option if the condition of the patient allows strengthening ventricular septal defect border.

Cardiogenic shock

Cardiogenic shock is the most common cause of death in patients hospitalized with acute myocardial infarction and is associated with a poor prognosis. More than 75% of cases are due to extensive left ventricular infarction and ventricular failure. Other causes include right ventricular infarction and papillary muscle rupture with acute severe mitral regurgitation. Activation of neurohormonal systems and the systemic inflammatory response worsens shock. To improve outcomes, cardiogenic shock needs to be recognized early in its course and its cause needs to be diagnosed rapidly. Treatment strategies using intra-aortic balloon counterpulsation and emergency revascularization by percutaneous coronary interventions or coronary bypass surgery have been shown to improve outcomes. To decrease the incidence of cardiogenic shock, public education regarding early presentation to hospital in the course of acute chest pain is important. Emergency medical transport systems may need to take patients with complicated acute myocardial infarction to hospitals with the capability to perform urgent revascularization.

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.

Excimer laser-assisted high-flow extracranial/intracranial bypass in patients with symptomatic carotid artery occlusion at high risk of recurrent cerebral ischemia: safety and long-term outcome

BACKGROUND AND PURPOSE

The goal of this study was to determine safety and long-term outcome of the excimer laser-assisted high-flow extracranial/intracranial (EC/IC) bypass in patients with symptomatic carotid artery occlusion (CAO) at high risk of recurrent stroke.

METHODS

In a prospectively collected cohort of 103 patients with symptomatic CAO, 15 patients were selected for excimer laser-assisted EC/IC bypass surgery on the basis of predefined selection criteria: (1) transient or moderately disabling symptoms of focal cerebral ischemia, not symptoms of the retina only; (2) continuing symptoms after documentation of the CAO; (3) evidence of a possible hemodynamic origin of symptoms; and (4) informed consent of the patient.

RESULTS

Eleven patients underwent the operation without complications One patient had a severely disabling stroke (Rankin grade 4) 11 days after the operation; the bypass was found occluded on reoperation. Two other patients had a moderately disabling stroke (Rankin grade 3) immediately after the operation. One patient died of myocardial infarction 1 day after surgery. Median follow-up time was 27 months. Of the 11 patients who underwent the operation without complications, 1 died 17 months after the operation of a brainstem stroke, and another patient had a new stroke ipsilateral to his CAO 10 months after the operation but without a change in Rankin grade.

CONCLUSIONS

The excimer laser-assisted high-flow EC/IC bypass operation is a potentially promising procedure in patients with symptomatic CAO and a presumably high risk of recurrent stroke, but the procedure carries a definite risk. This risk is probably related not only to the procedure itself but also to the selection of patients.

Venous stasis retinopathy in symptomatic carotid artery occlusion: prevalence, cause, and outcome

BACKGROUND AND PURPOSE

Chronic ocular ischemia is a rare form of ischemia of the eye in patients with carotid artery occlusion (CAO). The early and often asymptomatic stage of chronic ocular ischemia is referred to as venous stasis retinopathy (VSR). The aim of this study was to gain insight into the prevalence, cause, and outcome of VSR in patients with symptomatic CAO.

METHODS

In 110 patients with symptomatic CAO, we prospectively investigated the frequency of VSR, the association between the presence of VSR and impaired cerebral blood flow, and the proportion of patients who developed clinically manifest chronic ocular ischemia with ischemia of the anterior eye segment or blindness.

RESULTS

At study entry, VSR was found in 32 patients (29%; 95% CI, 21 to 38), particularly in those with symptoms classically associated with a hemodynamic cause, such as limb shaking (relative risk, 2.4; 95% CI, 1.0 to 5.9). Patients with VSR had lower pulsatility indexes in the ophthalmic artery in case of reversed flow, lower cerebral CO2 reactivity, and lower cerebropetal blood flow than patients without VSR. On follow-up (mean, 29 months), clinically manifest chronic ocular ischemia developed in 4 patients (annual rate, 1.5%; 95% CI, 0.4 to 3.8); it tended to occur more often in patients in whom VSR was present at study entry (relative risk, 7.3; 95% CI, 0.8 to 68).

CONCLUSIONS

One third of patients with symptomatic CAO has VSR on ophthalmoscopy. VSR is associated with an impaired flow state of the brain. Development of clinically manifest chronic ocular ischemia is rare.

Transcatheter closure of post-myocardial infarction ventricular septal defect with Amplatzer septal occluder

Rupture of the interventricular septum is an uncommon but often fatal complication of acute myocardial infarction. Transcatheter closure is an established method of treating selected congenital defects but clinical experience on transcatheter closure of postinfarction ventricular septal defects (VSDs) is minimal. We report a case of successful transcatheter closure of postinfarction VSD using the Amplatzer septal occluder.