Surgery for Post-Myocardial Infarct Ventricular Septal Defect

Abstract

Forty-three patients (mean age 62 +/- 1 years) were treated for ventricular septal defect (VSD) secondary to myocardial infarction. Whenever possible, operation was postponed until six weeks post-onset chest pain. However, hemodynamic instability, evidenced by cardiogenic shock, refractory pulmonary edema, or a rising blood urea nitrogen (BUN) forced operation in 21 patients within 21 days post-infarct (Group I). In seven patients operation was performed three to six weeks post-infarct (Group II). In only eight patients could operation be delayed beyond six weeks post-infarct (Group III). Clinical deterioration, once begun, progressed rapidly, and could be reversed only temporarily by intra-aortic balloon pumping, used in 26 patients for safe conduct of cardiac catheterization and for peri-operative hemodynamic support. Hospital survival was achieved in 24 of the 36 operated patients (66%). In Group I patients, ten of 21 survived. In Group II, six of seven survived. In Group III, eight of eight patients survived. There have been five late deaths with a mean follow-up of 41 months in survivors. Improved survival has been achieved recently by the greater use of prosthetic material to replace necrotic muscle and by a transinfarct incision regardless of infarct location. Operative mortality before 1973 was 47%; mortality after 1973 was only 18%, with a concomitant reduction of mortality (30%) even in Group I patients.

APerventricular device closure of post-myocardial infarction ventricular septal defect: Can it combine best of both worlds!

“…50% of these patients die within one week and about 85% within two months [2,9]. Attempts to stabilize the patient's condition with medical therapy often fail because most patients have a rapid deterioration and subsequently die [3].…”

“…The joint American Heart Association/American College of Cardiology (AHA/ACC) 2004 Guidelines recommend emergent repair of the VSD with concurrent coronary artery bypass grafting, as indicated, irrespective of hemodynamic status, with no change in this class I recommendation in the 2011 ACC/AHA guideline for coronary artery bypass surgery [1,10]. Current surgical management of this uncommon catastrophe includes: 1) deferring operation, if possible, until three weeks after infarction, 2) cardiac support with intra-aortic balloon pump insertion to allow preoperative definition of coronary and ventricular anatomy of patients with hemodynamic deterioration, and 3) a transinfarct incision with prosthetic replacement of excised ventricular free wall or septum, if necessary, and 4) possible repair of associated coronary or mitral valve pathology [8,9]. Cardiac surgery is considered the gold standard in the management of these defects.…”

Surgical Ventricular Restoration for Ischemic Cardiomyopathy with Functional Mitral Regurgitation

“…At the end of the 1970s, SVR with patchplasty had been reported for the posterior and anterior regions of the LV 27,28) . In 1980s, Dor and associates established a new surgical technique with a circular patch (endoventricular circular patch plasty; EVCCP) for antero-septo-apical aneurysms 29) .…”

III Diretriz sobre tratamento do infarto agudo do miocárdio

“…O tratamento cirúrgico do aneurisma de ventrículo esquerdo, que deve ser realizado apenas após a fase de cicatrização do IAM, inclui técnicas como: a) ressecção da área aneurismática do ventrículo esquerdo, com sutura linear dos bordos 587 ; b) substituição de parte da parede ventricular por material protético (dácron), com a finalidade de evitar a deformidade da cavidade ventricular em pacientes submetidos a infartectomia da parede inferior 588 ; c) reconstrução da geometria ventricular esquerda, inicialmente utilizando tecido de dácron ou pericárdio bovino e posteriormente plicaturas das paredes enfraquecidas (o uso da circulação extracorpórea sem clampeamento aórtico, ou seja, com o coração batendo, reduziu a mortalidade operatória dessa técnica de 12,6% para 3,5%) 589 ; d) endoaneurismorrafia com utilização de material sintético inelástico suturado no interior da cavidade ventricular, na transição entre o miocárdio sadio e o fibrosado, demonstrandose, com essa técnica, sobrevida de 87% em 20 meses 590 ; e) endoaneurismorrafia com utilização de prótese semi-rígida de pericárdio bovino 591 ; f) técnica do T invertido para o reparo da parede ventricular após a ressecção da área aneurismática 568 ; e g) ablação de focos de arritmia ventricular, geralmente em áreas fibrosadas do miocárdio, identificadas por meio de mapeamento eletrofisiológico intra-operatório, o que diminui o risco operatório 592 .…”