MMCTS
(April 25, 2005). doi:10.1510/mmcts.2004.000562
Copyright © 2005 European Association for Cardio-thoracic Surgery
Procedure
Surgery for post-infarction ventricular septal defect (VSD): double patch and glue technique for early repair
Claude Deville*,
Louis Labrousse,
Emmanuel Choukroun and
Francesco Madonna
Department of Cardio-Vascular Surgery, Hôpital Haut-Lévêque, avenue de Magellan, 33604 Bordeaux-Pessac, France
* Corresponding author: * Tel. : +33-557-656437; fax: +33-557-656157. E-mail: claude.deville{at}chu-bordeaux.fr
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Summary
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Repair of post-infarction ventricular septal defect (VSD) remains a challenging procedure with a high risk of VSD recurrence. In order to reduce this risk, a double patch and glue technique was introduced in the department in 1986. This surgical technique is hereunder presented. Since 1971, ninety-three patients have been operated on early (<15 days) after the occurrence of a post-infarction VSD. This retrospective study allows to compare the results of this double patch and glue technique to those obtained with the conventional one, in terms of hospital death and VSD recurrence. The double patch and glue technique avoids recurrence of VSD and plays a part in reducing hospital mortality.
Key Words: Myocardial infarction • Mechanical complication • Ventricular septal defect • Surgical technique
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Introduction
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Post-infarction ventricular septal defect (VSD) repair remains a surgically challenging procedure with a high risk of mortality and morbidity [1, 2, 3, 4, 5, 6], partly due to the recurrence of VSD occurring in 10 to 50% of the cases [2, 3, 4, 5].
Since 1986, we have been using a modified repair technique with glue between two patches (one on each side of the septum). This technique has proven, in our experience, its efficiency in decreasing post-operative recurrence of ventricular septal defect [7].
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Surgical technique
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Whether VSD is anterior or posterior, it is approached by opening both ventricles through the infarction necrotic area. First, the left ventricle is opened with an incision made close to the septal margin. So, the VSD site can be accurate and allows correct opening of the right ventricle (Schematic 1 and Photos 1 and 2).
Through each ventriculotomy a Dacron patch, adequate in size and shape, is widely positioned over the VSD.
First on the right side of the septum. Special attention to shape the right patch is required, and usually one or several incisions have to be made in the Dacron patch to allow crossing of the moderator band and of the tricuspid papillary muscle tip (Schematics 2 and 3).
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Schematic 2 Right side of ventricular septum with ventricular septal defect, tricuspid papillary muscle tip on moderator band.
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Schematic 3 Patch on the right side of the ventricular septum preserving important anatomical structures.
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When the right patch is well positioned, it is advisable to hold it in place with two or three stitches at its bottom margin, to avoid mobility of the patch when positioning the second patch on the left ventricular side of the septum.
This second patch is easier to shape and set since the septal surface of the left ventricle presents only fine trabeculations (Schematics 4 and 5). Only the insertion of the anterior mitral leaflet could be a concern in some cases of very posterior VSD.
Then both patches and the septum are sewn together by a running suture (polypropylene 4-0) at the periphery of the patches. This suture lets free the side of the patches crossing the ventriculotomies, allowing the injection of glue (MMCTSLink 14) between them to reinforce the friable infarcted septal tissue which is not resected at all (Photo 3 and Schematic 6).
Strips of felts are placed on each side of the right and left ventricular incision (Photo 4).
At last, heavy mattressed transseptal sutures are placed to simultaneously close both ventriculotomies, as shown in Schematic 7 and Photo 5.
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Schematic 7 Simultaneous closure of the two ventriculotomies with heavy mattressed and transseptal suture.
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Closure is performed without tension or reduction of the ventricular cavity. Meanwhile a prosthetic Dacron patch has to be added, in case of parietal resection, mainly in posterior infarction.
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Comments
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This technique using two patches and glue allows creating a new solid septum. Each patch is used as a support for the suture on the other, so the running suture is easy, fast and, as it is achieved very far away from the necrosed area, has little tendency to tear.
The double ventriculotomy allows a good exposition of the lesion and consequently a perfect repair.
As the ventriculotomies are done through an infarcted area, there is no additional detrimental damage.
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Results
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- No recurrences of VSD was observed in 37 patients operated on with this technique since 1986, compared to six recurrences in the 56 patients operated with the classic repair, P=0.09. This confirms our previous results published in 2002 [7].
- Hospital mortality with the double patch and glue technique concerns 10 out of 37 patients (27%) compared to 28 among 56 patients (50%) with the classic repair, P=0.006
- Both groups preoperative data were not significantly different (Table 1). Posterior location of the VSD was a little more frequent in group 1 than in group 2 (44.5% vs. 40.5%), but the site of VSD was not a risk factor for hospital mortality in group 2.
- Late death incidence did not differ in the two groups of patients and long-term survival excluding hospital mortality, at 2, 5 and 8 years was 87, 63 and 51% respectively. Among the late 23 survivors, 17 (73.9%) are in NYHA classes I or II.
- Results of post-infarction VSD early repair in recent literature are summarized Table 2.
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Conclusion
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Nevertheless, better patients’ management over the years may have played a part in improving surgical results in the treatment of post-infarction VSD. The use of the double patch and glue technique, by avoiding recurrence of the VSD, allowed reducing hospital mortality. This technique has to be recommended in the early repair of post-infarction VSD.
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References
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- Crenshaw BS, Granger CB, Birnbaum Y, Pieper KS, Morris DC, Kleiman NS, Vahanian A, Califf RM, Topo EJ. Risk factors, angiographic patterns and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. Gusto-I global utilisation of steptokinase and TPA for occluded coronary arteries. Trial Investigators. Circulation 2000;101:27–32.[Abstract/Free Full Text]
- Deja MA, Szostek J, Widenka K, Szafron B, Spyt TJ, Hickey MS, Sosnowski AW. Post infarction ventricular septal defect – can we do better? Eur J Cardiothorac Surg 2000;18:194–201.[Abstract/Free Full Text]
- Prêtre R, Ye Q, Grünenfelder J, Lachat M, Vogt PR, Turina MI. Operative results of ‘repair’ of ventricular septal rupture after acute myocardial infarction. Am J Cardiol 1999;84:785–788.[CrossRef][Medline]
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- David TE, Armstrong S. Surgical repair of postinfarction ventricular septal defect by infarct exclusion. Semin Thorac Cardiovasc Surg 1998;10:105–110.[Medline]
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Summary
Introduction
