Postinfarction Ventricular Septal Defect Closure Without Ventriculotomy—A Novel Method

Postinfarction ventricular septal defect is a rare complication of myocardial infarction with a high mortality rate (1).

Standard repair techniques—infarcectomy and infarct exclusion—are performed through a left ventriculotomy. These methods are surgically challenging and have a high risk of operative mortality (2–4).

This video describes the case of a sixty-six-year-old patient with a 1.4 cm ventricular septal rupture developed after a subacute myocardial infarction because of complete occlusion of the proximal right coronary artery. Surgeons performed a modified closure using two handmade patches parachuted through the aortic valve and the tricuspid valve, and without left ventriculotomy.

The Procedure

First, the patches were made before cardiopulmonary bypass. The measures were echocardiographically-based—the patch should be 2–3 cm larger than the maximum measured diameter of the defect. The left-side patch should be bigger than the right-side patch because of different pressures and to avoid any interference with the septal leaflet of the tricuspid valve.

The patch was made with an autologous or bovine pericardial disk reinforced with two Teflon layers and sewn together with a 5-0 Prolene running suture. Two or three Ethibon 2-0 mattress single stiches were passed through the central part of the larger left-side patch. The needles were then cut off.

After cardiopulmonary bypass institution, transversal aortotomy and right atriotomy were performed.  Right angle forceps were passed through the septal rupture to grab a surgical loop placed as a marker through the aortic valve, the septal defect, and the tricuspid valve.

The Ethibon sutures of the left-side patch were then knotted to the aortic extremity of the loop. Then, pulling out the tricuspid extremity of the loop, the patch was parachuted down in the left ventricle with the Teflon layer against the septum. The Ethibon sutures were passed across the septum, out of the right atrium and—, using a hollow need—, , were passed through the central part of the smaller right-side patch. The right-side patch was finally parachuted down in the right ventr,icle and the Ethibon stiches were knotted, tightening together the two patches. Intraoperative echocardiography was crucial to assess valve function and any residual shunt.

The patient was discharged from the intensive care unit after five days. He had an almost normal ejection fraction, preserved mitral and tricuspid valve function, and no residual shunt. The good surgical result was confirmed also by angiograph CT scan.

Conclusions

This case demonstrates a surgical approach technically simpler than standard techniques. It only requires an aortotomy and a right atriotomy and, in case of failure, it can be repeated or quickly converted into a classical approach. It is timesaving, with shorter cardiopulmonary bypass and cross-clamping time. It is also myocardial-saving, with no ventriculotomy or infarcectomy performed, and cross-clamping is shorter. It eases bleeding control and, compared with percutaneous closure, patch size can be more tailored on each side of the septum so surgeons can use the biggest patch possible. The absence of a waist between the discs allows a perfect location across the septum with no pressure on friable necrotic tissues due to Nitinol expanding radial force. Because ventricular septal ruptures are complex, hybrid approaches may be a good strategy.

Reference(s)

1. Elbadawi A, Elgendy IY, Mahmoud K, et al. Temporal trends and outcomes of mechanical complications in patients with acute myocardial infarction. JACC Cardiovasc Interv. 2019; 12: 1825-1836.

2. David T. Post-infarction ventricular septal rupture. Ann Thorac Surg. 2022; 11: 261-267.

3. Madsen JC, Daggett WM Jr. Repair of postinfarction ventricular septal defects. Semin Thorac Cardiovasc Surg. 1998; 10: 117-27.

4. Jeppsson A, Liden H, Johnsson P, Hartford M, Rådegran K. Surgical repair of post infarction ventricular septal defects: a national experience. Eur J Cardiothorac Surg. 2005; 27: 216-21.