Interact CardioVasc Thorac Surg 2008;7:1207-1209. doi:10.1510/icvts.2008.188359
© 2008 European Association of Cardio-Thoracic Surgery
Infarction-exclusion technique with the on-pump beating heart approach for ventricular septal perforation
Takeshi Shimamotoa,*,
Akira Maruia,
Yoshiaki Sajia and
Masashi Komedaa,b,c
a Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara, Sakyo, Kyoto 606-8507, Japan
b Department of Cardiovascular Surgery, Toyohashi Heart Center, 21-1 Gobudori, Oyama-cho, Toyohashi 441-8530, Japan
c Department of Cardiovascular Surgery, Yamato Seiwa Hospital, 9-8-2 Minamirinkan, Yamato 242-0006, Japan
Received 13 July 2008;
received in revised form 30 August 2008;
accepted 2 September 2008
Corresponding author. Tel.: +81-75-751-3784; fax: +81-75-751-4960.
E-mail address: shimamo{at}kuhp.kyoto-u.ac.jp (T. Shimamoto).
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Abstract
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We report a successful surgical management of postinfarction ventricular septal perforation by infarction-exclusion technique with the on-pump beating heart approach and concomitant coronary artery bypass grafting. The identification of the suture line by direct inspection and finger palpation could be more accurate in determining contractile, thus viable myocardium supporting the patch, and concomitant coronary artery bypass grafting with on-pump beating heart could minimize the cardioplegia-induced myocardial damage.
Key Words: Left ventricle; Cardiomyoplasty; Myocardial infarction
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1. Introduction
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Postinfarction ventricular septal perforation (VSP) remains a fatal complication of myocardial infarction and requires surgical treatment. Although the use of the infarction-exclusion technique improves surgical mortality [1], residual shunt and postoperative low-output syndrome lead to a poor outcome [2, 3]. Here, we report successful VSP repair by the infarction-exclusion technique performed with an on-pump beating heart approach. This method allows accurate identification of the suture line for patch placement and minimizes cardioplegia-induced myocardial damage.
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2. Case report
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An 80-year-old woman was referred to our hospital for deteriorating hemodynamics. The coronary angiogram showed total occlusion of the left anterior descending artery (LAD). The echocardiogram revealed anteroseptal and apical akinesis, and VSP at the mid-ventricular septum (Fig. 1). The left ventricular (LV) end-diastolic diameter (LVDd) was 55 mm, and the LV ejection fraction (LVEF) was 28%. Emergency surgery was performed through a median sternotomy, and she was placed on cardiopulmonary bypass with bicaval venous drainage. Initially, coronary artery bypass grafting (CABG) with autologous saphenous vein graft was performed for the proximal LAD stenosis under beating condition. Subsequently, an 8-cm longitudinal left ventriculotomy was made in the infarcted area, approximately 1–2 cm away from the LAD. VSP was easily identified with traction sutures.
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Fig. 1. Preoperative echocardiogram showing the apical 4-chamber view. Note the massive shunt flow (asterisk) through the VSP at mid-ventricular septum. RV, right ventricle; LA, left atrium; RA, right atrium.
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Next, the border between the contractile, intact myocardium and non-contractile, fragile myocardium was identified by direct inspection and finger palpation to determine the site for the placement of the sutures to support the patch. Notably, this border was closer to the non-infarcted side than to the line demarcating the dark red myocardium from the light brown myocardium (color-demarcation line; Fig. 2). Although intended, we did not place the patch in the on-pump beating heart because the posterior portion of the septum was not optimally exposed. Therefore, an aortic cross-clamp was applied for a short duration and the heart was arrested by cardioplegia. Pledget-reinforced interrupted sutures with 3-0 polypropylene were placed along the determined border, not along the color-demarcation line, at the interventricular septum. Spontaneous beating commenced immediately after the aortic cross-clamp was released. Subsequently, transmural sutures were placed along the non-infarcted anterior wall; a bovine pericardium patch (5 cmx10 cm) was anchored with these sutures; and the left ventriculotomy was closed in a double-layer fashion with felt strips. The durations of aortic cross-clamping and cardiopulmonary bypass were 24 min and 169 min, respectively. The postoperative course was uneventful, and the postoperative echocardiogram showed successful VSP exclusion without residual shunt, and improved LV dimension and function (LVDd=42 mm, LVEF=55%) with no mitral, tricuspid, or aortic regurgitation. She was discharged on foot on postoperative day 32. At two years postoperation, she is doing well; her cardiac status is NYHA class I, LVDd is 44 mm, and LVEF is 56%.
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Fig. 2. Intraoperative photograph (a) and schematic presentation (b) of the interventricular septum and the VSP (arrow) viewed through left ventriculotomy along the LAD. Note that sutures for the patch were placed along the determined border by direct inspection and finger palpation (solid line) and this line was closer to non-infarcted side than the color demarcation line (dotted line). S, interventricular septum.
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3. Comment
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This is the first report on VSP repair with the infarction-exclusion technique and concomitant CABG with an on-pump beating heart approach. This method has several potential merits to improve the quality of VSP repair.
First, the suture line was determined in the on-pump beating heart. Currently, VSP repair is performed under cardiac arrest, with the myocardium rendered flaccid by cardioplegia; moreover, the patch is secured along the color-demarcation line. However, myocardial infarct size evaluated microscopically is consistently larger than that measured macroscopically, and ischemic damages are seen in areas beyond the color-demarcation line [4]; this can be a potential cause of postoperative residual shunt, which has been reported to occur from 18% [5] to 50% [3]. Identification of the border between the infarcted and non-infarcted myocardium could be easier and more accurate by direct inspection and finger palpation, which enables the localization of the contractile myocardium in an on-pump beating heart. Further, the sutures placed along the contractile firm myocardium are less likely to tear. Second, myocardial revascularization was performed in the on-pump beating heart. Although this concomitant revascularization increases the operation time, survival after VSP repair is reported to improve in patients treated with concomitant CABG [6]. Our method may also salvage the borderline-infarcted myocardium supporting the patch [6] and minimize cardioplegia-induced myocardial damage.
Several factors need to be considered while using this on-pump beating heart approach. First, significant aortic regurgitation could contraindicate this approach, because it does not provide good surgical view for suturing along the interventricular septum. Second, intraventricular air should be thoroughly vented after patch placement; otherwise, the air would inevitably enter the systemic circulation.
In conclusion, the suture line for patch placement that excludes the infarcted area could be easily and more accurately determined with the on-pump beating heart approach for VSP repair. This approach may help minimize cardioplegia-induced myocardial damage; the concomitant CABG may salvage the jeopardized myocardium. Nonetheless, a further study is mandatory to validate the outcomes of this method.
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References
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Abstract
1. Introduction