How I would do my anterior VSD Closure John V. Conte, MD Professor Of Surgery Johns Hopkins...

How I would do my anterior VSD Closure

John V. Conte, MD

Professor Of Surgery

Johns Hopkins University School Of MedicineBaltimore, Maryland

Disclosures• No relevant financial relationships related to

this presentation

It Depends!!

Anterior Infarct = LAD InfarctIncidence 1-2% after acute MI

Present 2-7 days post-infarction

Treatment Surgical Closure

What does it depend on ?• Size of Infarct• Definition of Infarct Borders

– Smaller, well defined VSD’s do exist– More distal the better

• Coronary artery anatomy– LAD size– Right coronary dominance

• Comfort level with different techniques• Pre-op condition

Preop Optimization• Hemodynamic stability

– Inotropes?– IABP?– Diuresis?– Intubation?

• ECMO?– Primary reason to establish hemodynamic stability– Allowing tissue to “stabilize”/”firm up” questionable

• Myocardial edema the rule for weeks• To be truly beneficial in stable pts ECMO durations

would be long

Catheter Based Repair

Cardiofix® Starway Medical

Starflex® NMT Medical

Amplatzer®AGA Medical

Gore

When would I want Catheter based repair ?

• Cardiogenic Shock• Not a candidate for surgery• Very few individuals have

significant experience• Technically challenging catheter

based procedure

Two Basic Surgical Approaches

Patch Technique

Exclusion technique

Operative Approach & Considerations

• Bicaval cannulation– Percutaneous femoral venous

• Antegrade & retrograde cardioplegia• Construct Grafts first• Open through infarct• Minimal debridement• Repair VSD

– Unclamped in many cases– If it moves its alive and will hold sutures

Anterior Infarction

Anterior Ventriculotomy

Anterior Ventriculotomy

• Ventriculotomy thru infarct

• Assess full extent of infarct– Important for closure

• Note papillary muscle location

• Visualize how a patch or exclusion would be situated.

Anterior Ventriculotomy

• Minimal debridement or maniipulation of infarcted tissue

• Assess suture placement

• Decide which technique

Exclusion Technique

Exclusion Technique

• Large, ill defined VSD• Two Major advantages

– Sutures in healthy / non-infarcted tissue– Patch / Infarcted septum / anterior wall

not exposed to systemic pressures

• Key Concept:– You are creating new septum / medial

wall for Left Ventricle

Patch placement

• Deep bites thru good tissue • Continuous or Interrupted• Interrupted more flexible

– Sutures can be placed External to Internal

– Large needle– Bulky pledgets

• Do not undersize patch– Imperative to oversize

Patch placement

Patch placement

Patch placement

• Area close to valves can be tricky

• Additional reinforcing sutures helpful

• Trim patch as you go and at end

Patch Completion

Patch Completion

• Clamp off• LV vent off to deair• Additional pledgeted

sutures• Bioglue is your friend

– Out of systemic circulation

Ventriculotomy Closure

Anterior Wall Closure

Two Patch Technique

Patch Technique

• Limit to small, well defined infarcts• Avoids conduction system• Avoids large patch with associated

thromboembolic risks

Patch Technique – Septal patch

• Deep bites• Oversize patch • LV pressure helps

keep patch in place

Patch Technique – Septal patch

Septal Patch• Suture Considerations

Anterior Patch Closure

Post Op Care

• Biventricular pacing– Dys-synchrony and heart block common

• Inotropes• Inhaled pulmonary vasodilators• IABP “mandatory”• ECMO can be helpful

SummaryPatch Technique

• Smaller, well defined infarcts

• Hemodynamically stable

Exclusion Technique

• Large, ill defined infarcts• Hemodynamically

unstable or CHF