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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