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CASE STUDY
A STUDY OF POST MI VSD REPAIR BY INFARCT EXCLUSION TECHNIQUE WITH OR WITHOUT CONCOMITANT CABG
Presented by – Dr. Jyotindra Singh
INTRODUCTIONIn the era before reperfusion therapy, septal rupture complicated 1-3 % of acute myocardial infarctions.
Among the 41,021 patients in (GUSTO-I) trial, VSD was suspected in 140 patients (0.34 %)
Chronic heart failure, coronary artery disease, and previous MI lower the likelihood of ventricular septal rupture.
SHOCK Trial – Rupture occurred at median of 16 hours after
infarction
Natural History
Post MI VSD Without Surgery
– 25% died within 24hrs– 50% died within one week– 65% died within 2 weeks– 80% died within 4 weeks– 7% lived longer than one year
HEROICS TRIAL
AIMS
Objective: Our primary aim was to evaluate the effect of concomitant coronary artery bypass grafting (CABG) on post operative results and also to identify prognostic indicators.
The time intervals from infarct to rupture and from rupture to surgery were analysed.
This study evaluated our outcomes in today’s era of percutaneous advances of postinfarction VSD closure.
Secondary purpose included an analysis of multivariate predictors of in-hospital or 30-day mortality in this high risk population.
Materials & MethodsBetween March 1997 and April 2012, a total of 26 patients with a diagnosis of postinfarction VSD were operated at Nizams institute of medical science,Hyderabad.
Of these, 20 patients underwent VSD repair with concomitant CABG procedure while 6 patients had VSD closure alone.
A preoperative transthoracic echocardiography and catheterization study was done in all patients.
Counterpulsation with an intraaorticballoon pump (IABP), was used in 18 out of 26 patients.
PATIENT PROFILE
CABG +VSD
VSD REPAIR
0
5
10
15
2020
6
GROUP A-CABG+VSD CLOSURE GROUP B- VSD REPAIR ALONE
TABLE 1
.
GROUP A GROUP B02468
1012
FEMALES
Column2
Column1
8
4
12
2
PATIENT DETAILS CABG+ VSD CLOSURE VSD CLOSURE ONLYNumber of patients 20
6
AGE in years (Mean) 64(52-72.1) 61(49-68)
SEX(Female) 8/20 4/6
BMI 25.2 25.4
SMOKER 7/20 3/6
NYHA CLASS IV (%) 42% 26%
TABLE 2- RISK FACTORS
MI% G
rp-A
MI% G
RP-B0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
55
30
2
RISK FACTORS GROUP A GROUP B
Previous MI % 55.2 30
Hypertension % 56.0 36.1
Hypercholestremia%
50.3 17.4
Diabetes % 57.5 10.4
Renal dysfunction 11.4 11.5
Respiratory distress 28.2 21.3
CCF % 75.3 52.2
CATHETERISATION DETAILSVESSELS INVOLVED
GROUP AGROUP B
0
10
20
30
40
50
60
70
80
35
72
46
35
19
3
SINGLE DOUBLETRIPLE
INVOLVED INFARCTED ARTERY
GROUP A GROUP B0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
LAD; 54.2LAD; 62.2
45.837.8
Series 3RCALAD
TABLE 3-CATHETERISATION
PRE OPERATIVE
PATIENT PROFILE
ANTERIOR VSD 18
POSTERIOR VSD 8
PA mean (mm Hg) 34+/- 8
L-R shunt (ml) 56+/-20%
Time interval AMI-VSD (d) 7.2 ( 1 - 12 d)
Time interval VSD-OP (d) 27.2 ( 3 - 55d)
Time interval AMI-OP (d) 30 +/- 15days
IABP pre OP 18
Pre OP intubation 3
Pre OP thrombolysis 3
Pre OP cardiac Shock 6
TABLE 4-PATIENT PROFILE
0
2
4
6
8
10
12
14
16
1818
8PATIENT PROFILE
OPERATIVE TECHNIQUEA median sternotomy is performed If concomitant coronary artery bypass is planned, the Vein graft or Internal mammary artery was dissected at this point. The pericardium is opened and the heart inspected for evidence of transmural infarction. Single or double venous cannulation can be used, with standard aortic cannulation and full cardiopulmonary bypass is begun
OPERATIVE TECHNIQUEAn anterolateral left ventriculotomy is made through the area of infarction.
Stay sutures can be placed through the edges of the ventriculotomy to maintain an open visual field.
The interventricular septum, area of infarction, and site of rupture are visualized.
The necrotic portion of the septum is inspected .
Operative techniqueA DACRON patch is brought onto the field and first sewn to the basal and posterior septum behind the defect using 3-0 polypropylene in a continuous running fashion.
Sutures must be placed far from the infarct in healthy muscle.
The patch is then sewn with full thickness sutures to the anterolateral ventricular free wall beyond the area of infarction, carefully avoiding the muscle.
This completes closure of the left ventricular chamber excluding the defect and infarcted septum and ventriculotomy from the high pressures generated by the left ventricle
Operative technique Excess patch is trimmed off and the ventriculotomy is closed using Teflon strips sewn onto the ventricular wall using interrupted full thickness horizontal mattress sutures of 3-0 polypropylene .
The sutures are then tied, closing the ventriculotomy .
This first row of sutures reapproximates the muscle and secures the Teflon to it.
A second double running layer is placed incorporating the Teflon strips and upper muscle layers to provide strain relief and seal gaps.
.
POST-OP COMPLICATIONS
bleed
ingstr
oke
pace
maker AF
Renal
failur
e
Trache
ostom
y
0
5
10
15
20
25
30
35
10
5
10
20
25
56
0
16 16
33
0
group agroup bColumn1
TABLE 5-POST OP DATA GROUP A GROUP B
I A B P (%) 64% 73%
Duration of intra aortic balloon pump 46 (24-72) 26 (24-48)
Duration of inotrope support (h) 48 (24-96) 28 (24-48)
Re-exploration for bleeding (%) 10 6
Permanent stroke (%) 5 6
Permanent pacemaker (%) 10 16
Atrial fibrillation (%) 20 16.6
Renal failure (%) 25 33.3
Tracheostomy (%) 5 0
ICU (Days) 5 (4-8) 4 (4-6)
Post-operative length of stay (Days) 10 (6-12) 8 (7-10)
Patient outcome- Mortality rates
Anterior VSD
Posterior VSD
Emergency surgery -mortality
Surgery after 3 weeks-survival
30 days mortality
Hospital mortality
0 20 40 60 80 100 120
33.33
25
100
100
33
30.9
Series 3Series 2Series 1
GROUP A & GROUP B MORTALITY
GROUP AGROUP B
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
15
3
5
3
RESULTS
TO SUM UP26 patients underwent surgical repair for a PMIVSD in NIMS during March 1997and April 2012.
The number of female patients with PMIVSD- 12/26
Majority of the cases were single and double vessel diseases .
Mean duration between MI and appearance of VSD was 7.2 days (1-12 days) .
Time gap between VSD appearance and operation was 27.2 days.( 3- 55 days)
15 out of 20 patients survived in Group A compared to (3/6) in group B.
In hospital mortality was 30.9% while 30 days mortality was 33%.
RESULTSThe mortality of urgent repair within 3 days of intractable cardiogenic shock was 100% while 100% survival was seen who underwent surgery after 3 weeks of AMI .
Renal failure was the major cause of morbidity and mortality in post operative period.
Postoperative hospital stay in Group A was 10 days compared to 8 days in Group B.
Post operative 2D-Echo revealed residual shunts in 5 cases while none of the patients required reoperation .
Predictors of poor prognosis included -cardiogenic shock, -timing of surgery - total occlusion of infarct related artery, -Posterior versus anterior post-MI VSD - poor preoperative (NYHA) status
Follow up 8 patients out of 26 died within 1 month of surgery.
5 patients were lost in serial follow up.
13 patients were followed up for 1 to 60months (mean 25 ).3 patients died from non cardiac causes.
4 patients had pacemaker implantation within one month of surgery.
Of the patients, 92% were in NYHA class 1, and 8% in class 2.
4 patients had ventricular ectopics- not clinically significant or any sudden death.
5 patients had residual shunts not requiring surgery.
We did not find patients developing pulmonary hypertension late after surgery. Pulmonary pressure neither diminished, nor progressed during follow-up.
Our experience/ DiscussionPoor preoperative indicators./ Outcomes of thrombolysis. (TACTICS TRIAL )
Rising trend of female patients and increased mortality in this group.
The safety of coronary angiography in these unstable patients.
Timing of surgery
Anterior vs Posterior VSD mortality.
High mortality rate- Is it acceptable??
Follow up strategy/ Residual shunts
Study profile, success rate, and outcome.
Thiele H et al. Eur Heart J 2009;30:81-88
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: [email protected]
Follow up
.Actuarial survival at 5 years for most recent series generally ranges between 40% and 60%
Gaudiani et al - 40 % over all hospital mortality rate
– 88% of hospital survivors were alive at 5 years – 74% of survivors in NYHA functional class I and 21% of
survivors in class II Davies et al
– 5-, 10-, and 14-year survivals of 69%, 50%, and 37% – 82% patients were in NYHA functional class I or II
RESULTS
How to deal with residual shunt?
Residual Lt. Rt. shunt– Reported in up to 28% of
survivors– Associated with high mortality– Intra-operative TEE useful in
early detection and correction if deemed necessary
– attributable to the Reopening of a closed defectPresence of an overlooked VSD Development of a new septal perforation during the early postoperative period
How to deal with residual shunt
Repair through Right Atrium with Right Thoracotomy on beating heart technique
Reason: Redo surgery is complex High mortality and morbidity
Transcatheter closure with the Amplatzer septal occluder
REFERENCES1.Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors,angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. Circulation 2000;101:27–32.
2. Prêtre R, Rickli H, Ye Q, Benedikt P, TurinaMI. Frequency of collateral blood flow in the infarct-related coronary artery inrupture of the ventricular septum after acute myocardial infarction. Am J Cardiol 2000;85:497–9.
3. David TE: Operative management of postinfarction ventricular septal defect. Semin Thorac Cardiovasc Surg 1995, 7:208-13.
4. Hill JD, Stiles QR: Acute ischemic ventricular septal defect. Circulation 1989, 79(6 Pt 2):I112-I115.5. Labrousse L, Choukroun E, Chevalier JM, Madonna F, Robertie F.Surgery for post infarction ventricular septal defect (VSD): riskfactors for hospital death and long term results. Eur J Cardiothorac Surg 2002;21:725–31
6. AndersonDR,Adams S,BhatA, Pepper JR. Post-infarction ventricular septal defect: the importance of site of infarction and cardiogenic shock on outcome. Eur J Cardiothorac Surg 1989;3:554–7.7. Muehrcke DD, Daggett WM, Buckley MJ, Akins CW, HilgenbergAD, AustenWG. Post infarction ventricular
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