MODERATOR::::::::::::::DR.MADANpresented by:Dr.JYOTINDRA SINGH

CASE STUDY

A STUDY OF POST MI VSD REPAIR BY INFARCT EXCLUSIONTECHNIQUE WITH OR WITHOUT CONCOMITANT CABG

Dr.RAMESH CHANDRA MISHRA, Dr. M AMARESH RAO, Dr.PRAGATIKAPOOR,DR.RAMAKRISHNA,Dr.JYOTINDRA SINGH,

Nizams Institute of Medical Sciences, Department of Cardiothoracic surgery,Hyderabad

INTRODUCTIONPost infarction VSD is a defect in the ventricular septum that results from rupture of acutely infarcted myocardium.

In 1847,Latham first described a PMI-VSD,but not until 1923 it was described clinically by BRUNN.

1957-Cooley and colleagues first reported surgical repair of PMIVSD.

Even though most MIs involve some portion of the septal area, Even though most MIs involve some portion of the septal area, ventricular septal rupture is rare. ventricular septal rupture is rare.

It occurs in only 1 to 2% of patients with acute MI, and it causes It occurs in only 1 to 2% of patients with acute MI, and it causes early death in about 5% of post-MI patients.early death in about 5% of post-MI patients.

INTRODUCTION Chronic heart failure, coronary artery disease, and previous MI Chronic heart failure, coronary artery disease, and previous MI increase the likelihood that collateral circulation will be increase the likelihood that collateral circulation will be developed, and so lower the likelihood of ventricular septal developed, and so lower the likelihood of ventricular septal rupture.rupture.

Anterior septal rupture is caused by anterolateral infarction Anterior septal rupture is caused by anterolateral infarction when 32% of the left ventricle and 10% of the right ventricle when 32% of the left ventricle and 10% of the right ventricle were infarcted.were infarcted.

Posterior septal rupture is caused by inferoseptal infarction, Posterior septal rupture is caused by inferoseptal infarction, which results from occlusion of the dominant right coronary which results from occlusion of the dominant right coronary artery and occurs in the proximal half of the posterior septum artery and occurs in the proximal half of the posterior septum when 21% of the left ventricle and 31% of the right ventricle when 21% of the left ventricle and 31% of the right ventricle were infarcted.were infarcted.

INTRODUCTIONThe most frequent complications of acquired VSD are rapidly The most frequent complications of acquired VSD are rapidly progressing congestive heart failure, cardiogenic shock, progressing congestive heart failure, cardiogenic shock, hemorrhage, pulmonary edema, renal insufficiency,and hemorrhage, pulmonary edema, renal insufficiency,and eventual multiple organ failure; with these complications, eventual multiple organ failure; with these complications, mortality approaches50%.mortality approaches50%..

Debate as to whether coronary artery bypass grafting(CABG) Debate as to whether coronary artery bypass grafting(CABG) should be undertaken along with closure of the VSD has been should be undertaken along with closure of the VSD has been ongoing.ongoing.

The time intervals from infarct to rupture and from rupture to The time intervals from infarct to rupture and from rupture to surgery were analysed.surgery were analysed.

INTRODUCTIONThis study evaluated our outcomes in today’s era of This study evaluated our outcomes in today’s era of percutaneous advances of postinfarction VSD closure.percutaneous advances of postinfarction VSD closure.

Secondary purpose included an analysis of multivariate Secondary purpose included an analysis of multivariate predictors of in-hospital or 30-day mortality in this highrisk predictors of in-hospital or 30-day mortality in this highrisk population. population.

We reviewed our 5 year experience at the Nizams Institute We reviewed our 5 year experience at the Nizams Institute with the treatment of postinfarction VSD rupturewith the treatment of postinfarction VSD rupture

Materials & MethodsBetween March 1997 and April 2012, a total of 26 patients with Between March 1997 and April 2012, a total of 26 patients with a diagnosis of postinfarction VSD were operated at Nizams a diagnosis of postinfarction VSD were operated at Nizams institute of medical science,Hyderabad. institute of medical science,Hyderabad.

Of these, 20 patients underwent VSD repair with concomitant Of these, 20 patients underwent VSD repair with concomitant CABG procedure while 6 patients had VSD closure alone.CABG procedure while 6 patients had VSD closure alone.

A preoperative transthoracic echocardiography and A preoperative transthoracic echocardiography and catheterization study was done in all patients. catheterization study was done in all patients.

Besides counterpulsation with an intraaorticballoon pump Besides counterpulsation with an intraaorticballoon pump (IABP), no other mechanical assist devices were used(IABP), no other mechanical assist devices were used

TABLE 1

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22

TABLE 2-VARIOUS RISK FACTORSTABLE 2-VARIOUS RISK FACTORS

TABLE 3-CATHETERISATION

TABLE 4-PATIENT PROFILE

SURGICAL TECHNIQUEFollowing full cardiological assessment including echocardiography and coronary Following full cardiological assessment including echocardiography and coronary angiography,angiography,

patients were operated on through a median sternotomy. patients were operated on through a median sternotomy.

After cardiopulmonary bypass was established the septal rupture was approached After cardiopulmonary bypass was established the septal rupture was approached through the infarcted area of myocardium.through the infarcted area of myocardium.

TheVSD was then patched using Dacron patch or simply buttressed with sutures TheVSD was then patched using Dacron patch or simply buttressed with sutures alone.alone.

The ventriculotomy was then closed using pledgeted Teflon strips to support the The ventriculotomy was then closed using pledgeted Teflon strips to support the suture line, with exclusion of the infarcted myocardium. suture line, with exclusion of the infarcted myocardium.

Concomitant CABG was done in 20 cases out of 26 patients.Concomitant CABG was done in 20 cases out of 26 patients.

Bypass was discontinued after which inotropes and IABP were used when indicated Bypass was discontinued after which inotropes and IABP were used when indicated to stabilise the patient in the immediate postoperative periodto stabilise the patient in the immediate postoperative period

TABLE 5-POST OP DATA

RESULTS

RESULTSOverall, 26 patients underwent surgical repair for a post-infarct VSD in Nizams Overall, 26 patients underwent surgical repair for a post-infarct VSD in Nizams Institute of medical sciences during March 1997and April 2012.Institute of medical sciences during March 1997and April 2012.

Table 1 shows the a total of 18 patients underwent simultaneous procedure. Table 1 shows the a total of 18 patients underwent simultaneous procedure.

Mean duration between MI and appearance of VSD was 7.2 days while time gap Mean duration between MI and appearance of VSD was 7.2 days while time gap between VSD appearance and operation was 27.2 days.18 patients had pre between VSD appearance and operation was 27.2 days.18 patients had pre operative IABP insertion.operative IABP insertion.

10 patients underwent re exploration for post operative bleeding in Group A as 10 patients underwent re exploration for post operative bleeding in Group A as compared to 6 patients in Group B.compared to 6 patients in Group B.

Five patients in group A had permanent stroke.Five patients in group A had permanent stroke.

RESULTS

Duration of post hospital stay in Group A was 10 days compared to 8 days in Group Duration of post hospital stay in Group A was 10 days compared to 8 days in Group B(Table-5).B(Table-5).

Post operative 2D-Echo revealed residual shunts in 5 cases while none of the Post operative 2D-Echo revealed residual shunts in 5 cases while none of the patients required reoperation .patients required reoperation .

15 out of 20 patients survived in Group A compared to 50 % mortality (3/6) in group 15 out of 20 patients survived in Group A compared to 50 % mortality (3/6) in group B.In hospital mortality was 30.9% while 30 days mortality was 33%. B.In hospital mortality was 30.9% while 30 days mortality was 33%.

Rate of posterior VSD mortality was higher 37.5% compared to 29% in anterior VSD.Rate of posterior VSD mortality was higher 37.5% compared to 29% in anterior VSD.

There was 100% mortality in patients who underwent emergency surgery within 3 There was 100% mortality in patients who underwent emergency surgery within 3 days after AMI while 100% survival was seen who underwent surgery after 3 weeks days after AMI while 100% survival was seen who underwent surgery after 3 weeks of AMI .of AMI .

DISCUSSION The study aims to study a relatively recent population who underwent post MI VSD surgicalThe study aims to study a relatively recent population who underwent post MI VSD surgical

repair to examine preoperative high risk factors, the effect of simultaneous CABG on mid-termrepair to examine preoperative high risk factors, the effect of simultaneous CABG on mid-term

survival and to assess risk factors for in-hospital mortality.survival and to assess risk factors for in-hospital mortality.

The question of whether to perform bypass grafts at the same time as the VSD closure hasThe question of whether to perform bypass grafts at the same time as the VSD closure has

remained largely unresolved over recent years. remained largely unresolved over recent years.

The safety of coronary angiography in these unstable patients has been a concern.It has been The safety of coronary angiography in these unstable patients has been a concern.It has been shown that up to 4.5% of these patients can deteriorate haemodynamically during shown that up to 4.5% of these patients can deteriorate haemodynamically during catheterisation . catheterisation .

In our experience, coronary angiography did not adversely affect the clinical state of the In our experience, coronary angiography did not adversely affect the clinical state of the patients in our population. Often, it was useful not only in providing information about the patients in our population. Often, it was useful not only in providing information about the coronary arteries but also provided the opportunity to site an IABP.coronary arteries but also provided the opportunity to site an IABP.

DISCUSSION In the last few years, an upward trend has been occurring in the number of female patients In the last few years, an upward trend has been occurring in the number of female patients with post-MI VSD, and increased mortality among these patients. with post-MI VSD, and increased mortality among these patients.

A change in frequency of VSD location has been occurring; in the past, rupture was more likely A change in frequency of VSD location has been occurring; in the past, rupture was more likely to involve anterior region of the left anterior descending artery basin, whereas recent data to involve anterior region of the left anterior descending artery basin, whereas recent data shows predominance in the inferior–posterior region.shows predominance in the inferior–posterior region.

Despite intervention, operative mortality for post-MI VSD repair remains high (from 20% toDespite intervention, operative mortality for post-MI VSD repair remains high (from 20% to

40% by several studies40% by several studies

Our 30-day mortality rate was comparable at 33%.Our 30-day mortality rate was comparable at 33%.

Preoperative status of the patient has a bearing on prognosis. Preoperative status of the patient has a bearing on prognosis.

Poor ventricular function , deteriorating cardiovascular status [9], cardiogenic shock[10], inferior Poor ventricular function , deteriorating cardiovascular status [9], cardiogenic shock[10], inferior MI [10,11], increasing age ,and inotrope requirements have all been shown to be associated MI [10,11], increasing age ,and inotrope requirements have all been shown to be associated with a poor prognosis.with a poor prognosis.

DISCUSSIONThe development of shock is the most important predictor of survival. Persistence of class IVThe development of shock is the most important predictor of survival. Persistence of class IV

cardiogenic shock inPVSD is associated with 100% mortality [12]. cardiogenic shock inPVSD is associated with 100% mortality [12].

These findings are in line with our results concerning emergency operation. Worst results were These findings are in line with our results concerning emergency operation. Worst results were observed in patients with lack of improvement hemodynamic status in spite the useof an IABP.observed in patients with lack of improvement hemodynamic status in spite the useof an IABP.

A longer time between AMI and surgery favoured survival. Time period from AMI to VSDA longer time between AMI and surgery favoured survival. Time period from AMI to VSD

seems to be a significantfactor of survival.seems to be a significantfactor of survival.

It is clear that the higher mortality in patients operated on early is also due to the seriousness It is clear that the higher mortality in patients operated on early is also due to the seriousness of hemodynamic conditions which do not allow any delay in surgical treatment.of hemodynamic conditions which do not allow any delay in surgical treatment.

Higher mortality reported in posterior VSD can either be related to greater technical difficultiesHigher mortality reported in posterior VSD can either be related to greater technical difficulties

associated with surgical repair or to a higher incidence of right ventricular failure [17,18associated with surgical repair or to a higher incidence of right ventricular failure [17,18

Chronic VSD is easier to repair since the septum is well scarred and the patch can be securelyChronic VSD is easier to repair since the septum is well scarred and the patch can be securely

sutured .sutured .

LIMITATIONS The main limitation of this study is theretrospective nature of our work. The main limitation of this study is theretrospective nature of our work.

Moreover, our study population was smaller than multi-centre studies.Moreover, our study population was smaller than multi-centre studies.

However,our single centre observation study has comparatively a relative However,our single centre observation study has comparatively a relative large number of patients undergoing aPVSD reconstruction between 2007 large number of patients undergoing aPVSD reconstruction between 2007 and 2012.and 2012.

Thus, this study has the strength to show intuitional experiences in patients Thus, this study has the strength to show intuitional experiences in patients undergoing a PVSD reconstruction over a long periodundergoing a PVSD reconstruction over a long period..

REFERENCESREFERENCES1.Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors,angiographic patterns, and 1.Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors,angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. outcomes in patients with ventricular septal defect complicating acute myocardial infarction. Circulation 2000;101:27–32.Circulation 2000;101:27–32.

2. Prêtre R, Rickli H, Ye Q, Benedikt P, TurinaMI. Frequency of collateral blood flow in the 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 infarct-related coronary artery inrupture of the ventricular septum after acute myocardial infarction. Am J Cardiol 2000;85:497–9.infarction. Am J Cardiol 2000;85:497–9.

3. David TE: Operative management of postinfarction ventricular septal defect. Semin Thorac 3. David TE: Operative management of postinfarction ventricular septal defect. Semin Thorac Cardiovasc Surg 1995, 7:208-13.Cardiovasc Surg 1995, 7:208-13.

4. Hill JD, Stiles QR: Acute ischemic ventricular septal defect. Circulation 1989, 79(6 Pt 2):I112-4. Hill JD, Stiles QR: Acute ischemic ventricular septal defect. Circulation 1989, 79(6 Pt 2):I112-I115.I115.

5. Labrousse L, Choukroun E, Chevalier JM, Madonna F, Robertie F.Surgery for post infarction 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 ventricular septal defect (VSD): riskfactors for hospital death and long term results. Eur J Cardiothorac Surg 2002;21:725–31Cardiothorac Surg 2002;21:725–31

6. AndersonDR,Adams S,BhatA, Pepper JR. Post-infarction ventricular septal defect: the 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 importance of site of infarction and cardiogenic shock on outcome. Eur J Cardiothorac Surg 1989;3:554–7.1989;3:554–7.

7. Muehrcke DD, Daggett WM, Buckley MJ, Akins CW, HilgenbergAD, AustenWG. Post 7. Muehrcke DD, Daggett WM, Buckley MJ, Akins CW, HilgenbergAD, AustenWG. Post infarction ventricularinfarction ventricular

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STATISTICS