post-infarction ventricular septal rupture and free wall rupture

Post-infarction Ventricular Septal Rupture and Free Wall

Rupture

서울삼성병원성균관대학교

김욱성

History of VSR

LathamFirst described at autopsy in 1845

CooleyFirst successful surgical repair ina patient after 9 weeks throughRVtomy after VSR in 1956

Heimbecker,Allen,Woodwark,IbenSurgery for acute phase in the late1960s

General Statistics

Incidence1-2% of AMI and 0.2% in thrombolytic era

5% of early deaths after MIMale : Female = 3 : 21 vessel (64%), 2 vessels (7%), 3 vessels

(29%)

Disease progressAverage time from infarction to rupture : 2 ~ 4 days (a few hours ~ 2 weeks)

: closer to 1 day in thrombolytic eraChronic VSR : more than 4 ~ 6 weeks

Pathogenesis

Hyaline degeneration Fragmentation Enzymatic digestion Fissure formation Septal rupture

VSR : AMI = 26% : 15% (LV wall)Simple, complexSingle, multiple (5-11%)

Pathophysiology

Heart failureSize of infarctionMagnitude of Lt. to Rt. shunt

Anterior septal rupture LV dysfunction

Posterior septal ruptureRV dysfunction

Pathophysiology

Diagnosis

History of AMI

Physical Examination and Monitoring

New systolic murmurAbrupt deterioration in hemodynamics

Imaging StudiesEcho: Gold standardCoronary angiographyLV catheterization : Not recommended

Natural Course

25% of pts : Died within first 24 hrs

50% of pts : Died within 1 week

65% of pts : Died within 2 week

80% of pts : Died within 4 week

7% of pts : Lived longer than 1 yr

Preoperative Management

IABPCardiac outputLt. to Rt. shuntCoronary Perfusion

MedicationsInotropicsDiureticsVasodilators (?)

Unusual Reference for IABP

Post-infarction ventricular septal defect: delayed closure

with prolonged mechanical circulatory support

Baillot et al. Ann Thorac Surg. 1983 Feb;35(2):138-42

: Surgery after IABP support for 19-25 days in 3 patients

Goal of Surgery

Exclusion or removal of infarcted myocardium

Elimination of Lt. to Rt. shunt

Resection of Infarcted Myocardium

Double Patch Repair of VSR

Balkanay et al. Tex Heart Inst J 2005;32:43-6

Double Patch Technique

MMCTS (April 25, 2005)

Infarction Exclusion

Repair of VSR with 3D Patch

Double Patch Technique

Infarct Exclusion Technique

Surgical Techniques

Three Patch Technique

Surgical Techniques

Three Patch Technique

Repair through Rt. Atrium

Massetti et al. (J Thorac Cardiovasc Surg 2000;119:784-9)

Closure of VSR on Beating Heart

Piotr Siondalski, Interactive CardioVascular and Thoracic Surgery 6 (2007) 160–162

Weaning from CPB

Bleeding

Low cardiac outputIABPMilrinone

RV failure (especially posterior VSR)Volume loadingInotropicsPGE-1NO gas

VAD

Free wall Rupture

History of Free wall Rupture

William HarveyFirst described the free wall ruptu

re of the heart after AMI in 1647

Hatcher, FitzGibbon, MontegutFirst successful repairs in early 1

970s

Incidence

11% of AMI (VSR x 10)

Elderly women, first infarction, within 5 days

Ant. > Lat.

Simple versus complex (50:50)

Pathogenesis and Pathophysiology

Transmural MI

Infarct expansionAcute regional thinning and dilatation of infarct zone

Systemic HT, lack of collateral

After extensive hemorrhagic transformation of AMI

Pathogenesis and Pathophysiology

AcuteDeath in a few minutes

SubacuteSmaller tear, temporarily sealed by clot or fibrinous pericardial adhesions

Chronic False aneurysm

Diagnosis

Clinical picture of pericardial tamponade

EchocardiographyEffusion thickness > 10mmEcho-dense masses in the effusionVentricular wall defect

Natural History

Subacute Median survival : 8 Hours

Surgical Technique

Epicardial patching Direct suture

Debridement and patch closure

Infarct exclusion

Prêtre R, Ann Thorac Surg 2000;69:1342-5

Sutureless Tech.

Thank Youfor Your Attention!