SHA24/002004

Mohamed F. Ibrahim, FRCSEd, FRCS (C-Th)

Consultant Cardiac Surgeon Prince Salman Heart Center, King Fahad Medical City, Riyadh, Saudi Arabia

History • In 1934 the association between PIVSR and coronary artery disease was described (Sager 1934) • The first report of a surgical repair came in 1956 by Danton Cooley (Cooley 1956)

• The principal treatment of post-infarction VSR during the early 1960’s, was aggressive medical treatment • Surgical therapy was generally reserved for those patients who survived at least six weeks • Sager R. Arch Intern Med. 1934; 53:140 • Cooley DA. Surgery. 1957;41(6):930-7.

Natural History • Post MI VSR Without Surgery – 25% died within 24 hours – 65% died within 2 weeks – 80% died within 4 weeks – 7% lived longer than one year

Davies RH. J Thorac Cardiovasc Surg 1993, 106:592-8.

ASSOCIATED PATHOLOGY •

Ventricular aneurysm: in (35% to 68%)

• Mitral valve insufficiency: secondary to papillary muscle infarction (< 1%)

Gowda KS. Am Heart J. 1976;92:234-36 Schlesinger Z.Thorax.1971:26:615-18.

DIAGNOSIS

Anatomy of VSRs • Two types of VSR: Simple through and through defect usually located anteriorly Complex dissection tract through the septum with LV entry site remote from RV exit site commonly an inferior VSR  Multiple defects are found in 5-11%.

Edwards BS. Am J Cardiol.1984;54:1201.

Medical Therapy • To reduce after load and to increase forward cardiac output.

• Vasodilators • Inotropic agents • Vasopressors • Intra-aortic balloon pump (IABP)

Choice of Operative Approach • Right atrial approach: posterior VSR and redo surgery • Right ventricle approach: incision of the right ventricular outflow tract The first operations for repair of postinfarction VSR • Transinfarction approach:

Evolution of Surgical Techniques

Surgical Repair of Apical Postinfarction VSR Daggettâ&#x20AC;&#x2122;s Technique

Surgical Repair of VSR Daggettâ&#x20AC;&#x2122;s Technique

Repair of Postinfarction Anterior VSR Infarct Exclusion Technique

Repair of Post infarction Anterior VSR Infarct Exclusion Technique

Repair of Postinfarction Posterior VSR Infarct Exclusion Technique

Repair of Postinfarction Posterior VSR Infarct Exclusion Technique

Anterior VSR Repair

Residual VSRs Early or late after surgery in 10-25% of patients.

May be attributable to:  the reopening of a closed defect  the presence of an overlooked VSR  A new septal perforation during the early postoperative period

Residual Posterior VSR

WHICH PATIENT IS SUITABLE FOR AN OCCLUDER DEVICE ?

PSHC, KFMC Experience baseline Characteristics No. of pts

M / F

DM

HT N

Preop Creatinine

Pre IAPB

Time from MI to PSHC

Admission to OR

VSR

EF

Cardiogrnic shock

1

M

1

0

102

1

4

5

posterior

30

1

2

M

1

1

115

1

3

1

anterior

35

1

3

F

0

1

95

1

2

1

posterior

30

1

4

M

0

0

132

1

3

1

anterior

30

1

5

M

0

1

159

1

4

1

anterior

40

1

6

F

1

1

167

0

12

3

posterior

47

0

7

M

0

0

307

1

1

1

anterior

15

1

8

M

0

1

107

0

14

5

anterior

35

0

9

M

0

1

110

1

1

2

anterior

30

1

VSR + CABG = 6/9 (67%) Operation

No.

VSD+CABG X1

2

VSD+CABG X2

2

VSD+CABG X3

1

VSD+CABG X4

1

VSR alone = 3/9 (33%) Operation

No.

VSD

3

Post â&#x20AC;&#x201C;operative characteristics Patients

ICU stay (days)

Hospital stay (days)

Renal failure

Residual VSR

Bleeding

Mortality

Cause

1

4

25

1

0

0

0

0

2

3

13

0

0

1

0

0

3

2

2

0

0

0

1

Heart failure

4

5

5

0

0

0

1

Multi organ failure

5

3

4

0

0

1

1

Multi organ failure

6

2

10

0

1

0

0

0

7

1

1

0

0

0

1

Multi organ failure

8

2

12

0

0

0

0

0

9

3

18

0

0

0

0

0