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