[Surgical repair of postinfarction ventricular septal defect: modified Komeda-David procedure]

Since Cooley first reported surgical repair of postinfarction ventricular septal defect in 1957, there have been technical improvements in this procedure. However, the outcome of surgery has not been gratifying thus far. In 1990, Komeda and associates reported a single patch of bovine pericardium sutured to the healthy myocardium around the infarcted area on the left side of the septum that excludes the infarcted myocardium from the left ventricular cavity; a procedure based on a completely different idea. Since the satisfactory outcome of the surgical treatment in this procedure was obtained in a series of 12 patients, this surgical procedure has been in widespread use in Japan. On the other hand, this procedure has a drawback that there is a difficulty in suturing the patch and may lead to a postoperative residual shunt. We investigated a modified surgical procedure that could overcome this difficulty and would like to report it in this paper. At first, the perforated area should be covered with a felt strip and closed with mattress sutures. Secondly, the infarcted myocardium from the left ventricular cavity should be obliterated using a two-patch method. The primary advantage of this procedure is that it achieves a broader range of vision than a single patch method and enables easy suturing. Additionally, the development of a residual shunt can be prevented owing to the closure of perforation even if sutures fail to hold and leakage occurs. The tow-patch method has the advantage of avoiding tension against sutures since the patch is not everted around the sutures. However, the question arises whether only the healthy myocardium can be picked out and sutured without fail. In order to make the two-patch method more reloable the perforation should be closed in advance.