Surgical repair of postinfarction ventricular septal defect
M Komeda1, S E Fremes, T E David
1Division of Cardiovascular Surgery, Toronto Western Hospital, Ontario, Canada.
Insights
Repair of postinfarction ventricular septal defect (VSD) is challenging. Three-vessel coronary artery disease and cardiogenic shock significantly increase mortality risk in these patients.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Cardiac Surgery
Background:
- Postinfarction ventricular septal defect (VSD) is a severe complication.
- Patients often present in New York Heart Association functional class IV, with many in cardiogenic shock.
Purpose of the Study:
- To evaluate the outcomes of surgical repair for postinfarction ventricular septal defect (VSD).
- To identify predictors of operative mortality in patients undergoing VSD repair.
Main Methods:
- Retrospective analysis of 31 patients undergoing VSD repair between 1980 and 1989.
- Surgical technique evolved from extensive infarctectomy to patch closure excluding infarcted muscle.
- Coronary arteriography assessed coronary artery disease severity.
Main Results:
- Overall mortality was 10%, with three operative deaths.
- All deaths occurred in patients with cardiogenic shock and three-vessel coronary artery disease.
- Mortality was 20% for patients in shock and 27% for those with three-vessel disease.
Conclusions:
- Three-vessel coronary artery disease was the only significant predictor of operative mortality.
- Posterior VSD repair had twice the mortality of anterior VSD repair, though not statistically significant in univariate analysis.
- The study highlights the high-risk nature of postinfarction VSD repair, particularly in patients with extensive coronary disease.
Abstract:
Thirty-one patients underwent repair of postinfarction ventricular septal defect (VSD) from 1980 to 1989. All patients were in New York Heart Association functional class IV, and 15 of them were in cardiogenic shock when operated on. Coronary arteriography was performed in all patients before surgery: nine had one-vessel, 11 had two-vessel, and 11 had three-vessel disease. The VSD was anterior in 15 patients and posterior in 16. The operative technique evolved over the years from a fairly extensive infarctectomy and reconstruction of the septum and right and left ventricular walls with a double Dacron patch, to minimal or no infarctectomy and closure of the VSD by excluding the infarcted muscle from the left ventricular cavity. This is accomplished by suturing a single patch of bovine pericardium to healthy endocardium surrounding the infarcted muscle. The right ventricle is left intact. Overall mortality was 10%, with three operative deaths. All deaths occurred in patients in cardiogenic shock who had three-vessel coronary artery disease. Thus, the mortality for patients in shock was 20%, and the mortality for patients with three-vessel disease was 27%. The operative mortality for patients with posterior VSD was twice as high as in patients with anterior VSD. However, univariate analysis of various clinical, hemodynamic, and operative variables indicated that only three-vessel disease was predictive of operative mortality. Because the number of patients was small and the overall operative mortality relatively low, the results of this analysis may not be valid.(ABSTRACT TRUNCATED AT 250 WORDS)
