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An 84-year-old man visited a local doctor, complaining of general fatigue for the last 2 months and dyspnea at rest since the last few days. His echocardiogram revealed a defect hole measuring 1.5 cm at the base of the ventricular septum and left-to-right shunt blood flow. The diagnosis of ventricular septal perforation due to subacute myocardial infarction was confirmed, and an emergency surgery was performed. A right atrial oblique incision revealed a perforation just below the tricuspid valve septal apex. The perforation site was closed using the sandwich patch technique with two bovine pericardial membrane patches. The patient was transferred to the hospital for rehabilitation on day 18 postoperatively.
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Posterior ventricular septal perforation (VSP) is a severe complication of acute myocardial infarction (AMI). In some cases, it is difficult to manage residual shunts after VSP repair. We report a patient who required reoperation early after surgery due to a residual shunt and underwent successful repair through a newly devised maneuver. A 55-year-old man developed VSP after catheter intervention for AMI. He underwent VSP closure with extended sandwich repair via a right ventricular (RV) incision. A residual shunt was observed on the 4th day after surgery. Follow-up echocardiography showed progress of the residual shunt, and he developed cardiac failure ; therefore, reoperation was performed 16 days after the initial surgery. The residual shunt was successfully repaired with only a reinforcing left ventricular (LV) side patch via an LV incision to extend between the LV side patch and septal myocardium without removing the RV side patch. The patient's clinical course after reoperation was uneventful, and no residual shunt was observed on postoperative echocardiography.
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@#Objective To investigate the surgical methods and efficacy of myocardial infarction combined with ventricular septal perforation. Methods The clinical data of 60 patients with myocardial infarction combined with ventricular septal perforation admitted to the Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, from 2009 to 2018 were retrospectively analyzed. There were 39 males and 21 females, aged 63.3±8.3 years. Results Among the 60 patients, 43 (71.7%) patients were perforated in the apex, 11 (18.3%) in the posterior septum and 6 (10.0%) in the anterior septum. There were 24 (40.0%) patients of single coronary artery disease. Fourteen (23.3%) patients received intra-aortic balloon counterpulsation before surgery. The waiting time from ventricular septal perforation to surgery was 48.3 (3-217) d. All patients underwent ventricular septal perforation repair, among whom 53 (88.3%) patients received ventricular aneurysm closure or resection, and 49 (81.7%) patients received coronary artery bypass graft with an average of 2 distal anastomoses during the same period. Perioperative complications in the hospital included 8 (13.3%) deaths, 8 (13.3%) heart failure, 5 (8.3%) ventricular fibrillation, 3 (5.0%) pericardial tamponade, and 11 (18.3%) secondary thoracotomy and 11 (18.3%) residual shunt. Except for 8 patients who died in the hospital, the other 52 cured and discharged patients were followed up. The median follow-up time was 4.9 years. The 2-year and 5-year survival rate of the patients was 95.8%, and the 8-year survival rate was 89.0%. Major adverse cardiovascular events incidence was 19.2%, including 3 (5.8%) deaths, 5 (9.6%) heart failure, 2 (3.8%) myocardial infarction, and 4 (7.7%) cerebrovascular events. Conclusion For patients with ventricular septal perforation after myocardial infarction, surgery is an effective treatment method. Although the perioperative mortality rate is high, satisfactory long-term results can be achieved by carefully choosing the operation timing and methods.
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Ventricular septal rupture (VSR) has been a lethal complication after acute myocardial infarction. It occurs mostly within one week following onset of myocardial infarction. Medical managements and percutaneous defect closure are still of limited value. Surgical closure of VSR has been developed since the first report in 1957, however the recent STS database reported high surgical mortality of 54.2% in cases within 7 days following onset of myocardial infarction. Posterior VSR has been reported worse surgical mortality than anterior VSR. A novel procedure, the extended sandwich patch (ESP) method via the right ventricle (RV) incision was proposed and developed for overcoming these weaknesses. ESP method starts with the incision close to the culprit artery and the left ventricle (LV) is reached through the defect. After sufficient debridement of the necrotic myocardium, an octagonal fabric patch sized 6 centimeter is introduced into the LV. About eight transmural anchoring sutures are placed inside-out. The second fabric patch is placed on the RV septum and felt pledgetts on the free wall of LV. Before the final closure of the ESP, glue is placed into the defect. The RV incision is then simply closed. Low mortality and least the shunt recurrence were reported by our group. This life-saving procedure seems promising to employ for VSR closure even in cases within 7 days following onset of myocardial infarction or in the posterior type. To improve clinical outcomes of VSR, it is crucial to perform VSR closure with the secure method prior to developing multi-organ failure due to the deteriorating heart failure.
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Post-myocardial infarction ventricular septal perforation (VSP) is one of the lethal complications of transmural myocardial infarction. Although the treatment of VSP mostly requires surgical procedures using heterologous pericardium, thromboembolism rarely occurs in patients who undergo VSP repair. Herein we report the case of a patient who died of sudden massive cerebral infarction two weeks after the surgery. The autopsy findings revealed concaved mural LV thrombus in the dissected heart. It is suspected that the patient died of extensive cerebral infarction due to thromboembolic occlusion of the carotid or central cerebral artery. In the postoperative period after VSP repair, several risk factors for thrombus formation may occur, such as postoperative hypercoagulability due to systemic inflammation by the high operative invasiveness, the presence of foreign material in the impaired left ventricle, or pericardial patch suturing methods. Our clinical experience indicates that meticulous postoperative management may be needed, keeping LV thrombus formation in mind after VSP repair.
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The surgical outcome is worse when VSP is attempted soon after myocardial infarction due to the more poor general condition, preoperative cardiogenic shock, fragile infarcted myocardial tissue. We successfully rescued a 80-year cardiopulmonary arrest patient who was suffering from subacute postinfarcted VSP complicated by the left ventricular aneurysm. The VSP was closed with the sandwich patch technique approached from both ventricles. The left ventricular aneurysm was repaired with endoventricular circular patch plasty.
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A 76-year-old woman with acute myocardial infarction (AMI) suddenly fell down with cardiogenic shock. Echocardiography showed free wall rupture (FWR), therefore emergency operation was performed under IABP and PCPS assistance. Seven days after initial operation, onset of ventricular septal perforation (VSP) was recognized. Eighteen days after initial operation, the infarct exclusion technique with a bovine pericardial patch was performed. She has been doing well 4 months after the operation with trivial residual shunt. Mechanical complications after AMI are classified as FWR, VSP, and papillary muscle rupture. A combination of any two types of these is called ventricular double rupture. Ventricular double rupture is a very rare condition, and its prognosis is poor. We report here a surgical case with ventricular double rupture after AMI.
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Objective To investigate the clinical characteristics,treatment and prognosis of patients with acute myocardial infarction complicated with ventricular septal perforation and ventricular aneurysm formation. Methods The clinical data,treatment methods and prognosis of 11 patients, who admitted between January 2012 and December 2016 in Xinjiang Uygur Autonomous Region People 's Hospital,with acute myocardial infarction complicated with ventricular septal perforation and ventricular aneurysm were analyzed retrospectively. Results the killip grading of the 11 patients were Grade Ⅱ in 1 patients. Grade Ⅱ in 2 patients and Grade Ⅲ in 8 patients .The infarction site was found at the anterior wall in 3 patients,diffuse anterior well in 1 patients,inferior wall in 1 patient, anterior-inferior infarction in 3 patients and diffuse anterior-inferior infarction wall in 1 patient. Septal perforation was found at posterior septum in 5 patients muscular septum in. Patient and at apex in 5 patients. Septal perforation was identified within 24 hours of infarction in 1 patient,within 1-7 days in 3 patients and beyond 7 days after infarction in 7 patients .4 patients with septal perforation chosed conservative medical management only and 2 of them died 1 month later.2 patients had PCI in addition to medical treatment but both of them died in 3 months after discharge. 2 patients had IABP supper,and 1 of then died within 1 week during hospitalzation and the other one died 1 week after discharge. 2 patients received PCI and electric amplatzer closure(4-6 weeks after AMI,and 1 patient received PCI plus elective surgical septal repair and ventricular aneurysm reshaping at 6 months after AMI. All 3 patients survived during follow up. Conclusions For patients with acute myocardial infarction complicated with ventricular septal perforation and ventricular aneurysm formation,aggressive intervention and treatment will improve the clinical prognosis.
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<p>A 66-year-old man with an unknown medical history developed chest pain and a diagnosis of acute myocardial infarction (AMI) was given by his physician. Percutaneous coronary intervention was performed in the left anterior descending artery. Echocardiography revealed ventricular septal perforation (VSP) ; therefore, the patient was transferred to our hospital. After admission, his platelet count dropped rapidly during heparin administration, and left ventricular thrombosis and deep vein thrombosis were noted, raising a suspicion of heparin-induced thrombocytopenia (HIT). To establish cardiopulmonary bypass, argatroban alone was insufficient to prolong the Powered by Editorial Manager<sup>®</sup> and ProduXion Manager<sup>®</sup> from the Aries Systems Corporation activated clotting time (ACT) ; thus, nafamostat mesilate was also used for coronary artery bypass grafting and surgical repair of VSP. It took many hours to normalize the ACT, requiring re-exploration for excessive bleeding. On the 37th postoperative day, the patient was transferred to another hospital. We performed cardiac surgical procedures using argatroban in a patient who developed HIT during the course of VSP following AMI ; however, we had difficulty in controlling the ACT. Since, to the best of our knowledge, there are no previous studies reporting surgical case of VSP complicated by HIT, we present this case with a review of the relevant literature.</p>
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<p>We report two cases of extended sandwich patch technique through right ventriculotomy for ventricular septal perforation (VSP). One was an 82-year-old woman. Preoperative coronary angiography showed occlusion of the left anterior descending artery proximal to the first major septal branch. Operative inspection revealed relatively extensive infarction of the anterior wall, a part of which had the appearance of free wall rupture. In the other case of an 85-year-old woman, the culprit lesion was occlusion of the left anterior descending artery distal to several septal branches and to the first diagonal branch. Despite their old age and emergency surgery in cardiogenic shock status, their postoperative recovery was uneventful. In the former case, however, echocardiography at the early postoperative phase revealed significant expansion and thinning of the infarcted anterior wall. Furthermore, serial observations showed deterioration of the left ventricular systolic function and mitral regurgitation due to leaflet tethering. In addition to secure VSP closure by transmural stitches, extended sandwich patch technique can offer geometric and functional preservation of postinfarction left ventricle. Although this can eliminate the risk of postoperative low output syndrome even if anterior infarction is extensive, late follow-up will be required because this technique can also allow postinfarction left ventricular remodeling.</p>
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Objective To analyze the clinical features and prognosis of patients with acute myocardial infarction (AMI) complicated with different parts of heart rupture. Methods Patients diagnosed for AMI complicated with cardiac rupture from January 2010 to December 2015 in Beijing Anzhen Hospital were collected. All of them were divided into free wall rupture group and ventricular septal perforation group according to the rupture site. Clinical features, hospital related examination results, treatment and prognosis of these two groups were analyzed statistically. Results A total of 120 patients with AMI complicated with cardiac rupture were included in the study, including 64 patients with free wall rupture, and 56 patients with ventricular septal perforation. Compared with the ventricular septal perforation group by the single factor analysis, the patients in free wall rupture group had higher age (year: 68.88±9.31 vs. 63.86±8.68, t = 3.039, P = 0.003), lower body mass index [BMI (kg/m2): 22.74±2.07 vs. 25.21±2.99, t = -5.203, P = 0.000], higher rate of history of renal insufficiency (12.5% vs. 1.8%, χ2 = 4.942, P = 0.026), higher level of aspartate transaminase [AST (U/L): 76.00 (38.33, 197.50) vs. 33.50 (19.00, 137.50), Z = -2.788, P = 0.005], triglyceride [TG (mmol/L): 1.68±0.50 vs. 1.36±0.70, t = 2.903, P = 0.005], total cholesterol [TC (mmol/L): 4.21±0.74 vs. 3.87±1.01, t = 2.081, P = 0.040], high density lipoprotein cholesterol [HDL-C (mmol/L): 1.12±0.91 vs. 0.91±0.32, t = 2.910, P = 0.004] and cardiac troponin I [cTnI (μg/L): 18.83 (4.48, 81.68) vs. 0.82 (0.08, 8.50), Z =-5.011, P = 0.000], lower level of blood urea nitrogen [BUN (mmol/L): 7.11±3.11 vs. 10.14±6.97, t = -2.999, P = 0.004], brain natriuretic peptide [BNP (ng/L): 169.00 (98.50, 485.75) vs. 793.00 (478.75, 1 426.25), Z = -5.739, P = 0.000], and D-dimer [μg/L: 219.00 (141.00, 315.75) vs. 310.50 (188.75, 532.00), Z = -2.607, P = 0.009], smaller left ventricular end diastolic diameter [LVEDD (mm): 48.58±5.17 vs. 53.65±6.63, t = -4.631, P = 0.000] and left ventricular end systolic diameter [LVESD (mm): 33.54±5.40 vs. 37.24±6.53, t = -3.397, P = 0.001], lower proportion of left ventricular aneurysm formation [14.1% (9/64) vs. 76.8% (43/56), χ2 = 47.851, P = 0.000] and pulmonary arterial hypertension [20.3% (13/64) vs. 53.6% (30/56), χ2 = 14.368, P = 0.000], higher usage rate of aspirin [100% (64/64) vs. 75.0% (42/56), χ2 = 18.113, P = 0.000], clopidogrel usage rate [82.8% (53/6) vs. 46.4% (26/56), χ2 = 17.578, P = 0.000], ticagrelor usage rate [12.5% (8/64) vs. 1.8% (1/56), χ2 = 4.924, P = 0.026], and common heparin usage rate [53.1% (34/64) vs. 10.7% (6/56), χ2 = 24.174, P = 0.000], lower usage rate of nitrates [70.3% (45/64) vs. 85.7% (48/56), χ2 = 4.063, P = 0.044], higher percutaneous coronary intervention (PCI) operation rate [42.9% (27/64) vs. 12.5% (7/56), χ2 = 13.388, P = 0.000], lower coronary artery bypass graft (CABG) surgery rate [7.8% (5/64) vs. 48.2% (27/56), χ2 = 24.930, P = 0.000], success rate of CABG surgery [60.0% (3/5) vs. 100% (27/27), χ2 = 8.233, P = 0.004], and incidence rate of cerebral infarction in hospital [1.6% (1/64) vs. 10.7% (6/56), χ2 = 4.554, P = 0.033], higher hospital all-cause mortality [85.9% (55/64) vs. 23.2% (13/56), χ2 = 47.851, P = 0.000]. The differences of other indicators were not statistically sig nificant. Conclusions Patients with AMI complicated with free wall rupture usually have more risk factors and worse prognosis. These two types of patients should be treated with target.
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Objective To investigate the clinical characteristics and prognosis of acute myocardial infarction (AMI) combined with ventrical septal perforation (VSP).Methods Fifty-seven AMI + VSP patients were retrospectively analyzed their clinical characteristics and outcomes who were treated in the Fourth People' s Hospital of Shenyang and the First Hospital Affiliated to China Medical University from June 2000 to May 2014.Results Of all patients,43 (75.4％) VSP occurred anterior wall AMI,and 14 (24.6％) were not.Echocardiogram show the end diastolic diameter of left ventricle was (53.7 ± 9.5) mm,left ventricle ejection fraction was (48.5 ± 11.8)％,VSP diameter was (9.8 ±7.9) mm,and 37(64.9％) were with near apex.The level of cardiactroponin I,C-reactive protein,and N terminal of B type natriuretic peptide of patients were (16.7 ± 12.9) μg/L,(99.7 ± 31.40 mg/L,(3 051.2 ± 879.7) μg/L.Total mortality was 71.9％ (41/57) in 30 days and 78.9％ (45/57) in 1 year.The mortality of operation group was 73.9％ (17/23) in 30 days and 91.3％ (21/23) in 1 year.The mortality of consecutive therapy was 64.7％ (22/34) in 30 days and 76.5％ (26/34) in 1 year.Conclusion The mortality of AMI + VSP is higher and operation is the most effective therapeutic method.
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Coronary fistulae and ventricular septal perforation are very rare clinically, and even less caused by cardiac leiomyosarcoma. A case is reported that a 67-year-old female had cardiac leiomyosarcoma with progressive heart failure and coronary fistulae and ventricular septal perforation. This case was special since all ante-mortem examinations and cardiac surgery failed to detect the presence of any abnormal car-diac mass. Therefore, the malignant cardiac tumors could appear in an invasive form without mass and be one of the causes of the coronary fistulae and ventricular septal perforation.
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<b>Objective</b> : To investigate the surgical outcomes of left ventricular free wall rupture (LVFWR) and ventricular septal perforation (VSP) in terms of mechanical complications following acute myocardial infarction (AMI). <b>Methods</b> : Subjects comprised 26 patients (male : 12, female : 14, mean age : 74 years) who underwent surgery between 2001 and 2012. The LVFWR type was blowout in 2 cases and oozing in 5 cases. Immediately after diagnosis, 4 cases underwent intra-aortic balloon pumping (IABP) and 2 cases received extracorporeal membrane oxygenation (ECMO). LVFWR was repaired by suture and patch closure in 5 patients and by TachoComb in 2 patients. VSP was caused by anterior infarction in 15 cases and inferior infarction in 5 cases. IABP was inserted in 16 cases. VSP was repaired by the infarct exclusion technique in 17 patients, while 2 patients underwent suture or patch closure. <b>Results</b> : The operative mortality rate was 14.3% for LVFWR and 15.8% for VSP. The cause of operative death in 1 patient with blowout type LVFWR who was in a state of cardiopulmonary arrest on arrival, was low cardiac output syndrome (LOS). The causes of operative death in VSP included 2 patients with LOS and 1 patient who died suddenly 8 days postoperatively due to ventricular fibrillation. Two VSP patients underwent repeat surgery for residual shunt. The five-year Kaplan-Meier survival rates were 85% for LVFWR and 62% for VSP. Of 20 patients who received IABP preoperatively, the time from confirming LVFWR or VSP diagnosis after admission to IABP initiation was 103±45 (48-120) min in the survival group (<i>n</i>=17) and 259±174 (122-455) min in the operative mortality group (<i>n</i>=3). A significant difference was observed between the two groups (<i>p</i>=0.04). <b>Conclusion</b> : Therapeutic strategies including rapid diagnosis after admission, early insertion of IABP, and prompt surgery could improve the prognosis for patients with LVFWR and VSP following AMI.
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A 79 year-old woman was given a diagnosis of acute myocardial infarction and was immediately transferred to our hospital by a helicopter. Cardiologists successfully revascularized the occluded left anterior descending artery which was considered to be the care of this case. After that, they detected a large ventricular septal perforation by transthoracic echocardiography. We performed repair of the ventricular septal perforation 4 days later, with a modified infarct exclusion technique. Residual shunt flow was not seen by echocardiography after the operation. This patient recovered uneventfully and was discharged on postoperative day 55.
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We report 2 cases of postinfarction ventricular septal perforation (VSP) attributable to obstruction of the right coronary artery. Case 1 was a 63-year-old man in whom VSP developed after percutaneous coronary angioplasty for complete obstruction of the right coronary artery. He developed papillary muscle rupture intraoperatively, requiring mitral valve replacement and subsequent treatment for right-side heart failure. He was discharged l7 weeks after surgery. Case 2 was a 77-year-old man. During catheterization following the detection of 99% obstruction of the #2 segment of the right coronary artery, VSP was found and the patient underwent emergency surgery. Postoperative echocardiography and ventriculography did not reveal a residual shunt or mitral regurgitation (MR). However, he suddenly developed acute MR in the 4th postoperative week and died of acute heart failure. VSP attributable to obstruction of the right coronary artery is difficult to repair surgically because of its anatomical location, among other reasons, and mitral valve replacement is sometimes needed if VSP is accompanied by necrosis of the mitral valve papillary muscle. Appropriate care is therefore needed in this case.