Preoperative Impella Therapy in Patients with Ventricular Septal Rupture and Cardiogenic Shock: Hemodynamic and Organ Function Outcomes.

OBJECTIVES: We examined the effects of preoperative Impella treatment on haemodynamic stability, organ recovery, and postoperative outcomes in patients with postinfarction ventricular septal rupture and cardiogenic shock. METHODS: Between April 2018 and February 2024, the data of 10 of 15 patients with postinfarction ventricular septal rupture and cardiogenic shock who underwent Impella therapy were analyzed. Urgent surgery was contingent on haemodynamic stability with Impella/ECpella, except in the presence of organ failure. We utilized a generalized linear mixed model to evaluate organ ischaemia through changes in blood parameters upon admission and at subsequent intervals post-Impella insertion. RESULTS: Preoperative Impella or combined Impella and ECpella (five patients each) support were provided, with diagnoses and surgeries occurring at an average of 4 days (interquartile range: 2-5) and 8 days (interquartile range: 2-14) after myocardial infarction, respectively. Treatment significantly reduced lactate, alanine aminotransferase, creatine kinase-MB, and troponin I levels (p ≤ 0.05 for all). Conversely, no significant change was noted in the aspartate aminotransferase level or estimated glomerular filtration rate. Hemoglobin and platelet counts decreased despite transfusions (p < 0.001). No surgical deaths occurred; however, 70% of the patients required prolonged mechanical ventilation and 80% were transferred for rehabilitation. CONCLUSIONS: Impella or ECpella treatment can improve haemodynamic and organ failure outcomes in postinfarction ventricular septal rupture and cardiogenic shock. However, the risks of prolonged support, including hemorrhagic events and the need for extended rehabilitation, point to a need for comparative studies to optimize support duration.

Advent of severe mitral regurgitation in surgical ventricular restoration and ventricular septal rupture repair.

BACKGROUND: Per-procedural severe mitral regurgitation is a rare complication in concomitant surgical ventricular restoration and postinfarction ventricular septal rupture repair. It is challenging to discover the underlying etiology and adopt an appropriate strategy, in particular, in a high-risk patient. CASE PRESENTATION: Semi-emergent surgical ventricular restoration combined with ventricular septal rupture closure and coronary artery bypassing was performed in a 67-year-old male patient. Severe mitral regurgitation was detected after the weaning of cardiopulmonary bypass. Two key questions arose in the management of this condition: did the regurgitation exist previously and was dissimulated by significant left-to-right shunt, or it occurred secondarily to the Dor procedure? Which was the better management strategy, chordal-sparing mitral valve replacement or mitral plasty? We believed that severe mitral regurgitation was under-estimated pre-operatively and we performed an downsizing annuloplasty to treat mitral regurgitation. The outcomes were promising and the patient did well in follow-up. CONCLUSIONS: Our case brought out an open discussion on the etiology and therapeutic strategies of this complicated condition.

Treatment Strategies for Ventricular Septal Rupture After Myocardial Infarction: A Single-Center Experience.

Objective: To analyze treatment strategies, prognosis, and related risk factors of patients with postinfarction ventricular septal rupture, as well as the impact of timing of surgical intervention. Methods: A total of 23 patients diagnosed with postinfarction ventricular septal rupture who were non-selectively admitted to Shanxi Provincial Cardiovascular Hospital between October 2017 and August 2021 were included in this study. The relevant clinical data, operation-related conditions, and follow-up data were summarized for all patients. The Kaplan-Meier method and log-rank test were used for the cumulative incidence of unadjusted mortality in patients with different treatment methods. Multivariate logistic regression was used to evaluate the independent risk factors for in-hospital patient mortality. Results: The mean age of the study patients was 64.43 ± 7.54 years, 12(52.2%) were females. There was a significant difference in terms of postoperative residual shunt between the surgical and interventional closure groups (5.9 vs. 100%, respectively; P < 0.001). The overall in-hospital mortality rate was 21.7%; however, even though the surgical group had a lower mortality rate than the interventional closure group (17.6 vs. 33%, respectively), this difference was not statistically significant (P = 0.576). Univariate analysis showed that in-hospital survival group patients were significantly younger than in-hospital death group patients (62.50 ± 6.53 vs. 71.40 ± 7.37 years, respectively; P = 0.016), and that women had a significantly higher in-hospital mortality rate than men (P = 0.037). The average postoperative follow-up time was 18.11 ± 13.92 months; as of the end of the study all 14 patients in the surgical group were alive, Two out of four patients survived and two patients died after interventional closure. Univariate analysis showed that interventional closure was a risk factor for long-term death (P < 0.05). Conclusion: Surgical operation is the most effective treatment for patients with postinfarction ventricular septal rupture; however, the best timing of the operation should be based on the patient's condition and comprehensively determined through real-time evaluation and monitoring. We believe that delaying the operation time as much as possible when the patient's condition permits can reduce postoperative mortality. Interventional closure can be used as a supplementary or bridge treatment for surgical procedures.

Postinfarction ventricular septal defect closure.

After a median full sternotomy, cardiopulmonary bypass is installed in the usual manner. Apical ventriculotomy is performed through the infarcted myocardium. Polypropylene pledgeted mattress sutures are passed from the right to the left ventricular side through the ventricular septal defect, with the pledgets remaining on the right ventricle. Great care must be taken to place the suture on healthy myocardium and away from the edge of the ventricular septal defect; otherwise the chances of a recurrent postoperative ventricular septal defect would increase. The sutures are subsequently positioned through a heterologous patch, previously prepared to be appropriate for the ventricular septal defect closure. A collar of 3 to 4 cm is left on the external side of the patch. A 4-0 polypropylene running suture is placed through this collar and the left ventricle to further reinforce the ventricular septal defect closure. The left ventricular incision is closed with polypropylene 3-0 continuous sutures. For each ventricular edge, the running suture is passed through 2 polytetrafluoroethylene felts: one on the endoventricular side and the other on the epicardial side. Finally, the suture line is reinforced with a continuous 2-0 polypropylene suture, which is passed through the polytetrafluoroethylene felts, the ventricular wall, and the heterologous patch used to close the ventricular septal defect.

Postinfarction posterobasal ventricular septal defect closure with a triple-layer patch.

We present the case of a 65-year-old patient who developed a large posterobasal ventricular septal defect resulting from an extensive acute myocardial infarction involving the inferior and basal septum and wall. We repaired the interventricular lesion by verticalizing the cardiac apex to perform a left posterobasal ventriculotomy. We removed a great part of the residual infarcted tissue, leaving the residual scar in place. Our technique first involved creating a double-layer patch comprising heterologous pericardium and a non-collagen-impregnated Sauvage Dacron patch, fixed with single pledgeted U-stitches from the right side of the anterior septum; then we applied a third layer of heterologous pericardium on the left side of the septum in order to have only a pericardial surface in contact with blood on both ventricular sides. A running suture was used to complete the procedure from the middle to the posterior rim of the ventricular septal defect.  The final triple-layer patch allowed us to obtain a complete and durable closure of the defect. The subsequent closure of the left ventriculotomy was performed with a similar bilayer pericardium-Dacron patch (always leaving pericardium on the internal surface). This technique proved effective, guaranteeing resistance to suture stress, less risk of leakage, and reduced thrombogenicity.

Postinfarction ventricular septal rupture: can we improve clinical outcome of surgical repair?

Postinfarction ventricular septal rupture (VSR) is a lethal structural complication following acute myocardial infarction (AMI). Surgical repair of VSR was first reported in 1957 by Cooley. Since then, many methods have been introduced, variously using right and/or left ventriculotomy. Daggett used infarctectomy and septal reconstruction via left ventriculotomy, reporting 52% operative mortality when repair was attempted within 21 days, but only 7% when done after 3 weeks. Komeda and David described single pericardial patch infarct exclusion without infarctectomy through a left ventriculotomy in 1990. It seemed conceptually simple, and became a standard technique. Modifications of that technique and development of other methods have been reported by many surgeons. Nonetheless, recent clinical outcomes of surgical repairs demonstrated operative mortality from 19 to 81%. Predictors for poor survival include cardiogenic shock, the need for repair within 7 days after AMI, posterior VSR and shunt recurrence. Reasons for poor outcomes after surgical repair of VSR include preoperative cardiogenic shock, the unclear boundary between infarction and viable myocardium in the acute phase, and frequent shunt recurrence. Surgical complications such as bleeding from an LV incision and low output syndrome are significant concerns as well. We propose that the fundamental requirements for VSR closure include a sufficiently large patch securely fixed on the LV side of the septum, minimal damage to LV function, and simplicity of technique. Our "extended sandwich patch technique" fulfills those requirements, and has yielded improved outcomes without shunt recurrence, even within 7 days following onset, and for posterior VSR.

Post-Infarction Ventricular Septal Rupture: 10 Years of Experience / 대한흉부외과학회지

BACKGROUND: Postinfarction ventricular septal rupture is associated with mortality as high as 85~90%, if it is treated medically. This report documents our experience with postinfarction ventricular septal rupture that was treated surgically. MATERIAL AND METHOD: We retrospectively reviewed the medical records of 11 patients who were operated on due to postinfarction ventricular septal rupture between August 1996 and August 2006. There were 4 men and 7 women, with a mean age of 70+/-11 years (age range: 50~84 years). The location of the rupture was anterior in 7 cases and posterior in 4 cases. The interval between the onset of acute myocardial infarction and the occurrence of the ventricular septal rupture was 2.0+/-1.3 days (range: 1~5 days). Operation was performed at an average of 2.4+/-2.7 days (range: 0~8 days) after the diagnosis of septal rupture. Preoperative intraaortic balloon pump therapy was performed in 10 patients. RESULT: The infarct exclusion technique was used in all cases. Coronary artery bypass grafting was done in 8 cases, with the mean number of distal anastomosis being 1.0+/-0.8. There was one operative death. In 2 patients, reoperation was performed due to a residual septal defect. The postoperative morbidities were transient atrial fibrillation (n=7), paroxysmal supraventricular tachycardia (n=1), low cardiac output syndrome (n=3), bleeding reoperation (n=2), delayed sternal closure (n=2), acute renal failure (n=2), pneumonia (n=1), intraaortic balloon pump-related thromboembolism (n=1), and transient delirium (n=2). Nine patients have been followed up for a mean of 38+/-40 months except for one follow-up loss. There have been 3 late deaths. At the latest follow-up, all 6 survivors were in a good functional class. CONCLUSION: We demonstrated satisfactory operative and midterm results with our strategy of preoperative intraaortic balloon pump therapy, early repair of septal rupture by infarct exclusion and combined coronary revascularization.