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DOI: 10.1055/s-0031-1297696
Multiple patch technique for treatment of ischemic ventricular septum defects or contained ventricular rupture
Objectives: Ischemic ventricular septal defects (VSD) or contained ventricular ruptures (CVR) may pose a considerable surgical challenge, specifically in the acute setting. Perioperative mortality rates of >50% have been described. We describe a novel therapeutic approach in a recent case series of acute VSD or CVR.
Methods: Within the last 10 months, 9 patients (age 41–80 years) presented with VSD or CVR. Seven patients had an acute VSD (4 inferiorly, 3 anteriorly). Three patients had CVR – two subacute pseudoaneurysms located posterolaterally and posteriorly, respectively. One had a peracute posterior LV rupture with previous CABG years earlier. The operative approach consisted of ventricular incision of the infarcted zone on the arrested (7 patients) or beating heart (2 cases). Closure of the defects was achieved by implantation of a primary Dacron-patch with multiple felt enforced U-sutures. We then superimposed a second Dacron-patch of significant greater dimensions by sewing a running suture into healthy myocardium (fixing it to the base of mitral valve in inferior defects). In the case of the peracute rupture of the posterior ventricular wall, we placed a pericardial patch as a third layer covering the entire infero-diaphragmatic wall of the heart. The rationale of this multi-layered patch-closure is to stepwise reduce forces on the outer patch, allowing hemostasis and avoiding residual shunts.
Results: All patients left the operating room hemodynamically stable without excessive bleeding and no redo for bleeding was necessary. One patient (80yrs) died despite normal hemodynamics on the first postoperative day. The reason of death was complete arterial occlusion of all peripheral, abdominal and cerebral arteries (possibly HIT II). All other patients were discharged in good condition between the 8th and 34th post op day with no residual shunt (30 day mortality rate 1%).
Conclusions: We suggest that placing multiple overlaying patches to close ischemic VSD and ventricular ruptures is a useful treatment option in this high risk group, specifically in the acute setting.