Post-infarction Ventricular Septal Rupture and Free Wall Rupture
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Transcript of Post-infarction Ventricular Septal Rupture and Free Wall Rupture
Post-infarction Ventricular Septal Rupture and Free Wall
Rupture
서울삼성병원성균관대학교
김욱성
History of VSR
LathamFirst described at autopsy in 1845
CooleyFirst successful surgical repair ina patient after 9 weeks throughRVtomy after VSR in 1956
Heimbecker,Allen,Woodwark,IbenSurgery for acute phase in the late1960s
General Statistics
Incidence1-2% of AMI and 0.2% in thrombolytic era
5% of early deaths after MIMale : Female = 3 : 21 vessel (64%), 2 vessels (7%), 3 vessels
(29%)
Disease progressAverage time from infarction to rupture : 2 ~ 4 days (a few hours ~ 2 weeks)
: closer to 1 day in thrombolytic eraChronic VSR : more than 4 ~ 6 weeks
Pathogenesis
Hyaline degeneration Fragmentation Enzymatic digestion Fissure formation Septal rupture
VSR : AMI = 26% : 15% (LV wall)Simple, complexSingle, multiple (5-11%)
Pathophysiology
Heart failureSize of infarctionMagnitude of Lt. to Rt. shunt
Anterior septal rupture LV dysfunction
Posterior septal ruptureRV dysfunction
Pathophysiology
Diagnosis
History of AMI
Physical Examination and Monitoring
New systolic murmurAbrupt deterioration in hemodynamics
Imaging StudiesEcho: Gold standardCoronary angiographyLV catheterization : Not recommended
Natural Course
25% of pts : Died within first 24 hrs
50% of pts : Died within 1 week
65% of pts : Died within 2 week
80% of pts : Died within 4 week
7% of pts : Lived longer than 1 yr
Preoperative Management
IABPCardiac outputLt. to Rt. shuntCoronary Perfusion
MedicationsInotropicsDiureticsVasodilators (?)
Unusual Reference for IABP
Post-infarction ventricular septal defect: delayed closure
with prolonged mechanical circulatory support
Baillot et al. Ann Thorac Surg. 1983 Feb;35(2):138-42
: Surgery after IABP support for 19-25 days in 3 patients
Goal of Surgery
Exclusion or removal of infarcted myocardium
Elimination of Lt. to Rt. shunt
Resection of Infarcted Myocardium
Double Patch Repair of VSR
Balkanay et al. Tex Heart Inst J 2005;32:43-6
Double Patch Technique
MMCTS (April 25, 2005)
Infarction Exclusion
Repair of VSR with 3D Patch
Double Patch Technique
Infarct Exclusion Technique
Surgical Techniques
Three Patch Technique
Surgical Techniques
Three Patch Technique
Repair through Rt. Atrium
Massetti et al. (J Thorac Cardiovasc Surg 2000;119:784-9)
Closure of VSR on Beating Heart
Piotr Siondalski, Interactive CardioVascular and Thoracic Surgery 6 (2007) 160–162
Weaning from CPB
Bleeding
Low cardiac outputIABPMilrinone
RV failure (especially posterior VSR)Volume loadingInotropicsPGE-1NO gas
VAD
Free wall Rupture
History of Free wall Rupture
William HarveyFirst described the free wall ruptu
re of the heart after AMI in 1647
Hatcher, FitzGibbon, MontegutFirst successful repairs in early 1
970s
Incidence
11% of AMI (VSR x 10)
Elderly women, first infarction, within 5 days
Ant. > Lat.
Simple versus complex (50:50)
Pathogenesis and Pathophysiology
Transmural MI
Infarct expansionAcute regional thinning and dilatation of infarct zone
Systemic HT, lack of collateral
After extensive hemorrhagic transformation of AMI
Pathogenesis and Pathophysiology
AcuteDeath in a few minutes
SubacuteSmaller tear, temporarily sealed by clot or fibrinous pericardial adhesions
Chronic False aneurysm
Diagnosis
Clinical picture of pericardial tamponade
EchocardiographyEffusion thickness > 10mmEcho-dense masses in the effusionVentricular wall defect
Natural History
Subacute Median survival : 8 Hours
Surgical Technique
Epicardial patching Direct suture
Debridement and patch closure
Infarct exclusion
Prêtre R, Ann Thorac Surg 2000;69:1342-5
Sutureless Tech.
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