Ischemic VSD Repair With Transapical Mitral Valve Replacement

The development of ischemic ventricular septal rupture is an uncommon but frequently fatal complication. Mortality with medical treatment only is extremely high. Septal rupture results in a left-to-right shunt, with right ventricular volume overload, increased pulmonary blood flow, and secondary volume overload of the left atrium and ventricle. In some cases, this condition is accompanied by a concomitant mitral valve regurgitation in need of surgical therapy. This poses a challenge as to the management strategy and the surgical access. We present a treatment concept consisting of a transapical closure of the ventricular septal defect and a simultaneous replacement of the mitral valve through the same access. Furthermore, this technique allows the anchoring of a pericardial patch in healthy myocardial tissue.

History and Clinical Presentation

A 67-year-old male patient, a smoker, hypertensive, obese,and hyperlipidemic, presented with chest pain, ECG and cardiac enzymes showed inferior STEMI. Balloon to door time was 33 minutes. Coronary angiography showed totally occluded RCA, 2 DES were inserted. 3 days later, the patient developed dyspnoe NYHA III. TTE and TEE showed VSD (2,6 X 2 X 1.8 cm basal till midinferior septum), LVEF 45%, TAPSE 17mm, moderately severe mitral regurgitation.

Surgical Steps

1. Exposure at operation is achieved by dislocating the heart up and out of the pericardial sac and then retracting its cephalad as in PDA distal anastomosis.
2. Opening the LV posteriorly from apex to the base of the heart.
3. Outline the VSD and exposure of the mitral valve.
4. Resection of PML and part of AML.
5. Transapical MVR using SJM Epic mitral valve 29.
6. Closure of VSD using 6X 8 cm pericardial patch which is sewn to the healthy tissue of the left side of the ventricular septum with interrupted mattress sutures (prolene sutures 4/0 with pledget of teflon felt).
7. All sutures are placed before any are tied.
8. Reinforcement of the patch more peripherally with a second layer (interrupted mattress prolene sutures 4/0 with pledget of teflon felt).
9. Fixation of the patch to the strut of the mitral valve prosthesis.
10. Closure of the left ventriculotomy using continuous mattress sutures of 2/0 MH prolene with buttressing strips of teflon felt, passing through the free edge of VSD patch.
11. A second running suture is used to ensure a secure left ventriculotomy closure.

Conclusions

Reinforcement of the patch more peripherally with a second layer to the healthy tissues (2 points fixing technique) reduces the incidence of postoperative residual VSD due to dehiscence of the patch. Transapical mitral valve replacement provides another fixation point to the VSD patch by anchoring it to the strut of the mitral valve prothesis, in addition to avoidance of bicaval canulation and left atriotomy and therefore sparing trauma and operation time in an already traumatized heart .

References

1. renshaw BS, Granger CB, Birnbaum Y, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation. 2000;101(1):27–32.
2. Komeda M, Fremes SE, David TE. Surgical repair of postinfarction ventricular septal defect. Circulation. 1990 Nov;82(5 Suppl):IV243-7. PMID: 2146043.
3. Batts KP, Ackermann DM, Edwards WD. Postinfarction rupture of the left ventricular free wall: clinicopathologic correlates in 100 consecutive autopsy cases. Hum Pathol. 1990;21(5):530–5.

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