A modified infarct exclusion technique: Triple-patch technique for postinfarction ventricular septal perforation

Abstract

Postinfarction ventricular septal perforation (VSP) remains an important complication of myocardial infarction. The prevalence is approximately 1% to 2% among patients withacutemyocardialinfarction,anditisoftenfatalunless surgical treatment is performed. Despite numerous improvements in surgical technique, the mortality remains about 19% to 40%. 1 Perioperative low-output syndrome and residual shunt are associated with a poor outcome. We operated on 4 patients with our simple technique that minimizes residual shunting. Materials and Methods OPERATIVE TECHNIQUE. Cardiopulmonary bypass was established, and myocardial revascularization if necessary was performed on the beating heart before repair of the VSP. The heart was then arrested with a cardioplegic solution, and repair was done through a longitudinal left ventriculotomy in the infarcted area, about 1 to 2 cm away from the left anterior descending coronary artery. First, a tailored small bovine pericardial patch was used to close the VSP directly with a running 3-0 polypropylene suture. Then two bovine pericardial patches were cut into rectangular shapes. One pericardial patch was sutured to the noninfarcted endocardium around the ventricular septal side, and the other patch was sutured to the noninfarcted endocardium of the anterolateral ventricular wall, both with running 3-0 polypropylene sutures. These two patches were then cut and sewn to determine the ideal size and shape of the pouch fitting the left ventricular cavity to make an infarct exclusion. After the VSP patch and endoventricular pouch were sutured, fibrin glue was applied to fill the cavity between the patches. The ventriculotomy was closed in two layers with two polytetrafluoroethylene felt strips and 2-0 polypropylene sutures (Figure 1). PATIENTS. Between 1996 and 2006, a total of 10 patients underwent VSP repair. Through 2003, we performed VSP repair by the David‐Komeda method in 6 patients. Since 2004, the new triplepatch technique has been used for all patients. STATISTICAL ANALYSIS. Preoperative and postoperative variables were compared between the two operative groups with the Mann‐Whitney U test.