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

Abstract

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.