Posterior Ventricular Septal Defect Research Articles

A RARE CASE OF POST-MYOCARDIAL INFARCTION VENTRICULAR SEPTAL DEFECT

A RARE CASE OF POST-MYOCARDIAL INFARCTION VENTRICULAR SEPTAL DEFECT

Akut infero-posterior miyokard enfarktüsü sonrası ventriküler septal rüptür ön tanısı ile ameliyat edilen erişkin bir hastada intraoperatif tanı: Konjenital posterior ventriküler septal defekt

Ventricular septal rupture is one of the most important and life-threatening mechanical complications of myocardial infarction. In particular, infero-posterior ventricular septal defect occurring after posterior myocardial infarction is a more catastrophic clinical condition and surgical treatment is more difficult. In an adult patient with myocardial infarction, a ventricular septal defect was found in the posterior ventricular septum. The patient developed pulmonary edema was diagnosed with ventricular septal rupture as a mechanical complication in addition to myocardial infarction. However, while it was observed that ventricular septal rupture did not occur as a mechanical complication due to myocardial infarction in surgical treatment, and it was determined that the patient had a congenital ventricular septal defect accompanying coronary artery disease. Congenital posterior ventricular septal defect was successfully closed with a Dacron patch via right atriotomy. Since we have not encountered such a case in the literature before, we want to present this case

Advantages of intraoperative implantation of Impella 5.5 SmartAssist in the Management of Acute Post-Infarction Ventricular Septal Defect with cardiogenic shock

BackgroundDespite advances in surgical techniques and aggressive therapy of post-infarction ventricular septal defect (VSD) with cardiogenic shock, the overall morbidity and mortality is frustratingly high. The Impella 5.5 SmartAssist (Abiomed, Danvers, MA) is a surgically implanted temporary device, recently approved by the FDA (https://www.businesswire.com/news/home/20190925005454/en/) for treatment of patients in cardiogenic shock, and may fill a technological gap for patients who require acute circulatory support after VSD closure.Case presentationWe report our initial experience for two patients with post myocardial infarction VSD in the setting of cardiogenic shock supported with trans-aortic implantation Impella 5.5 SmartAssist. First patient had a posterior VSD with a left to right shunt (Qp/Qs ratio of 3.3), blood pressure 80/35 mmHg, right ventricle dysfunction, severe pulmonary arterial hypertension (an estimated systolic pulmonary artery pressure of 45 mmHg), and severe mitral valve regurgitation. Second patient was admitted for massive MI with large anterior VSD (Qp/Qs ratio of 2.8). Under cardiopulmonary bypass with cardioplegic arrest both patients underwent urgent VSD closure with trans-aortic implantation of the Impella. Minimal postoperative support was required. Patients were discharged on postoperative day 10 and 14 and remained well 3 months later. Follow-up echocardiogram showed no residual shunt.ConclusionsEarly surgical implantation of Impella 5.5 SmartAssist can prevent multiorgan dysfunction and stabilize the patients in cardiogenic shock with post-myocardial infarction VSD.

Modified Yasui Operation Using Cryopreserved Femoral Vein Homograft

The Yasui operation is indicated in an interrupted aortic arch and a posterior malaligned ventricular septal defect with a narrow subaortic region. We present a modification of the Yasui procedure in which the aortic reconstruction was simplified using a nonvalved cryopreserved femoral vein homograft to connect the pulmonary artery to the descending aorta. A side-to-side anastomosis was performed between the femoral vein homograft and ascending aorta to complete the neoaortic reconstruction. After baffling the left ventricle to the pulmonary artery with a patch, a valved segment from the same femoral vein homograft was used to restore continuity of the right ventricular outflow.

Congenitally corrected transposition of the great arteries: is it really a transposition? An anatomical study of the right ventricular septal surface

Congenitally corrected transposition of the great arteries (ccTGA) is a rare congenital malformation which associates discordant atrioventricular and ventriculo-arterial connections. Although frequently associated with a ventricular septal defect (VSD), its anatomy remains controversial. This could be due in hearts with usual atrial arrangement to the apparently different anatomy of the left-sided right ventricle compared with a right-sided right ventricle. We wanted to compare the RV septal anatomy between ccTGA, transposition of the great arteries and normal heart and to determine the anatomy of the VSD in ccTGA. We analysed 102 human heart specimens: 31 ccTGA, 36 transpositions of the great arteries, 35 normal hearts. According to the last classification of VSD (ICD-11), VSD were classified as outlet if located above the superoseptalcommissure of the tricuspid valve and inlet if underneath. We measured the lengths of the superior and inferior limbs of the septal band and the angle between the two limbs. To assess the orientation of the septal band, we also measured the angle between superior limb and the arterial valve above. A VSD was present in 26 ccTGA (84%) and was an outlet VSD in 16 cases (61%). The mean angle between the two limbs of the septal band was 76.4° for ccTGA compared with 90.6° for transposition of the great arteries (P=0.011) and 76.1° for normal hearts (P= NS). The mean angle between the superior limb of the septal band and the arterial valve above was 70.6° for ccTGA compared with 90.6° for transposition of the great arteries (P=0.0004) and 69.1° for normal hearts (P= NS). The inferior limb of the septal band was significantly shorter in ccTGA (P<0.0003): SL/IL length ratio was 21.4 for ccTGA, 2.2 for transposition of the great arteries and 1.5 for normal hearts. The typical VSD in ccTGA is an outlet VSD. Its frequent misdiagnosis as an inlet VSD might be explained by the shortness of the inferior limb, which creates the illusion of a posterior VSD, and by the fact that the VSD is usually assessed from the left ventricular aspect. Surprisingly, the orientation of the septal band is similar in ccTGA and normal heart, despite the discordant atrioventricular connections, and different in ccTGA and transposition of the great arteries, despite the discordant ventriculo-arterial connections. These findings suggest that the mechanism leading to transposition in ccTGA and in TGA probably is different. The term 'double discordance' might therefore be more appropriate as a description of this complex anomaly.

Congenitally corrected transposition of the great arteries: Is it really a transposition?

Congenitally corrected transposition of the great arteries (ccTGA) associates atrioventricular discordance and ventriculo-arterial discordance. The anatomy of the associated ventricular septal defect (VSD) remains controversial. We analyzed 102 human heart specimens: 31 ccTGA, 36 TGA, 35 normal hearts (NH), to compare the right ventricular septal anatomy between the 3 groups and to determine the anatomy of the VSD in ccTGA. VSD were classified as outlet if above the septal insertions of the tricuspid valve, inlet if underneath. We measured the lengths of the anterior (AL) and posterior (PL) limbs of the septal band, the angle between the two limbs and, in order to assess the orientation of the septal band, the angle between AL and the arterial valve above (AL-AV). VSD was present in 26 ccTGA (83.9%) and was outlet in 16 cases (62%). Mean AL-PL angle was 76.4° (ccTGA) compared to 90.6° (TGA, P = 0.011) and 76.1° (NH, P = ns). Mean AL-AV was 70.6° (ccTGA) compared to 90.6° (TGA, P = 0.0004) and 69.1° (NH, P = ns). PL was significantly shorter in ccTGA: AL/PL length ratio 21.4 (ccTGA), 2.2 (TGA), 1.5 (NH), P < 0.0003. The typical VSD in ccTGA is an outlet VSD. Its frequent misdiagnosis as an inlet VSD is due to the short PL, which creates the illusion of a posterior VSD. Surprisingly, the orientation of the septal band is similar in ccTGA and NH, despite the atrioventricular discordance, and different in ccTGA and TGA, despite the ventriculo-arterial discordance. ccTGA is not a TGA and the term “double discordance” might be more appropriate.

Congenitally corrected transposition of the great arteries: Is it really a transposition?

Congenitally corrected transposition of the great arteries (ccTGA) is a rare congenital malformation which associates atrioventricular discordance and ventriculo-arterial discordance. Although a ventricular septal defect (VSD) is frequently associated, its anatomy remains controversial. To compare the right ventricular septal anatomy between ccTGA, transposition of the great arteries (TGA) and normal heart (NH) and to determine the anatomy of the VSD in ccTGA. We analyzed 102 human heart specimens: 31 ccTGA, 36 TGA, 35 NH. VSD were classified as outlet if located above the septal insertions of the tricuspid valve, inlet if underneath. We measured the lengths of the anterior (AL) and posterior (PL) limbs of the septal band and the angle between the two limbs. In order to assess the orientation of the septal band, we measured the angle between AL and the arterial valve above (AL-AV). VSD was present in 26 ccTGA (83.9%) and was an outlet VSD in 17 cases (65.4%). Mean AL-PL angle was 76.4° for ccTGA compared to 90.6° for TGA (P = 0.011) and 76.1° for NH (P = ns). Mean AL-AV was 70.6° for ccTGA compared to 90.6° for TGA (P = 0.0004) and 69.1° for NH (P = ns). PL was significantly shorter in ccTGA (P < 0.0003): AL/PL length ratio was 21.4 for ccTGA, 2.2 for TGA and 1.5 for NH. The typical VSD in ccTGA is an outlet VSD. Its frequent misdiagnosis as an inlet VSD is due to the short PL, which creates the illusion of a posterior VSD. Surprisingly, the orientation of the septal band is similar in ccTGA and NH, despite the atrioventricular discordance, and different in ccTGA and TGA, despite the ventriculo-arterial discordance. Even if a transposition is present, ccTGA should not be considered a sub-group of TGA and the term “double discordance” might be more appropriate. These anatomic characteristics may also play a role in the dysfunction of the systemic right ventricle, which occurs earlier in TGA post-atrial switch than in ccTGA.

How Small Is Too Small? Decision-Making and Management of the Small Aortic Root in the Setting of Interrupted Aortic Arch.

Interrupted aortic arch is commonly associated with a posterior malalignment ventricular septal defect (VSD) and left ventricular outflow tract (LVOT) hypoplasia. Standard repair is carried out in the neonatal period and includes re-establishing arc continuity and VSD closure. Reintervention on the LVOT for obstruction is a common and an ongoing source of morbidity and mortality. A variety of preoperative echocardiographic measurements have been identified to identify patients at risk for developing LVOT obstruction but an aortic valve annulus dimension (mm) < patient's weight (kg) + 1 mm is a reasonable threshold to identify a patient at increased risk for future LVOT reintervention. Prophylactic direct approaches to prevent future LVOT obstruction include myectomy/myotomy and left-sided placement of the VSD patch but do not reliably prevent late LVOT obstruction. Patients amendable to a biventricular repair but with important LVOT hypoplasia are probably best served with a Yasui operation, either as a primary operation or staged with a Norwood procedure. In the case of complex redo operations, a Ross-Konno provides another valuable option for a durable repair. Though smaller preoperative LVOT structures predict the need for reoperation, careful preoperative planning may minimize the need for LVOT reintervention and improve long-term survival.

Repair of Posterior Infarct Ventricular Septal Defect in a Patient with Dextrocardia and Situs Inversus

We report a patient with situs inversus who developed a large posterior interventricular septum pseudoaneurysm with a septal defect following a myocardial infarction. The ventricular septum was approached through the left ventricle and the entrance of the pseudoaneurysm was repaired with a strip of equine pericardium.

RISK FACTORS OF MORTALITY AFTER SURGICAL CORRECTION OF VENTRICULAR SEPTAL DEFECT FOLLOWING MYOCARDIAL INFARCTION

Rupture of the ventricular septum following myocardial infarction (MI) is an uncommon but serious complication, usually leading to congestive heart failure and cardiogenic shock. Surgical repair is the only definitive treatment for this condition but is associated with a high operative mortality. This study sought to analyze the associated risk factors and outcomes in this population. A retrospective review was performed on 34 consecutive patients who had undergone surgical repair of ventricular septal defect (VSD) following MI from December 1991 to June 2013. Preoperative, clinical and echocardiographic variables were analysis. Mean age was 69±5 years and 44% were females. The VSD was anterior in 11 (32%) and posterior in 23 (68%) patients. Twenty-four (71%) patients were in cardiogenic shock. Mean aortic cross clamp time was 94 minutes and mean cardiopulmonary bypass time was 141 minutes. Median interval from MI to VSD repair was 7 days. Overall operative mortality within 30 days was 65%. Mortality within the posterior VSD group was 74% and the anterior VSD group was 46% (p=0.1) Concomitant CABG did not influence early or late survival. Multivariate analysis identified age and time between MI and operation as independent predictors of 30-day and long-term mortality. Surgical repair of post-infarction VSD carries a high operative mortality. Age and time between MI and operation are independent predictors of 30-days and long-term mortality. In presence of such high-expected postoperative mortality with conventional surgery, alternative therapy may need to be considered (percutaneous VSD closure and heart transplant) especially in patients with posterior VSD.

The Novel Use of Heart Transplantation for the Management of a Case With Multiple Complications After Acute Myocardial Infarction

Rupture of the interventricular septum after myocardial infarction (MI) is an uncommon but serious complication, usually leading to congestive heart failure and cardiogenic shock. Surgical repair is usually the only definitive treatment for these patients because medical management is associated with a 30-day mortality approaching 100%. However with conventional surgical repair, operative mortality rates range from 33% to 53%. Furthermore, outcomes in patients with posterior ventricular septal defect (VSD) have been reported to have mortality rates up to 86%. Therefore, alternative treatment should be considered to improve management of this mechanical complication. We report the case of a 63-year-old man in whom VSD developed after an inferior MI. The patient presented with shortness of breath and a recent ST-elevation inferior MI. Transthoracic echocardiography revealed a 50% left ventricular ejection fraction with mild-moderate right ventricular dysfunction. A posterior VSD (diameter ≥ 12 mm), moderate ischemic mitral regurgitation (MR), and a posterior pseudoaneurysm were also seen. The operative risk was considered to be too high for VSD repair because the surgery would have to include bypass grafting, mitral valve replacement, and pseudoaneurysm correction. Consequently, an urgent heart transplantation was considered the best option. The patient underwent heart transplantation 9 days after initial symptoms, and the recovery was unremarkable. To achieve a definitive optimal treatment, we propose that patients with posterior VSD with significant MR or pseudoaneurysm, or both, should be considered as heart transplant candidates.

Technical modifications in the repair of acute ischemic posterior ventricular septal defect without ventriculotomy.

Transventricular repair for acute ischemic posterior ventricular septal defect is challenging and is associated with high operative morbidity and mortality. We have adopted the alternative technique of transatrial repair and recently have added technical modifications that result in less residual or recurrent septal shunt. This study reports those modifications and the related outcomes. Retrospective review of 10 patients with acute ischemic posterior ventricular septal defect operated from November 2006 through March 2013. The septal defect was repaired through the right atrium with a prosthetic patch. Interlocking sutures and an additional continuous suture line buttress around the perimeter of the patch were added to the repair in four (40%) patients. Killip class IV heart failure was present in nine (90%) of the patients, and all received preoperative intra-aortic balloon pump therapy. No patient who received the recent technical modifications experienced a residual or recurrent shunt. However, three (50%) patients who did not undergo this modification developed either a residual septal shunt (n = 1), an early recurrent septal shunt (n = 1), or a ventricular rupture (n = 1). There was no 30-day or in-hospital mortality after surgery, but a single patient died two years after operation due to congestive heart failure. The remaining patients are alive after surgery at a median of 2.0 years. The transatrial repair of an acute ischemic posterior ventricular septal defect is a safe technique. The addition of interlocking pledgetted sutures and a patch suture line buttress decreases the incidence of residual and recurrent septal shunt.

Impella 5.0 microaxial pump as a right ventricular assist device after surgical treatment of posterior post-infarction ventricular septal defect

The Impella Recover LP 5.0 is an aortic transvalvular microaxial pump designed to unload the left ventricle and to ensure a systemic flow in severe left ventricular dysfunction. We propose a new suggestion for the Impella 5.0 as a temporary right ventricular assist device after the surgical treatment of a posterior post-infarction ventricular septal defect.

後壁梗塞に伴う心室中隔穿孔に対して右房アプローチが有用であった1例

後壁梗塞に伴う心室中隔穿孔に対して右房アプローチが有用であった1例

R25C mutation in the NKX2.5 gene in Italian patients affected with non-syndromic and syndromic congenital heart disease

Heterozygous mutations in the transcription factor Nkx2.5 indicate a genetic cause for congenital heart diseases (CHDs) in human beings. The present study aimed to assess the prevalence of NKX2.5 mutations in Italian patients with sporadic non-syndromic and syndromic CHD, as well as to appraise any genotype-phenotype correlations. One hundred Italian patients affected with CHD (90 had sporadic non-syndromic CHD and 10 had syndromic CHD) were screened for NKX2.5 mutations. The coding region and flanking regions involved in gene splicing of the CSX/NKX2.5 gene were amplified from genomic DNA by PCR, and mutational analysis was performed using denaturing high performance liquid chromatography and DNA sequencing. One previously reported NKX2.5 mutation (c.73C>T, p.R25C) was identified in two of the 100 CHD patients (2%). We have detected the p.R25C alteration in a woman showing aneurysm of the membranous septum, aortic coarctation and bicuspid aortic valve, that was a different phenotype from those previously reported, and for the first time in a patient with syndromic CHD with Down's syndrome (posterior ventricular septal defect, atrial septal defect, left superior cava vein ' sinus, and patent ductus arteriosus). Our results confirm that NKX2.5 mutations are not a common cause of CHD; furthermore, the p.R25C variation may increase susceptibility to development of CHD in patients with and without chromosomal abnormalities.

Long-Term Results After Surgical Repair of Postinfarction Ventricular Septal Rupture by Infarct Exclusion Technique

Ventricular septal defect (VSD) is one of the most serious and life-threatening complications of acute myocardial infarction. The aim of this study was to evaluate the early and long-term results of the patients after surgical repair of postinfarction VSD by infarct exclusion technique. A total of 32 consecutive patients (mean age, 62.5 +/- 10.5 years) underwent postinfarction VSD repair using a standardized technique in our department. A retrospective analysis of clinical and operative data, predictors of early mortality, and long-term survival was performed. The localization of VSD was posterior in 50% and anterior in 50% of the patients. The hospital mortality was 31.2% (10 patients). The most common cause of hospital death was persistent low cardiac output. The mortality of the posterior VSD group was significantly lower than that of the anterior VSD group (18.7% and 43.7%, respectively, p = 0.01). Intra-aortic balloon pump support and absence of cardiac shock were significantly associated with a lower risk of hospital mortality (p = 0.0001 and p = 0.0009, respectively). The actuarial survival rates of in-hospital survivors at 5 and 10 years were 79% +/- 2% and 51% +/- 3%, respectively. The repair of postinfarction VSD by the infarct exclusion is feasible and safe. This technique seems to offer sufficient favorable early and long-term results compared with other techniques. Early indication, preoperative intra-aortic balloon pump support may improve the surgical results. Preoperative cardiogenic shock carries a poor prognosis for this patient group.

Mitral Regurgitation due to Recurrent Septal Rupture after Repair of a Postinfarction Posterior Ventricular Septal Defect - A Case Report -

Mitral Regurgitation due to Recurrent Septal Rupture after Repair of a Postinfarction Posterior Ventricular Septal Defect - A Case Report -

Cardiogenic Shock in Patient with Posterior Postinfarction Septal Rupture-Successful Treatment with Extracorporeal Membrane Oxygenation (ECMO) as a Ventricular Assist Device

We present the case of a 62-year-old female patient admitted to our center for cardiogenic shock due to large inferior myocardial infarct. Echocardiography revealed dysfunction of left ventricle, dilation of right ventricle, mitral valve insufficiency, and a large posterior ventricular septal defect (VSD). Coronary angiography showed occlusion of the right coronary artery. An attempt of percutaneous coronary intervention (PCI) of right coronary and posterior descending artery was not successful due to old thrombi. Despite inotropes and intraaortic balloon pump (IABP) there was severe hemodynamic instability. Therefore, we commenced veno-arterial extracorporeal membrane oxygenation (ECMO) as a ventricular assist device (VAD). Immediately we obtained the stabilization of the patient and the improvement of the clinical conditions. The third day after implantation, the closure of the defect, mitral valve plasty, and bypass to posterior descending artery were performed. The patient was discharged from the hospital 59 days after the operation. Six months after the operation, the patient was in good condition.

Acute ventricular septal defect treated with an Impella recovery as a 'bridge therapy' to heart transplantation

We present the case of a 59-year-old male, admitted to hospital for cardiogenic shock due to massive infero-lateral myocardial infarction. Angiography showed occlusion of the right coronary artery and widespread critical lesions of both the anterior descending and circumflex artery. Echocardiography showed inferior akinesia with a large posterior ventricular septal defect (VSD). The haemodynamic instability induced us to use a left ventricular assist device (L-VAD) like Impella for easiness of its percutaneous implantation and for its duration. We obtained the stabilisation of the patient and the improvement of the clinical conditions. The location of the ventricular septal defect (VSD), from one side, and the serious and widespread coronaropathy (not suitable for any kind of revascularisation), from the other side, led us to choose heart transplantation for this patient. Heart transplantation was performed on the 12th day after myocardial infarction without complication and the patient was discharged on the 35th postoperative day. In our opinion, when the position of the VSD is unseemly and there coexists a widespread coronaropathy not eligible for revascularisation, heart transplantation may represent an efficacious alternative. Moreover, the use of L-VAD, reducing interventricular shunt and ensuring an adequate cardiac output, allows to obtain clinical stabilisation before heart transplantation.

Repair of Postinfarction Ventricular Septal Defect Through the Right Atrium

Repair of post infarction posterior ventricular septal defect has generally been performed with a ventriculotomy through the infarcted zone. This approach has a significant mortality and morbidity due to haemorrhage, extension of infarction or further compromise of ventricular function secondary to suture placement. We present a case with delayed repair of a post infarction posterior septal defect using a right atrial approach, where no discrete infarct or other abnormality of the free ventricular wall was found.