A 54-year-old male came with history of chest pain of 3 weeks duration. He was a known diabetic and hypertensive. He was not on any treatment at that time. His symptoms worsened after three weeks, when he presented to the hospital. On evaluation, he was detected to have ventricular septal rupture following acute coronary syndrome. He had features of pulmonary edema and congestive heart failure. Echocardiogram showed moderate LV dysfunction with ejection fraction of 35%, mild MR and 18mm ventricular septal rupture at the apex with dyskinetic apex. Coronary angiogram showed severe triple vessel dis-ease. After initial stabilization, he was taken up for surgery after a week when his renal function started deteriorating.
Surgical Procedure
He underwent ventricular septal repair using Gore-Tex patch and coronary artery bypass grafting (CABG x5) under cardiopulmonary bypass and intra-aortic balloon pump counter-pulsation. His post-operative period was stormy with repeat episodes of cardiac failure requiring prolonged inotropic support and ICU care, which was further complicated by renal dysfunction that was managed conservatively.
Discussion
Ventricular septal rupture repair is a rare surgical intervention with a high complication and mortality rate. On the other hand, if it is left untreated, it has a high mortality. In the acute phase, because the remaining septum is mushy necrotic muscle, they are not receptive to sutures. The hospital survival after ventricular septal rupture repair varies between 30–47%. These high mortalities have to be set against the mortality without surgery which is 94%.
Surgical principles of VSR closure include hypothermic cardiopulmonary bypass with myocardial protection, trans-infarction approach to the VSR, trimming of infarcted muscle around the VSR, closure of the VSR with a patch to avoid tension and closure of the ventricle without tension, with Teflon felt using buttressed sutures. Closure of ventricular septal rupture following myocardial infarction is an infrequent operation with a very high operative risk. Nonetheless, early surgical intervention offers the only realistic chance of survival and this opportunity should not be denied to patients. Immediate intra-aortic balloon counterpulsation provides some haemodynamic optimization while preparations are made for surgery.
The good long term outcome for survivors makes the high early mortality worthwhile. Transcatheter closure of ventricular septal rupture in the acute setting has been reported. This may provide temporary hemodynamic relief and therefore allow surgical closure after the infarcted myocardium around the rupture has had time to fibrose. With the current devices, closure can be very difficult
Discussion
Ventricular septal rupture repair is a rare surgical intervention with a high complication and mortality rate.
In the acute phase, because the remaining septum is mushy necrotic muscle, they are not receptive to sutures. The hospital survival after ventricular septal rupture repair varies between 30–47%. These high mortalities have to be set against the morality without surgery, which is 94%. Surgical principles of VSR closure include hypothermic cardiopulmonary bypass with myocardial protection, trans-infarction approach to the VSR, trimming of infarcted muscle around the VSR, closure of the VSR with a patch to avoid tension and closure of the ventricle without tension, with Teflon felt using buttressed sutures.
Closure of ventricular septal rupture following myocardial infarction is an infrequent operation with a very high operative risk. Nonetheless, early surgical intervention offers the only realistic chance of survival and this opportunity should not be denied to patients. Immediate intra-aortic balloon counterpulsation provides some haemodynamic optimisation while preparations are made for surgery. Another adjunct for those patients who are severely hemodynamically compromised are ventricular assist devices. As the technology of devices advances they should become increasingly available and increasingly adaptable; one can imagine the situation where a temporary device will maintain a patient’s haemodynamics while the edges of the septal rupture fibrose sufficiently to allow a definitive surgical closure later.
