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Post MI Ventricular Septal Defects

Post MI Ventricular Septal Defects. Nick Tehrani, MD. Overview. VSD Complicates 1-2% of cases of acute myocardial infarction. First successful correction reported by Cooley in 1957. Overview. High mortality despite various improvements in therapy 30 day mortality- 74% 1 year mortality- 78%

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Post MI Ventricular Septal Defects

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  1. Post MI Ventricular Septal Defects Nick Tehrani, MD

  2. Overview • VSD Complicates 1-2% of cases of acute myocardial infarction. • First successful correction reported by Cooley in 1957.

  3. Overview • High mortality despite various improvements in therapy • 30 day mortality- 74% • 1 year mortality- 78% GUSTO analysis, Crenshaw et al, Circ. 1/2000

  4. Overview • Relative Improvement in survival due to • Earlier diagnosis • Earlier flow restoration • More aggressive surgical intervention

  5. Overview • Incidence declining due to: • Earlier restoration of flow, preventing transmural MI • More aggressive BP control post MI

  6. Overview • Predictors of VSD • Advanced age, • Anterior location of infarction, • Female sex, • No history of smoking Per GUSTO analysis • Thrombolysis after 12 hours also suggested as a predisposing factor.

  7. Overview • Average time to rupture • 2-4 days • Range: few hours  2 weeks • Time course may be accelerated by thrombolysis, possible related to intramyocardial hemorrhage

  8. Overview • Coronary anatomy and VSD • Post MI VSDs more commonly associated with 100% occlusion of the infarct related artery • This was observed in all of our patients

  9. Anatomy of VSDs • Two types of VSD • Simple: through and through defect usually located anteriorly • Complex: serpentiginous dissection tract remote from the primary septal defect- most commonly an inferior VSD • Patient BG had such a presentation

  10. Transesophageal Echocardiogram of Complex VSD

  11. Angiography

  12. Anatomy of VSDs • Antro-apical septal rupture • Comprise approximately 60-80% of cases • LAD occlusion is always the culprit

  13. Anatomy of VSDs • Posterior septal rupture • Approximately 20-40% of cases • Occlusion of • Dominant RCA => extensive RV infarction • Dominant LCX (Less common), RV mostly spared

  14. Anatomy of VSDs • Multiple defects (5-11% of cases) • Secondary to infarct extension • Evolve within days of each other

  15. Anatomy of VSDs • Our series • Antro-apical septum Three of four cases • Posterior septum One of four cases

  16. Pathophysiology • Antero-apical septal rupture • Tamponade • Secondary RV failiure due to acute volume overload

  17. Pathophysiology • Posterior septal rupture • Commonly complicated by MR • Shunt reversal due to elevated RVEDP

  18. Diagnosis • Loud/harsh pansystolic murmur • Within the first week post AMI • Best heard at Lt. Lower sternal border • Less loud at the apex • Associated with a palpable thrill • Depending on the location, may radiate to the axilla mimicking MR

  19. Diagnosis • Up to 50% of patients experience chest pain associated with the development of murmur • CHF and shock often associated with the development of murmur

  20. Diagnosis • Color Flow Doppler • 100% sensitive and specific in differentiating VSD from acute MR • Site of septal rupture correctly identified in 41 of 42 patients • One of our 4 patients had had a negative TTE earlier in the day, and no apparent homodynamic changes prior to the catheterization later that day Smyllie et. Al. 1990 JACC

  21. Diagnosis Earlier diagnosis and surgical intervention, may be due to greater availability of Echocardiography at peripheral centers.

  22. Diagnosis • Need for cardiac catheterization • 2/3 of the patients have multivessel coronary artery disease • Decreased operative mortality and improved late survival has been shown in patients with multivessel disease • Cardiogenic shock not a deterrent to Cath => Coronary angiography should be performed

  23. Diagnosis

  24. Pre-Operative Management • Hemodynamic stabilization so as to minimize peripheral organ compromise • Reduce Systemic vascular resistance, and thus, the left-to-right shunt • Maintain or improve coronary artery blood flow • Maintain cardiac output and arterial pressure to ensure peripheral organ perfusion => IABP

  25. Timing of Surgery • Controversial (in the past) • Non-randomized studies showing: • Early repair, 40% - 50% mortality • Late repair (past 3 weeks), 10% mortality => Aggressive Medical management aimed at delaying surgical intervention

  26. Timing of Surgery • Short-coming of the argument Patients with less sever hemodynamic compromise, more likely to survive the acute phase without need for prompt surgery: Lower pre-op risk =>Better outcome

  27. Timing of Surgery • Short-coming of the argument Patients with greater hemodynamic compromise, and more severe insult: Higher pre-op risk=>Worse outcome

  28. Timing of Surgery • Surgery should be performed soon after diagnosis in most patients • Patients is cardiogenic shock should be operated on immediately after anigography • Hemodynamically stable patients should have surgery on an urgent basis

  29. Operative Technique • Classical approach to antero-septal rupture • Infarctectomy, and • Reconstruction of the ventricular septum with Dacron patches

  30. Operative Technique • Classical approach to infro-posterior rupture • Infarctectomy, and • Reconstruction of infroposterior VSD, • Reconstructionfree wall with Dacron patches.

  31. Outcome • In a review of 139 cases reported in the literature prior to 1977 Six month survival without surgical intervention was less than 10%. Kirklin, Churchill Livingston 1993

  32. Outcome • Predictors of early mortality per multivariable logistic regression analysis in a series of 22 patients • DM • Elevated RA pressure (RV involvement/IMI) • Absence of intraoperative IABP

  33. Outcome • Predictors of early mortality per GUSTO analysis • Advanced age • Inferior location of MI

  34. Outcome • In patients with cardiogenic shock mortality reported to be the highest • Posterior VSD (IMI) is another factor strongly associated with poor surgical outcome due to • Difficulty of exposure, and • Frequent concomitant infarction of the postero-medial papillary muscle Compilation from 6 series from the late 80s

  35. Outcome • David, in a series of 44 patients reported no difference between mortality rates for the posterior and anterior VSD using the Exclusion technique

  36. Exclusion Technique • Exclusion technique • LV excluded from the infarcted muscle using a bovine pericardial patch sutured to the healthy peri-infarct endocardium • No infarctectomy is performed • RV is undisturbed • Better RV function preservation • May help support the posteromedial papillary muscle

  37. Exclusion technique Exclusion technique

  38. Outcome • Residual Lt.  Rt. shunt • Reported in up to 28% of survivors • Associated with high mortality • Intra-operative TEE useful in early detection and correction if deemed necessary • Seen in one of our patients. • Patient was treated medically

  39. Residual VSD

  40. Post-Op state • Dialysis • Commonly required in patients in shock • Not required by either of our two survivors • Prolonged ventilatory support • Residual or recurrent VSD • Reoperation may be necessary depending on the shunt size and hemodynamics

  41. Clinical Profile of our Patients

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