A modified closure technique for postinfarction ventricular septal defect via a right ventricular incision

A modified closure technique for postinfarction ventricular septal defect via a right ventricular... Abstract Postinfarction ventricular septal defect has been a challenge to cardiac surgeons. Recently, a number of reports have recommended ventricular septal defect closure through the right ventricle. However, when inferior myocardial infarction widely extends to the left ventricle, it is necessary to modify a patch-closure technique due to extensive fragile necrotic myocardium. We describe a simplified surgical technique via a right ventricular incision. postinfatction septal defect, right evntricular incision, closure technique INTRODUCTION Postinfarction ventricular septal defect (VSD) after acute myocardial infarction is a fatal complication. Few patients survive without surgical intervention. However, the surgical mortality rate remains high, ranging from 20% to 50%, despite advances in various surgical techniques [1]. Although a left ventricular incision is the standard approach, VSD closure through the right ventricle (RV) has reportedly shown favourable results [2, 3]. However, when inferior myocardial infarction widely extends to the left ventricle (LV) involving the RV, it is necessary to modify an inferior VSD patch-closure technique due to extensive fragile necrotic myocardium. TECHNIQUE Cardiopulmonary bypass is initiated via the ascending aorta with bicaval cannulation (Video 1). Myocardial protection is achieved with antegrade and retrograde cold blood cardioplegia. Operative schema is shown in Fig. 1. In patients with inferior VSD, a longitudinal incision is made in the RV wall 1–1.5 cm away from the posterior descending artery (PDA). After trimming of fragile necrotic tissue at the VSD edge, a bovine pericardial patch larger than the trimmed defect is prepared. Then, 3-0 Prolene mattress sutures are circumferentially placed in the bovine patch outside the operative field. Each suture is placed trans-septally and transmurally from inside the LV through the VSD. It is important to place the transmural stitches in healthy LV muscle as far as possible from the VSD edge, taking care not to injure papillary muscles. The bovine patch is then introduced into the LV and fitted to the LV and septum. Sutures brought outside of the heart are placed in another, larger bovine patch (Fig. 2). Before knotting, BioGlue (CryoLife, Kennesaw, GA, USA) is applied to the space between the 2 patches. Finally, the RV can be simply closed by suturing between the RV free wall and the second patch, without suturing to the LV wall. Because the RV free wall was fragile due to extended inferior myocardial infarction, Teflon felt reinforcing strips are placed on the RV wall. Three patients were operated with this technique. There were no operative deaths. All patients have no residual leak, aneurysmal formation of the LV or congestive heart failure during more than 1-year follow-up. Figure 1 View largeDownload slide The schematic drawing of 2-patch technique via a right ventricular incision. The grey-painted parts show myocardial infarcted area. The RV is closed, placing Teflon felt reinforcing strips on the RV wall, without suturing to the LV wall. LV: left ventricle; PDA: posterior descending artery; RV: right ventricle. Figure 1 View largeDownload slide The schematic drawing of 2-patch technique via a right ventricular incision. The grey-painted parts show myocardial infarcted area. The RV is closed, placing Teflon felt reinforcing strips on the RV wall, without suturing to the LV wall. LV: left ventricle; PDA: posterior descending artery; RV: right ventricle. Figure 2 View largeDownload slide The schematic drawing of the surgical view before the right ventricular closure, showing a large VSD patch. LV: left ventricle; RV: right ventricle; VSD: ventricular septal defect. Figure 2 View largeDownload slide The schematic drawing of the surgical view before the right ventricular closure, showing a large VSD patch. LV: left ventricle; RV: right ventricle; VSD: ventricular septal defect. Video 1 A modified closure technique via a right ventricular technique. Video 1 A modified closure technique via a right ventricular technique. Close DISCUSSION This technique is considered when the inferior myocardial infarction widely extends to the LV involving the RV. Asai et al. [2] introduced the ‘sandwich technique’ via an RV incision with low incidence of postoperative leak and good result. Hosoba et al. [3] then reported the extended sandwich patch technique for myocardial infarction with good short- and mid-term survival. In an RV approach, a residual VSD shunt is rare, because all mattress stitches are trans-septal or transmural. Moreover, this type of technique eases bleeding control. However, the reported method [2] is slightly complicated due to suture placement beneath the PDA, between a second patch and felt pledget outside the heart. Unlike reported articles [2, 3], the important point of our technique is that a large RV-side single patch is continuously applied inside the RV and outside the LV without Teflon felt pledget enforcement. Moreover, the RV is simply closed by directly suturing between the fragile RV free wall and the second patch. Another advantage of this technique is the adjustability of RV volume by freely changing the suture line between the second patch and the RV wall. The RV can be reconstructed without becoming too small. A concern with this technique is to make sacrifice of the PDA between 2 patches. However, in most cases, there is already no advantage of coronary artery bypass in the PDA area. This modified and simple sandwich technique is technically easy and simple to perform when inferior myocardial infarction extends to the LV beyond the PDA. Conflict of interest: none declared. REFERENCES 1 Arnaoutakis GJ, Zhao Y, George TJ, Sciortino CM, McCarthy PM, Conte JV. Surgical repair of ventricular septal defect after myocardial infarction: outcomes from the Society of Thoracic Surgeons National Database. Ann Thorac Surg  2012; 94: 436– 43; discussion 443–4. Google Scholar CrossRef Search ADS PubMed  2 Asai T, Hosoba S, Suzuki T, Kinoshita T. Postinfarction ventricular septal defect: right ventricular approach-the extended ‘sandwich’ patch. Semin Thorac Cardiovasc Surg  2012; 24: 59– 62. Google Scholar CrossRef Search ADS PubMed  3 Hosoba S, Asai T, Suzuki T, Nota H, Kuroyanagi S, Kinoshita T et al.   Mid-term results for the use of the extended sandwich patch technique through right ventriculotomy for postinfarction ventricular septal defects. Eur J Cardiothorac Surg  2013; 43: e116– 20. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

A modified closure technique for postinfarction ventricular septal defect via a right ventricular incision

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Oxford University Press
Copyright
© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ISSN
1569-9293
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1569-9285
D.O.I.
10.1093/icvts/ivx350
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Abstract

Abstract Postinfarction ventricular septal defect has been a challenge to cardiac surgeons. Recently, a number of reports have recommended ventricular septal defect closure through the right ventricle. However, when inferior myocardial infarction widely extends to the left ventricle, it is necessary to modify a patch-closure technique due to extensive fragile necrotic myocardium. We describe a simplified surgical technique via a right ventricular incision. postinfatction septal defect, right evntricular incision, closure technique INTRODUCTION Postinfarction ventricular septal defect (VSD) after acute myocardial infarction is a fatal complication. Few patients survive without surgical intervention. However, the surgical mortality rate remains high, ranging from 20% to 50%, despite advances in various surgical techniques [1]. Although a left ventricular incision is the standard approach, VSD closure through the right ventricle (RV) has reportedly shown favourable results [2, 3]. However, when inferior myocardial infarction widely extends to the left ventricle (LV) involving the RV, it is necessary to modify an inferior VSD patch-closure technique due to extensive fragile necrotic myocardium. TECHNIQUE Cardiopulmonary bypass is initiated via the ascending aorta with bicaval cannulation (Video 1). Myocardial protection is achieved with antegrade and retrograde cold blood cardioplegia. Operative schema is shown in Fig. 1. In patients with inferior VSD, a longitudinal incision is made in the RV wall 1–1.5 cm away from the posterior descending artery (PDA). After trimming of fragile necrotic tissue at the VSD edge, a bovine pericardial patch larger than the trimmed defect is prepared. Then, 3-0 Prolene mattress sutures are circumferentially placed in the bovine patch outside the operative field. Each suture is placed trans-septally and transmurally from inside the LV through the VSD. It is important to place the transmural stitches in healthy LV muscle as far as possible from the VSD edge, taking care not to injure papillary muscles. The bovine patch is then introduced into the LV and fitted to the LV and septum. Sutures brought outside of the heart are placed in another, larger bovine patch (Fig. 2). Before knotting, BioGlue (CryoLife, Kennesaw, GA, USA) is applied to the space between the 2 patches. Finally, the RV can be simply closed by suturing between the RV free wall and the second patch, without suturing to the LV wall. Because the RV free wall was fragile due to extended inferior myocardial infarction, Teflon felt reinforcing strips are placed on the RV wall. Three patients were operated with this technique. There were no operative deaths. All patients have no residual leak, aneurysmal formation of the LV or congestive heart failure during more than 1-year follow-up. Figure 1 View largeDownload slide The schematic drawing of 2-patch technique via a right ventricular incision. The grey-painted parts show myocardial infarcted area. The RV is closed, placing Teflon felt reinforcing strips on the RV wall, without suturing to the LV wall. LV: left ventricle; PDA: posterior descending artery; RV: right ventricle. Figure 1 View largeDownload slide The schematic drawing of 2-patch technique via a right ventricular incision. The grey-painted parts show myocardial infarcted area. The RV is closed, placing Teflon felt reinforcing strips on the RV wall, without suturing to the LV wall. LV: left ventricle; PDA: posterior descending artery; RV: right ventricle. Figure 2 View largeDownload slide The schematic drawing of the surgical view before the right ventricular closure, showing a large VSD patch. LV: left ventricle; RV: right ventricle; VSD: ventricular septal defect. Figure 2 View largeDownload slide The schematic drawing of the surgical view before the right ventricular closure, showing a large VSD patch. LV: left ventricle; RV: right ventricle; VSD: ventricular septal defect. Video 1 A modified closure technique via a right ventricular technique. Video 1 A modified closure technique via a right ventricular technique. Close DISCUSSION This technique is considered when the inferior myocardial infarction widely extends to the LV involving the RV. Asai et al. [2] introduced the ‘sandwich technique’ via an RV incision with low incidence of postoperative leak and good result. Hosoba et al. [3] then reported the extended sandwich patch technique for myocardial infarction with good short- and mid-term survival. In an RV approach, a residual VSD shunt is rare, because all mattress stitches are trans-septal or transmural. Moreover, this type of technique eases bleeding control. However, the reported method [2] is slightly complicated due to suture placement beneath the PDA, between a second patch and felt pledget outside the heart. Unlike reported articles [2, 3], the important point of our technique is that a large RV-side single patch is continuously applied inside the RV and outside the LV without Teflon felt pledget enforcement. Moreover, the RV is simply closed by directly suturing between the fragile RV free wall and the second patch. Another advantage of this technique is the adjustability of RV volume by freely changing the suture line between the second patch and the RV wall. The RV can be reconstructed without becoming too small. A concern with this technique is to make sacrifice of the PDA between 2 patches. However, in most cases, there is already no advantage of coronary artery bypass in the PDA area. This modified and simple sandwich technique is technically easy and simple to perform when inferior myocardial infarction extends to the LV beyond the PDA. Conflict of interest: none declared. REFERENCES 1 Arnaoutakis GJ, Zhao Y, George TJ, Sciortino CM, McCarthy PM, Conte JV. Surgical repair of ventricular septal defect after myocardial infarction: outcomes from the Society of Thoracic Surgeons National Database. Ann Thorac Surg  2012; 94: 436– 43; discussion 443–4. Google Scholar CrossRef Search ADS PubMed  2 Asai T, Hosoba S, Suzuki T, Kinoshita T. Postinfarction ventricular septal defect: right ventricular approach-the extended ‘sandwich’ patch. Semin Thorac Cardiovasc Surg  2012; 24: 59– 62. Google Scholar CrossRef Search ADS PubMed  3 Hosoba S, Asai T, Suzuki T, Nota H, Kuroyanagi S, Kinoshita T et al.   Mid-term results for the use of the extended sandwich patch technique through right ventriculotomy for postinfarction ventricular septal defects. Eur J Cardiothorac Surg  2013; 43: e116– 20. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

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Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Mar 1, 2018

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