- Case report
- Open Access
- Open Peer Review
Off-pump repair of a post-infarct ventricular septal defect: the 'Hamburger procedure'
© Barker et al; licensee BioMed Central Ltd. 2006
- Received: 10 March 2006
- Accepted: 12 May 2006
- Published: 12 May 2006
We report a novel off-pump technique for the surgical closure of post-infarct ventricular septal defects (VSDs). The case report describes the peri-operative management of a 76 year old lady who underwent the 'Hamburger procedure' for closure of her apical VSD. Refractory cardiogenic shock meant that traditional patch repairs requiring cardiopulmonary bypass would be poorly tolerated. We show that echocardiography guided off-pump posterior-anterior septal plication is a safe, effective method for closing post-infarct VSDs in unstable patients. More experience is required to ascertain whether this technique will become an accepted alternative to patch repairs.
- Ventricular Septal Defect
- Ventricular Septal Defect
- Transcatheter Closure
- Patch Repair
Ventricular septal defect (VSD) is a rare but significant complication following myocardial infarction. Medical management alone is inadequate, and although recent advances in transcatheter closure have been promising , surgical repair if often the only option. Various surgical techniques have been described including single or double patch procedures with infarct exclusion [2, 3]. These open procedures require the use of cardiopulmonary bypass (CPB) and 30-day mortality ranges from 23 to 42% [3, 4].
Recently, an off-pump closure technique called the 'Hamburger procedure' has been pioneered as an alternative to open procedures that require CPB and ventriculotomy . The aim of our report is to describe how a post-infarct VSD may be repaired without CPB and to highlight the importance of echocardiography to guide VSD closure.
A 76 year-old female smoker was thrombolyzed with Tenecteplase after an acute anterior myocardial infarction. Unfortunately she remained hypotensive and so she underwent emergency angiography which showed patent coronary arteries except for the left anterior descending artery which was occluded distally. After this procedure she was noted to have a pansystolic murmur and transthoracic echocardiography (TTE) using a Vivid 7 Pro (GE Vingned, Norway), confirmed a 1 cm antero-apical VSD and an akinetic ventricular apex.
To manage her hypotension inotropes were commenced and an intra-aortic balloon pump was inserted. After stabilization for 5 days, diuretics and nitrates were added for progressing pulmonary oedema. Repeat TTE images showed no change, and although the right ventricle was mildly dilated, global left ventricular function was preserved. A decision was made to perform a delayed surgical repair to reduce operative risk.
She was reviewed in the local multi-disciplinary meeting and transcatheter closure was not thought to be appropriate. Four weeks after admission, she developed short episodes of ventricular tachycardia which were controlled by amiodarone. Two days later she deteriorated becoming hypotensive with worsening pulmonary oedema. She became hypoxic and hypercarbic and dobutamine infusion was added along with an escalation in her diuretic therapy. Sedation and mechanical ventilation were then required. Repeat TTE remained unchanged. A pulmonary artery flotation catheter was inserted and norepinephrine was commenced to treat persistent hypotension. Renal function began to deteriorate with serum creatinine rising to 190 μmol l-1.
Soon after surgery, she began to improve and her inotropes and frusemide were discontinued. However she required a tracheotomy to facilitate weaning from mechanical ventilation. She was transferred to a rehabilitation facility 4 weeks after the operation. She was found to be asymptomatic and mobilising independently at 6 month follow-up.
We would like to acknowledge the work of Mr A Wood based at St Bartholomew's Hospital, London, UK. He initially pioneered this off-pump VSD closure technique and should therefore be credited with the initial experience of this procedure. Also we would like to thank Ms Naseeba Hussain for help with preparation of the images.
- Mullasari AS, Umesan CV, Krishnan U, Srinivasan S, Ravikumar M, Raghuraman H: Transcatheter closure of post-myocardial infarction ventricular septal defect with Amplatzer septal occluder. Catheter Cardiovasc Interv. 2001, 54 (4): 488-489. 10.1002/ccd.1317.View ArticleGoogle Scholar
- Chang YL, Hsu CP, Lai ST, Yu TJ, Hwang JH, Shih CT, Yung MC, Chang SH, Wang JS: Surgical techniques for emergent repair of post-infarction ventricular septal defect: compare endocardial patch and infarct exclusion method with traditional method. J Chin Med Assoc. 2003, 66 (12): 722-726.PubMedGoogle Scholar
- Labrousse L, Choukroun E, Chevalier JM, Madonna F, Robertie F, Merlico F, Coste P, Deville C: Surgery for post infarction ventricular septal defect (VSD): risk factors for hospital death and long term results. Eur J Cardiothorac Surg. 2002, 21 (4): 725-731. 10.1016/S1010-7940(02)00054-4.View ArticlePubMedGoogle Scholar
- Barker TA, Ramnarine IR, Woo EB, Grayson AD, Au J, Fabri BM, Bridgewater B, Grotte GJ: Repair of post-infarct ventricular septal defect with or without coronary artery bypass grafting in the northwest of England: a 5-year multi-institutional experience. Eur J Cardiothorac Surg. 2003, 24: 940-946. 10.1016/S1010-7940(03)00465-2.View ArticlePubMedGoogle Scholar
- Chikwe J, Morgan IS, Wood A: Off-Pump Repair Of Postinfarction Ventricular Septal Defect. Abstract presented at the International Society for Minimally Invasive Cardiothoracic Surgery 8th Annual Meeting. 2005Google Scholar
- Mantovani V, Mariscalco G, Leva C, Blanzola C, Sala A: Surgical repair of post-infarction ventricular septal defect: 19 years of experience. Int J Cardiol. 2005,Google Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.