This article has Open Peer Review reports available.
"The non-ischemic repair" as a safe alternative method for repair of anterior post-infarction VSD
© Apostolakis et al; licensee BioMed Central Ltd. 2010
Received: 20 July 2009
Accepted: 19 February 2010
Published: 19 February 2010
Patient's myocardium with post-infarction ventricular septum defect (VSD) is characterized by severe dysfunction. The "additive ischemia" caused by the operating process of cross-clamp ischemia and reperfusion injury, has a significant aggravation to the myocardium and overall negative impact to patient's outcome. We present a useful, safe and advantageous methodology in order to abolish "the toxic phase" of ischemia-reperfusion which is adopted by most as the "classic repair method" of myocardial protection. This abolition is in our opinion, particularly beneficial in order to reverse postoperatively the Low Cardiac Output Syndrome (LOS) and achieve better short and long term results. By using this method we avoid the aortic occlusion, the use of systematic hypothermia and any cardioplegic arrest. Furthermore, the total cardio-pulmonary bypass (CPB) time is significantly reduced, tissue debridement and stitching is much easier and safer. We think the method is applicable for every anterior and apical case of post-infarction septum rupture. After application of method in 3 patients with anterior post-myocardial infarction VSD, we are convinced that the patient will have a better postoperative haemodynamic condition and therefore a better outcome.
The rupture of the interventricular septum after myocardial infarction constitutes a severe mechanical complication of the coronary artery disease with very high surgical mortality (19-50%) and morbidity [1, 2]. Many factors contribute to an unfavourable surgical outcome such as the emergency, the coexisting 3-vessel coronary artery disease, the posterior rupture, the "non-complete revascularization" operation, the "intractable" shock and the secondary organ-failure (mainly renal) [2, 3]. The adequate myocardial protection during the operation is considered to be the cornerstone for a better outcome postoperatively [4, 5]. The classic method of systemic hypothermia, aortic occlusion, and intermittent administration of cold blood cardioplegic solution is a well established method for the reconstruction of the post-infarction VSD [1–4, 6]. Nevertheless, cardioplegic arrest is related to perioperative myocardial injury, which is considered as a severe determinant of postoperative haemodynamic condition, and therefore of clinical outcome [7, 8]. This is the reason of suggestions by some authors for other alternative methods as that of using continuous myocardial perfusion after aortic occlusion, or by using intermittent ventricular fibrillation, or by administration of normothermic cardioplegia [9, 10]. We propose another alternative method of myocardial protection during surgical repair of the anterior or apical cases of ruptures of the ventricular septum, and we recommend this as simple, safe and efficient.
Patient's myocardium with post-infarction VSD is characterized by severe dysfunction [2, 3]. Many unfavourable factors such as the recent infarction, the shock condition, the increased tissue (myocardial) edema, the inotropic support, the increased endogenous produced catecholamines, as well as the coexisting hypoxia due to pulmonary congestion are causing severe malfunction of the rest "rescued" myocardium. The additional ischemia to this myocardium, due to aortic occlusion and systemic and local hypothermia, entails significant postoperative functional deterioration and finally, possible unfavourable outcome. The methodology of myocardial protection using obligatory aortic occlusion, continuous or even intermittent, which was applied from the beginning of the surgical treatment of the post myocardial infarction mechanical complications, is still consider to be by many authors "inevitable" [1–3, 5, 6]. Even Gummert et al  in their chapter about the use of beating heart methodology in patients with acute myocardial infarction, state: "ventricular septal defect, acute mitral regurgitation, and myocardial free wall rupture following acute myocardial infarction require reparative surgery under cardioplegic arrest, and therefore will not be discussed any further in this chapter". The attempt to avoid systematic hypothermia, aortic occlusion and cardioplegia infusion is aiming to avoid cardiac arrest and to nullify the ischemic time. Our methodology has a series of significant advantages, especially important in our opinion for the early and also the late postoperative results: a) it does not aggravate the myocardium with the "toxic influence" of the ischemia - reperfusion process, b) additionally it does not have the adverse effect of the systemic hypothermia, c) it allows to the left ventricle to contract empty of volume on extracorporeal circulation, condition which consider to be the most favorable from the energy consumption point of view ("... the oxygen consumption of the beating, empty heart -as on cardiopulmonary bypass- is less than under any other condition.") , d) it significantly reduces the CPB time, another important detrimental factor, mainly because it avoids the hypothermia but also because we don't use any other catheter for cardioplegia infusion etc., e) it precludes possible complications from the cardioplegic infusion such as injury to the coronary vessels, coronary embolism, myocardial oedema etc., f) it allows easier distinction of the excision borders of the non-viable septum up to the point of the viable bleeding tissue, g) it secures safer "palpable feeling" for the proper setting and above all correct riveting of the sutures in a contracting not arrested myocardium which keeps the natural muscular tone (it avoids crushing the arrested myocardium), h) it can be applied in the anterior and apical ruptures which are the majority of the ruptures representing 60-80% of all cases , and finally ι) it allows seasonably control and correction of any local bleeding point in the ventriculotomy suture line during the phase of the passive lung expansion, and the temporary left ventricle overloading. Our method's disadvantage is that it can not be applied in the cases of inferior septal ruptures, unless they are either small or chronic, and the temporarily produced aortic regurgitation can be well tolerated by the patient. We have to note that there is no risk of aortic embolism during the maneuvers, because the existence of continuously positive intra-aortic pressure and patient's Trendelenburg position. Up today we have used the method in 3 patients with anterior rupture ascertaining the previous mentioned advantages in emergent setting. We observed a better global cardiac function during the early postoperative phase. It has been observed an amelioration of about 10% of the left ventricle ejection fraction. Two of the patients survived without complications and discharged after 13 and 17 days respectively from hospital, but unfortunately, the third one died 28 days postoperatively in intensive care unit (ICU) from multiple organ failure (MOF). The small number of our patients does not allow us to randomly compare the haemodynamic and clinical results, but we greatly believe that the complete abolition of the ischemic-time improves the safety conditions of the operation, the early results, as well as the survival in these patients. However, further multicenter randomized trials are necessary in order to establish the superiority of this method.
- Kouchoukos N, Blackstone E, Doty D, Hanley F, Karp R, (Eds): Kirklin/Barratt-Boyes Cardiac Surgery. Postinfarction Ventricular Septal Defect. 2003, Churchill-Livingstone, 456-69. 3Google Scholar
- Mangi A, Agnihotri A, Torchiana D: Postinfarction ventricular septal defect. Sabiston and Spencer Surgery of the Chest. 2005, Elsevier Saunders, 1549-57. 7Google Scholar
- Agnihotri A, Madsen J, Daggett W: Surgical treatment of complications of acute myocardial infarction: Postinfarction ventricular septal defect and free wall rupture. Cardiac Surgery in the Adult. Edited by: Cohn L, Edmunds H. 2003, McGraw-Hill, 681-708. 2Google Scholar
- David T: Operative management of postinfarction ventricular septal defect. Semin Thorac Cardiovasc Surgery. 1995, 7: 208-213.Google Scholar
- Madsen J, Daggett W: Repair of postinfarction ventricular septal defects. Semin Thorac Cardiovasc Surgery. 1998, 10: 117-27.View ArticleGoogle Scholar
- Gummert J, Borger M, Rastan A, Mohr F: Beating heart coronary artery bypass in patients with acute myocardial infarction: a new strategy to protect the myocardium. Myocardial Protection. Edited by: Salerno T, Ricci M. 2004, Futura Blackwell Publishing, 146.Google Scholar
- Croal B, Hillis G, Gibson P, Fazal MT, El-Shafei H, Gibson G, Jeffrey RR, Buchan KG, West D, Cuthbertson BH: Relationship between postoperative cardiac troponin I levels and outcome of cardiac surgery. Circulation. 2006, 114: 1468-75. 10.1161/CIRCULATIONAHA.105.602370.View ArticlePubMedGoogle Scholar
- Onorati F, De Feo M, Mastroroberto P, Cristodoro L, Pezzo F, Renzulli A, Cotrufo M: Determinants and prognosis of myocardial damage after coronary artery bypass grafting. Ann Thorac Surg. 2005, 79: 837-45. 10.1016/j.athoracsur.2004.07.060.View ArticlePubMedGoogle Scholar
- Weisel R: Myocardial protection during for mechanical complications of myocardial infarction. Mechanical Complications of Myocardial Infarction. Edited by: David T. 1993, Austin: R.G. Landes CompanyGoogle Scholar
- Hendren W, O'Keefe D, Geffin G, Denenberg AG, Love TR, Daggett WM: Maximal oxygenation of dilute blood cardioplegia solution. Ann Thorac Surg. 1994, 58: 1558-9.View ArticlePubMedGoogle Scholar
- Hottenrott C, Maloney J, Buckberg G: Studies of the effects of ventricular fibrillation on the adequacy of regional myocardial flow. I. Electrical vs. spontaneous fibrillation. J Thorac Cardiovasc Surg. 1974, 68: 615-25.PubMedGoogle 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.