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Double-patch technique for postinfarction ventricular septal perforation
HOW TO DO IT
Double-Patch Technique for Postinfarction Ventricular Septal Perforation Noriyuki Tabuchi, MD, Hiroyuki Tanaka, MD, Hirokuni Arai, MD, Tomohiro Mizuno, MD, Hideki Nakahara, MD, Nagahisa Oshima, MD, Masaaki Toyama, MD, and Makoto Sunamori, MD Department of Cardiothoracic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, and Department of Cardiac Surgery, Kameda Medical Center, Chiba, Japan
CASE REPORTS
A modified infarct-exclusion technique for postinfarction ventricular septal perforation is presented. The perforation is closed directly by a small patch next to the conventional patch, and biological glue is applied between the patches to induce stable polymerization. The patch stuck to the infarcted septum, and no residual shunt was observed in any patient because the wide
adhesion prevents excessive pressure on the suture line. Seven of 9 patients in whom this method was used had good results. This technique appears suited for repair of ventricular septal perforations, especially those with extensive fresh infarction. (Ann Thorac Surg 2004;77:342–3) © 2004 by The Society of Thoracic Surgeons
A
patch is sutured to the healthy endocardium around the infarct in the septum and lateral ventricular wall using a running 4-0 polypropylene suture to exclude the VSP and the infarcted muscle from the left ventricular cavity [1]. Our modification is as follows: A second small patch of bovine pericardium is used to close the VSP directly with running sutures [4]. Because it is sutured to necrotic myocardium, this patch alone is not strong enough to sustain the pressure from the right ventricle, but it is strong enough to temporarily prevent shunting of blood from the right ventricle while the glue stabilizes. After the two patches are in position, biological glue (GRF glue in 7 patients and fibrin glue in 2) is applied to fill the cavity between the patches (Fig 1). The left ventriculotomy is closed. Once stabilized, the glue immediately creates a firm bond between the septum and the patches, as was shown by echocardiography (Fig 2). This technique was also used to repair posterior-type VSPs.
lthough the introduction of the infarct exclusion technique has improved outcomes [1], the surgical repair of postinfarction ventricular septal perforation (VSP) continues to have a high mortality rate of 19% to 40% [1, 2]. A residual shunt, hemodynamic instability, and subsequent multiorgan failure are considered risk factors affecting operative mortality [2, 3]. An early operation is preferable to prevent hemodynamic deterioration from damaging other major organs [3]. However, such an operation tends to present difficulties managing fragile myocardium [2, 3]. Thus, it would be of great help if the fragile ventricular septum and suture line could be reinforced. Since 1999, we have modified the conventional technique of infarct exclusion with use of a biological glue, mainly gelatin-resorcin-formaldehyde (GRF) glue (Pharmacie Centrale, CHU Henri Mondor, Cre´teil, France) [4]. Another small patch is positioned to close the VSP directly, and glue is applied as a sealant between the two patches [4, 5]. This allows immediate fixation of the endocardial patch to the myocardium, thereby protecting the fragile myocardium and avoiding excessive tension localized to the suture line.
Technique With the patient under cardiac arrest, a left ventriculotomy, parallel to and 2 cm away from the anterior descending coronary artery, is made through the infarcted anterior wall. A properly tailored bovine pericardial Accepted for publication May 29, 2003. Address reprint requests to Dr Tabuchi, Department of Cardiothoracic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo-ku, Tokyo 113-8519, Japan; e-mail: [email protected].
© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Comment It is noteworthy that there was no residual shunting in our series of 9 patients, although all operations were performed urgently within 24 hours after diagnosis. Echocardiography showed that the GRF glue made a firm bond between the infarcted septum and the patch immediately after the operation. The wide adhesion between the patch and the ventricular wall appears to protect against excessive tension localized to the suture line, thereby theoretically preventing recurrence of VSP. Using the double-patch technique, anterior VSPs were repaired in 7 patients and posterior VSPs in 2 patients. Two patients died after severe pump failure caused by high occlusion of the dominant coronary artery. The other 7 patients recovered quickly without major complications. 0003-4975/04/$30.00 doi:10.1016/S0003-4975(03)01008-7
Fig 1. Double-patch technique for ventricular septal perforation shown in cross-section of a heart. The hatched area is the cavity filled with biological glue. (LV ⫽ left ventricle; RV ⫽ right ventricle.)
The choice of biological glue is important because the issue of possible toxicity of GRF glue has been raised [6]. We used mainly GRF glue in our series because BioGlue
HOW TO DO IT TABUCHI ET AL DOUBLE-PATCH TECHNIQUE FOR VSP
343
is not yet available in Japan. During follow-up (range, 6 months to 4 years), neither new aneurysmal formation in the ventricles nor recurrence of VSP has been noted; the appearance of either would have made us suspect a toxic effect from the GRF glue. Pathological examination of patients who underwent VSP repair using GRF glue revealed excellent regrowth of collagen and elastic fibers in infarcted myocardium where the glue was applied [7], findings suggesting that the small amount of formaldehyde in the glue did not affect the remodeling of the fibrous architecture of the ventricle. However, because of toxicity concerns, it might be better in the future to use one of a new generation of glues instead of GRF glue [8]. Early operation is essential to decrease operative mortality from VSP by preventing damage from hemodynamic derangement to other major organs such as the lungs and kidneys [3]. Even though all our operations were done on an urgent basis, there has been no residual shunting in our series. Reinforcement of the fragile myocardium by biological glue and use of the doublepatch technique appear to provide satisfactory early repair of VSP.
References
Fig 2. Postoperative echocardiogram. The endocardial patch (arrows) is completely adherent to the myocardium. (LV ⫽ left ventricle; RV ⫽ right ventricle.)
1. David TE, Armstrong S. Surgical repair of postinfarction ventricular septal defect by infarct exclusion. Semin Thorac Cardiovasc Surg 1998;10:105–10. 2. Skillington PD, Davies RH, Luff AJ, et al. Surgical treatment for infarct-related ventricular septal defects. Improved early results combined with analysis of late functional status. J Thorac Cardiovasc Surg 1990;99:798 –808. 3. Deja MA, Szostek J, Widenka K, et al. Post infarction ventricular septal defect— can we do better? Eur J Cardio-thorac Surg 2000;18:194 –201. 4. Tabuchi N, Mizuno T, Kuriu K, Toyama M. Double patch technique for repairing postinfarction ventricular septal defect. Jpn J Thorac Cardiovasc Surg 2001;49:264 –6. 5. Tanaka H, Hasegawa S, Sakamoto T, Sunamori M. Postinfarction ventricular septal perforation repair with endoventricular circular patch plasty using double patches and gelatinresorcinol-formaldehyde biological glue. Eur J Cardio-thorac Surg 2001;19:945–8. 6. Kazui T, Washiyama N, Bashar AHM, et al. Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortic root. Ann Thorac Surg 2001;72:509 –14. 7. Hata M, Shiono M, Orime Y, et al. Pathological findings of tissue reactivity of gelatin resorcin formalin glue: an autopsy case report of the repair of ventricular septal perforation. Ann Thorac Cardiovasc Surg 2000;6:127–9. 8. Hewitt CW, Marra SW, Kann BR, et al. BioGlue Surgical Adhesive for thoracic aortic repair during coagulopathy: efficacy and histopathology. Ann Thorac Surg 2001;71:1609 – 12.
CASE REPORTS
Ann Thorac Surg 2004;77:342–3
Double-Patch Technique for Postinfarction Ventricular Septal Perforation Noriyuki Tabuchi, MD, Hiroyuki Tanaka, MD, Hirokuni Arai, MD, Tomohiro Mizuno, MD, Hideki Nakahara, MD, Nagahisa Oshima, MD, Masaaki Toyama, MD, and Makoto Sunamori, MD Department of Cardiothoracic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, and Department of Cardiac Surgery, Kameda Medical Center, Chiba, Japan
CASE REPORTS
A modified infarct-exclusion technique for postinfarction ventricular septal perforation is presented. The perforation is closed directly by a small patch next to the conventional patch, and biological glue is applied between the patches to induce stable polymerization. The patch stuck to the infarcted septum, and no residual shunt was observed in any patient because the wide
adhesion prevents excessive pressure on the suture line. Seven of 9 patients in whom this method was used had good results. This technique appears suited for repair of ventricular septal perforations, especially those with extensive fresh infarction. (Ann Thorac Surg 2004;77:342–3) © 2004 by The Society of Thoracic Surgeons
A
patch is sutured to the healthy endocardium around the infarct in the septum and lateral ventricular wall using a running 4-0 polypropylene suture to exclude the VSP and the infarcted muscle from the left ventricular cavity [1]. Our modification is as follows: A second small patch of bovine pericardium is used to close the VSP directly with running sutures [4]. Because it is sutured to necrotic myocardium, this patch alone is not strong enough to sustain the pressure from the right ventricle, but it is strong enough to temporarily prevent shunting of blood from the right ventricle while the glue stabilizes. After the two patches are in position, biological glue (GRF glue in 7 patients and fibrin glue in 2) is applied to fill the cavity between the patches (Fig 1). The left ventriculotomy is closed. Once stabilized, the glue immediately creates a firm bond between the septum and the patches, as was shown by echocardiography (Fig 2). This technique was also used to repair posterior-type VSPs.
lthough the introduction of the infarct exclusion technique has improved outcomes [1], the surgical repair of postinfarction ventricular septal perforation (VSP) continues to have a high mortality rate of 19% to 40% [1, 2]. A residual shunt, hemodynamic instability, and subsequent multiorgan failure are considered risk factors affecting operative mortality [2, 3]. An early operation is preferable to prevent hemodynamic deterioration from damaging other major organs [3]. However, such an operation tends to present difficulties managing fragile myocardium [2, 3]. Thus, it would be of great help if the fragile ventricular septum and suture line could be reinforced. Since 1999, we have modified the conventional technique of infarct exclusion with use of a biological glue, mainly gelatin-resorcin-formaldehyde (GRF) glue (Pharmacie Centrale, CHU Henri Mondor, Cre´teil, France) [4]. Another small patch is positioned to close the VSP directly, and glue is applied as a sealant between the two patches [4, 5]. This allows immediate fixation of the endocardial patch to the myocardium, thereby protecting the fragile myocardium and avoiding excessive tension localized to the suture line.
Technique With the patient under cardiac arrest, a left ventriculotomy, parallel to and 2 cm away from the anterior descending coronary artery, is made through the infarcted anterior wall. A properly tailored bovine pericardial Accepted for publication May 29, 2003. Address reprint requests to Dr Tabuchi, Department of Cardiothoracic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo-ku, Tokyo 113-8519, Japan; e-mail: [email protected].
© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Comment It is noteworthy that there was no residual shunting in our series of 9 patients, although all operations were performed urgently within 24 hours after diagnosis. Echocardiography showed that the GRF glue made a firm bond between the infarcted septum and the patch immediately after the operation. The wide adhesion between the patch and the ventricular wall appears to protect against excessive tension localized to the suture line, thereby theoretically preventing recurrence of VSP. Using the double-patch technique, anterior VSPs were repaired in 7 patients and posterior VSPs in 2 patients. Two patients died after severe pump failure caused by high occlusion of the dominant coronary artery. The other 7 patients recovered quickly without major complications. 0003-4975/04/$30.00 doi:10.1016/S0003-4975(03)01008-7
Fig 1. Double-patch technique for ventricular septal perforation shown in cross-section of a heart. The hatched area is the cavity filled with biological glue. (LV ⫽ left ventricle; RV ⫽ right ventricle.)
The choice of biological glue is important because the issue of possible toxicity of GRF glue has been raised [6]. We used mainly GRF glue in our series because BioGlue
HOW TO DO IT TABUCHI ET AL DOUBLE-PATCH TECHNIQUE FOR VSP
343
is not yet available in Japan. During follow-up (range, 6 months to 4 years), neither new aneurysmal formation in the ventricles nor recurrence of VSP has been noted; the appearance of either would have made us suspect a toxic effect from the GRF glue. Pathological examination of patients who underwent VSP repair using GRF glue revealed excellent regrowth of collagen and elastic fibers in infarcted myocardium where the glue was applied [7], findings suggesting that the small amount of formaldehyde in the glue did not affect the remodeling of the fibrous architecture of the ventricle. However, because of toxicity concerns, it might be better in the future to use one of a new generation of glues instead of GRF glue [8]. Early operation is essential to decrease operative mortality from VSP by preventing damage from hemodynamic derangement to other major organs such as the lungs and kidneys [3]. Even though all our operations were done on an urgent basis, there has been no residual shunting in our series. Reinforcement of the fragile myocardium by biological glue and use of the doublepatch technique appear to provide satisfactory early repair of VSP.
References
Fig 2. Postoperative echocardiogram. The endocardial patch (arrows) is completely adherent to the myocardium. (LV ⫽ left ventricle; RV ⫽ right ventricle.)
1. David TE, Armstrong S. Surgical repair of postinfarction ventricular septal defect by infarct exclusion. Semin Thorac Cardiovasc Surg 1998;10:105–10. 2. Skillington PD, Davies RH, Luff AJ, et al. Surgical treatment for infarct-related ventricular septal defects. Improved early results combined with analysis of late functional status. J Thorac Cardiovasc Surg 1990;99:798 –808. 3. Deja MA, Szostek J, Widenka K, et al. Post infarction ventricular septal defect— can we do better? Eur J Cardio-thorac Surg 2000;18:194 –201. 4. Tabuchi N, Mizuno T, Kuriu K, Toyama M. Double patch technique for repairing postinfarction ventricular septal defect. Jpn J Thorac Cardiovasc Surg 2001;49:264 –6. 5. Tanaka H, Hasegawa S, Sakamoto T, Sunamori M. Postinfarction ventricular septal perforation repair with endoventricular circular patch plasty using double patches and gelatinresorcinol-formaldehyde biological glue. Eur J Cardio-thorac Surg 2001;19:945–8. 6. Kazui T, Washiyama N, Bashar AHM, et al. Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortic root. Ann Thorac Surg 2001;72:509 –14. 7. Hata M, Shiono M, Orime Y, et al. Pathological findings of tissue reactivity of gelatin resorcin formalin glue: an autopsy case report of the repair of ventricular septal perforation. Ann Thorac Cardiovasc Surg 2000;6:127–9. 8. Hewitt CW, Marra SW, Kann BR, et al. BioGlue Surgical Adhesive for thoracic aortic repair during coagulopathy: efficacy and histopathology. Ann Thorac Surg 2001;71:1609 – 12.
CASE REPORTS
Ann Thorac Surg 2004;77:342–3