- Email: [email protected]
Resection of acute posterior ventricular aneurysm with repair of ventricular septal defect after acute myocardial infarction
Resection of acute posterior ventricular aneurysm with repair of ventricular septal defect after acute myocardial infarction Three patients with true posterior myocardial infarctions and ventricular septal defects were treated by posterior infarctectomy, closure of the defect, and appropriate combinations of mitral valve replacement and coronary grafting. Aortic balloon pumping was not used. The technique of injarctectomy and ventricular septal defect closure is illustrated. Two of the 3 patients have excellent long-term results.
Ivan K. Crosby, M.B., B.S., F.R.C.S., F.A.C.C., Joseph M. Craver, M.D., * Richard S. Crampton, M.D., F.A.C.C., Joel P. Schrank, M.D., F.A.C.C., and Harry A. Wellons, M.D., F.A.C.C., Charlottesville, Va.
AlthOUgh acute ventricular septal defect, papillary muscle rupture, and left ventricular aneurysm infrequently complicate myocardial infarction, when they do occur they are usually associated with profound hemodynamic deterioration. The mortality rate within 24 hours after acute rupture of the interventricular septum is 25 per cent and rises to 93 per cent within 12 months of infarction. '· 2 Acute papillary muscle rupture secondary to myocardial infarction carries a 70 per cent mortality rate within the first 24 hours." Surgical repair of an acute ventricular septal defect after myocardial infarction was first attempted in 1956,4 and the first reported successful insertion of a prosthetic mitral valve for acute papillary muscle rupture was performed in 1965. 5 From the Departments of Thoracic and Cardiovascular Surgery and Internal Medicine, University of Virginia, Charlottesville, Va. Received for publication Jan. 29, 1975. Address for reprints: Dr. Ivan K. Crosby, Box 181, University of Virginia Medical Center, Charlottesville, Va. 22901. 'Current address: Carlyle Fraser Heart Center, Crawford W. Long Hospital of Emory University, Atlanta, Ga.
Subsequently, there have been over 100 reported cases of successful repair of either an acute ventricular septal defect or papillary muscle rupture. By contrast, repair of an acute ventricular septal defect and resection of an acute ventricular aneurysm has been reported far less frequently.v-" Repair of all these acute mechanical defects after myocardial infarction is rare. R This report describes resection of an acute true posterior aneurysm with repair of the acute ventricular septal defect in 3 patients within a month of myocardial infarction. At the time of surgical repair, 1 patient had concomitant mitral valve replacement, the second a coronary bypass graft, and the third a double coronary bypass procedure. All required surgical correction because of persistent biventricular failure. The technique of infarct resection and ventricular septal defect closure was the same in all 3 patients. Case reports CASE 1. A 62-year-old man entered a local hospital with an acute inferior infarction and
57
The Journal of
58
Crosby et al.
Thoroc ic and Cardiovascular Surgery
Fig. 1. In the left anterior oblique view, injection into the left ventricle (L. V .) shows the septal aneurysm and the ventricular septal defect (V.S.D .). RiV«, Right ventricle.
Fig. 2. In the right anterior oblique projection, the septal aneurysm and the mitral regurgi tation are well illustrated. pulmonary edema. A harsh holo systolic murmur, not present earlier, appeared at the lower left sternal border and apex on the second hospital day . Sudden cardiac asytole on the second hospital day responded to resuscitation, and he was transferred to the University Ho spital via a mobile coronary care unit while being supported by intravenous norepinephrine. Left ventricular angiography documented a large diaphragmatic and posterior septal aneurysm of the left ventricle, a small inferior ventricular septal defect, and mod er ate mitral regurgitation (Figs. 1 and 2, Table I) . Contractility of the anterior and lateral walls
was normal. Coronary angiography demonstrated tot al proximal occlusion of the right coronary artery with poor distal runoff and multiple 20 to 30 per cent ob structions in the left anterior descending and circumflex vessels. Bed rest, transvenous cardiac pacing, regulation of acid-base balance, and treatment with digit al is and diuretics temporaril y prevented further hemodynamic deterioration . Howev er, severe biventricular failure persisted , and on the twelfth hospital da y, 14 day s after the acute infarction, surgical correction was undertaken. The mitral valve was resected because of a ruptured papillary muscle , and a
Volume 70 Number 1 July, 1975
Surgical repair after acute myocardial infarction
59
A
B
#
.
l
)
Fig. 3. A, By rotation of the heart superiorly, the diaphragmatic surface, the posterior descending coronary artery, and the posterior areas of both the left and the right ventricles are displayed. The dotted area indicates the extent of the infarctectomy. B, Following infarctectomy, the perforations in the ventricular septum are easily visualized. C, The septum is sandwiched between strips of Teflon felt, as are the epicardial surfaces of both the left and the right ventricles. The area of infarctectomy and the ventricular septal defect are closed in a single suture line. D, The saphenous vein graft to the circumflex coronary artery is demonstrated in relationship to the infarctectomy suture line. Beall prosthesis was implanted . The diaphragmatic left ventricular aneurysm (12 by 6 crn.) was resected, and the small ventricular septa l defect was closed in the same suture line, which was buttressed with Teflon felt. The operative findings and the technique of surgical repair are demonstrated in Fig. 3. The partially stenotic coronary lesions did not warrant bypass grafting. When cardiopulmonary bypass was discont inued, the patient's cardiac performance required temporary inotropic support. His course was uneventful until the tenth postoperative da y, when atrial flutter requ ired cardioversion. The patient was discharged on the twenty-fourth postoperative day .
Seven months after the operation, he had no murmurs and was doing well on digitalis and oral diuretic therapy. CASE 2 . A 50-year-old hypertensive man entered a local emergency room for severe nausea, vomiting, and substernal pain . One week later, he returned in cardiogenic shock with pulmonary edema. A new holosystolic murmur was noted. He required metaraminol, frequent cardioversion for supraventricular tachyarrhythmias, and lidocaine for ventricular ectopy. He was transferred to the University of Virginia Hospital, and medical management of acidemia, arrhythmias, digitalis toxicity, and congestive heart failure was
60
The Journol of Thorocic ond Cordiovosculor Surgery
Crosby et al.
Table I. Cardiac catheterization data Parameter
LVP(mm. Hg) RVP(mm. Hg) PAP (mm. Hg) PCWP (mm. Hg) QP:QS ratio Cardiac index (L./min';sq. M.)
Case I
Case 2
Case 3
87/22 81/22 96/22 40/11 45/13 41/15 39/19 (26) 38/16 (24) 39/21 (24) a = 19 a = 21 a = 16 v = 29 v = 21 v = 21 (16) (17) (17) 4.0 1.3 3.0 2.2
2.2
1.8
Legend: LVP, Left ventricular pressure. RVP, Right ventricular pressure. PAP, Pulmonary artery pressure. PCWP, Pulmonary capillary wedge pressure. QP:QS, Pulmonarysystemic flow ratio.
initiated. Left ventricular angiography revealed a ventricular septal defect in the lower posterior muscular septum, normal contractility anteriorly and laterally, and no mitral regurgitation. There was a large biventricular posterior aneurysm. Coronary angiography revealed total occlusion of the right coronary artery and 90 per cent stenosis of the left circumflex artery (Table I). Three weeks after infarction, because biventricular failure had worsened and arrhythmias increased, surgery was undertaken. The patient tolerated induction of anesthesia poorly and required urgent cardiopulmonary assistance. A right and left posteroinferior aneurysm (10 by 15 em.) was resected, the ventricular septal defect was repaired, and the ventriculotomies were closed. A saphenous vein graft was inserted into the left circumflex coronary artery (Fig. 3). There were no murmurs postoperatively and the patient was discharged on the fourteenth postoperative day taking digoxin. Apart from intermittent paroxysmal atrial flutter, he has had a satisfactory course on digoxin, a diuretic, and quinidine for the 11 months since his operation. CASE 3. A 71-year-old man entered a local hospital with an acute inferior myocardial infarction and advanced atrioventricular block. On the fourth hospital day he sustained a left hemiparesis; on the seventh day, the infarction extended; and on the tenth day a loud systolic murmur appeared. Left ventricular angiography revealed a posterior aneurysm and a ventricular septal defect (Table I). One month after infarction he underwent resection of the posterior infarct, closure of the ventricular septal defect, and double coronary bypass grafting. Postoperatively there were no murmurs. Cardiac output was excellent for 36 hours, during which time all ventilatory support was discontinued. Subsequently, malignant ventricular arrhythmias appeared which responded transiently to cardioversion and antiarrhythmic drugs. Despite a satis-
factory surgical repair and revascularization, the patient died of refractory ventricular arrhythmias 72 hours postoperatively.
Discussion
Advances in cardiopulmonary bypass technique and the development of devices to assist compromised circulation have led to an increasingly aggressive approach to the acute mechanical complications of myocardial infarction. Temporary circulatory assist devices have stabilized the condition of these patients preoperatively and have provided vital support during the low cardiac output states in the early postoperative interval. !I-12 The experience in these 3 patients, however, demonstrates that aggressive medical management of biventricular failure can forestall surgical treatment and enable cardiac catheterization to be successfully undertaken without the need of temporary circulatory assistance. When stabilization by such medical means is possible, the risk of surgical correction in the immediate postinfarction period can be reduced." 11, 13 There is difference of opinion concerning the optimal time for surgical intervention in such patients; previous reports recommend waiting from 6 weeks to 6 months after infarction.v" As in these 3 patients, when marginal compensation shows no further improvement on medical therapy or when critical deterioration occurs, prompt surgical intervention is required. Another important concept is the repair of all elements contributing to a compromise of cardiac function." 11. In Aorto-coronary bypass grafts for critically stenosed vessels supplying the remaining functional ventricular muscle, resection of the infarcted aneurysmal tissue, closure of the ventricular septal defect, and mitral valve replacement may be critical to successful management. Although correction of all of these pathological features enhances left ventricular performance,' 7. IS ventricular arrhythmias are not always successfully controlled, as in Case 3. In this patient, the anatomic problem was successfully corrected and the
Volume 70 Number 1 July, 1975
Surgical repair after acute myocardial infarction
hemodynamic outcome was satisfactory, but the man died due to severe ventricular arrhythmias. Patients with anterior or septal infarction associated with ventricular septal defect have a better chance of surviving after surgical repair than do those with posteroinferior infarctions and ventricular septal defect.2, 11 The posterior infarctions associated with acute ventricular septal defect are particularly lethal, both because infarctions of the ventricular septum and ventricular wall are more extensive and because the blood supply to the posterior papillary muscle is frequently compromised." The resultant severe acute mitral regurgitation superimposed on acute left ventricular injury frequently results in fatal left ventricular failure. Only ten posterior aneurysms were identified in one series of over 400 elective ventricular aneurysmectomies.w Since the patient with a posterior aneurysm frequently does not survive long enough for surgery to be undertaken, successful resection of posterior aneurysm is uncommon. Graham- reported operative deaths in 6 of 7 patients treated surgically for acute ventricular septal defect after posterior infarction. Daggett," in a series of 8 patients with inferior myocardial infarction and acute ventricular septal defect, used the intra-aortic balloon pump to support 5 of the patients preoperatively. Surgery resulted in closure of the ventricular septal defect in 4 of the 8 patients and in long-term survival in 3 of the 8 patients. The surgical technique outlined in Fig. 3 has resulted in satisfactory closure of the acute ventricular septal defect in all 3 patients. The total correction of all pathological lesions, resulting in long-term survival in 2 patients, underscores the need for early recognition and aggressive medical and surgical therapy when these mechanical defects complicate posterior infarctions. REFERENCES Sanders, R. J., Kern, W. H., and Blount, S. G.: Perforation of the Interventricular Septum Complicating Myocardial Infarction, Am. Heart J. 51: 736, 1956.
61
2 Graham, A. F., Stinson, E. B., Daily, P.O., and Harrison, D. C.: Ventricular Septal Defects After Myocardial Infarction, J. A. M. A. 225: 708, 1973. 3 Sanders, R. J., Neubuerger, K. D., and Ravin, A.: Rupture of Papillary Muscles: Recurrence of Rupture of Posterior Muscle in Posterior Myocardial Infarction, Chest 31: 316, 1957. 4 Cooley, D. A., Belmonte, B. A., Zeis, L. B., and Schnur, S.: Surgical Repair of Ruptured Interventricular Septum Following Acute Myocardial Infarction, Surgery 41: 930, 1957. 5 Austen, W. G., Sokol, D. M., DeSanctis, R. W., and Sanders, S. A.: Surgical Treatment of Papillary Muscle Rupture Complicating Myocardial Infarction, N. Engl. J. Med. 278: 1137, 1968. 6 Daicoff, G. R., and Rhodes, M. L.: Surgical Repair of Ventricular Septal Rupture and Ventricular Aneurysm, J. A. M. A. 203: 457, 1968. 7 Freeny, P. C., Schattenberg, T. T., Danielson, G. K., McGoon, D. c., and Greenberg, B. H.: Ventricular Septal Defect and Ventricular Aneurysm Secondary to Acute Myocardial Infarction, Circulation 43: 360, 1971. 8 Rawlins, M. D., Mendel, D., and Braimbridge, M. V.: Ventricular Septal Defect and Mitral Regurgitation Secondary to Myocardial Infarction, Br. Heart J. 34: 322, 1972. 9 Mundth, E. D., Buckley, M. J., Daggett, W. M., Sanders, C. A., and Austen, W. G.: Surgery for Complications of Myocardial Infarction, Circulation 45: 1279, 1972. 10 Buckley, M. J., Craver, J. M., Gold, H. K., Mundth, E. D., Daggett, W. M., and Austen, W. G.: Intra-aortic Balloon Pump Assist for Cardiogenic Shock After Cardiopulmonary Bypass, Circulation 47, 48: 90, 1973 (Suppl, III). 11 Buckley, M. J., Mundth, E. D., Daggett, W. M., Gold, H. K., Leinbach, R. C., and Austen, W. G.: Surgical Management of Ventricular Septal Defect and Mitral Regurgitation Complicating Acute Myocardial Infarction, Ann. Thorac. Surg. 16: 598, 1973. 12 Daggett, W. M., Mundth, E. D., Gold, H. K., Leinbach, R. C., Buckley, M. J., and Austen, W. G.: Early Repair of Ventricular Septal Defect Complicating Inferior Myocardial Infarction, Circulation 49, 50: 112, 1974 (Suppl, III). 13 Shumacker, H. B., Jr.: Suggestions Concerning Operative Management of Postinfarction Septal Defects. J. THORAC. CARDIOVASC. SURG. 64: 452, 1972. 14 Mallory, G. K., White, P. D., and Salcedo, S.: The Speed of Healing Myocardial Infarction: A Study of the Pathologic Anatomy in Two Cases, Am. Heart J. 18: 647, 1939.
62
Crosby et al.
15 Willman, V. L., Kaiser, G. C., and Barner, H. B.: Myocardial Infarction-Ventricular Septal Defect, Arch. Surg. 107: 275, 1973. 16 Barnhost, D. A.: Discussion of Willman, V. L., et al.l" 17 Ritter, E. R.: Intractable Ventricular Tachycardia Due to Ventricular Aneurysm With Surgical Care, Ann. Intern. Med, 71: 1155, 1969. 18 Herman, M. V., Heinle, R. A., Klein, M. D.,
The Journal of Thoracic and Cardiovascular Surgery
and Gorlin, R.: Localized Disorders in Myocardial Contraction Asynergy and Its Role in Congestive Heart Failure, N. Eng!. J. Med. 277: 222, 1967. 19 Heikkila, J.: Mitral Incompetence as a Complication of Acute Myocardial Infarction, Acta Med. Scand. (Suppl.) 475: 1, 1967. 20 Loop, F. D., Effler, D. B., Webster, J. S., and Groves, L. K.: Posterior Ventricular Aneurysms, N. Eng!. J. Med. 288: 237, 1973.
Ivan K. Crosby, M.B., B.S., F.R.C.S., F.A.C.C., Joseph M. Craver, M.D., * Richard S. Crampton, M.D., F.A.C.C., Joel P. Schrank, M.D., F.A.C.C., and Harry A. Wellons, M.D., F.A.C.C., Charlottesville, Va.
AlthOUgh acute ventricular septal defect, papillary muscle rupture, and left ventricular aneurysm infrequently complicate myocardial infarction, when they do occur they are usually associated with profound hemodynamic deterioration. The mortality rate within 24 hours after acute rupture of the interventricular septum is 25 per cent and rises to 93 per cent within 12 months of infarction. '· 2 Acute papillary muscle rupture secondary to myocardial infarction carries a 70 per cent mortality rate within the first 24 hours." Surgical repair of an acute ventricular septal defect after myocardial infarction was first attempted in 1956,4 and the first reported successful insertion of a prosthetic mitral valve for acute papillary muscle rupture was performed in 1965. 5 From the Departments of Thoracic and Cardiovascular Surgery and Internal Medicine, University of Virginia, Charlottesville, Va. Received for publication Jan. 29, 1975. Address for reprints: Dr. Ivan K. Crosby, Box 181, University of Virginia Medical Center, Charlottesville, Va. 22901. 'Current address: Carlyle Fraser Heart Center, Crawford W. Long Hospital of Emory University, Atlanta, Ga.
Subsequently, there have been over 100 reported cases of successful repair of either an acute ventricular septal defect or papillary muscle rupture. By contrast, repair of an acute ventricular septal defect and resection of an acute ventricular aneurysm has been reported far less frequently.v-" Repair of all these acute mechanical defects after myocardial infarction is rare. R This report describes resection of an acute true posterior aneurysm with repair of the acute ventricular septal defect in 3 patients within a month of myocardial infarction. At the time of surgical repair, 1 patient had concomitant mitral valve replacement, the second a coronary bypass graft, and the third a double coronary bypass procedure. All required surgical correction because of persistent biventricular failure. The technique of infarct resection and ventricular septal defect closure was the same in all 3 patients. Case reports CASE 1. A 62-year-old man entered a local hospital with an acute inferior infarction and
57
The Journal of
58
Crosby et al.
Thoroc ic and Cardiovascular Surgery
Fig. 1. In the left anterior oblique view, injection into the left ventricle (L. V .) shows the septal aneurysm and the ventricular septal defect (V.S.D .). RiV«, Right ventricle.
Fig. 2. In the right anterior oblique projection, the septal aneurysm and the mitral regurgi tation are well illustrated. pulmonary edema. A harsh holo systolic murmur, not present earlier, appeared at the lower left sternal border and apex on the second hospital day . Sudden cardiac asytole on the second hospital day responded to resuscitation, and he was transferred to the University Ho spital via a mobile coronary care unit while being supported by intravenous norepinephrine. Left ventricular angiography documented a large diaphragmatic and posterior septal aneurysm of the left ventricle, a small inferior ventricular septal defect, and mod er ate mitral regurgitation (Figs. 1 and 2, Table I) . Contractility of the anterior and lateral walls
was normal. Coronary angiography demonstrated tot al proximal occlusion of the right coronary artery with poor distal runoff and multiple 20 to 30 per cent ob structions in the left anterior descending and circumflex vessels. Bed rest, transvenous cardiac pacing, regulation of acid-base balance, and treatment with digit al is and diuretics temporaril y prevented further hemodynamic deterioration . Howev er, severe biventricular failure persisted , and on the twelfth hospital da y, 14 day s after the acute infarction, surgical correction was undertaken. The mitral valve was resected because of a ruptured papillary muscle , and a
Volume 70 Number 1 July, 1975
Surgical repair after acute myocardial infarction
59
A
B
#
.
l
)
Fig. 3. A, By rotation of the heart superiorly, the diaphragmatic surface, the posterior descending coronary artery, and the posterior areas of both the left and the right ventricles are displayed. The dotted area indicates the extent of the infarctectomy. B, Following infarctectomy, the perforations in the ventricular septum are easily visualized. C, The septum is sandwiched between strips of Teflon felt, as are the epicardial surfaces of both the left and the right ventricles. The area of infarctectomy and the ventricular septal defect are closed in a single suture line. D, The saphenous vein graft to the circumflex coronary artery is demonstrated in relationship to the infarctectomy suture line. Beall prosthesis was implanted . The diaphragmatic left ventricular aneurysm (12 by 6 crn.) was resected, and the small ventricular septa l defect was closed in the same suture line, which was buttressed with Teflon felt. The operative findings and the technique of surgical repair are demonstrated in Fig. 3. The partially stenotic coronary lesions did not warrant bypass grafting. When cardiopulmonary bypass was discont inued, the patient's cardiac performance required temporary inotropic support. His course was uneventful until the tenth postoperative da y, when atrial flutter requ ired cardioversion. The patient was discharged on the twenty-fourth postoperative day .
Seven months after the operation, he had no murmurs and was doing well on digitalis and oral diuretic therapy. CASE 2 . A 50-year-old hypertensive man entered a local emergency room for severe nausea, vomiting, and substernal pain . One week later, he returned in cardiogenic shock with pulmonary edema. A new holosystolic murmur was noted. He required metaraminol, frequent cardioversion for supraventricular tachyarrhythmias, and lidocaine for ventricular ectopy. He was transferred to the University of Virginia Hospital, and medical management of acidemia, arrhythmias, digitalis toxicity, and congestive heart failure was
60
The Journol of Thorocic ond Cordiovosculor Surgery
Crosby et al.
Table I. Cardiac catheterization data Parameter
LVP(mm. Hg) RVP(mm. Hg) PAP (mm. Hg) PCWP (mm. Hg) QP:QS ratio Cardiac index (L./min';sq. M.)
Case I
Case 2
Case 3
87/22 81/22 96/22 40/11 45/13 41/15 39/19 (26) 38/16 (24) 39/21 (24) a = 19 a = 21 a = 16 v = 29 v = 21 v = 21 (16) (17) (17) 4.0 1.3 3.0 2.2
2.2
1.8
Legend: LVP, Left ventricular pressure. RVP, Right ventricular pressure. PAP, Pulmonary artery pressure. PCWP, Pulmonary capillary wedge pressure. QP:QS, Pulmonarysystemic flow ratio.
initiated. Left ventricular angiography revealed a ventricular septal defect in the lower posterior muscular septum, normal contractility anteriorly and laterally, and no mitral regurgitation. There was a large biventricular posterior aneurysm. Coronary angiography revealed total occlusion of the right coronary artery and 90 per cent stenosis of the left circumflex artery (Table I). Three weeks after infarction, because biventricular failure had worsened and arrhythmias increased, surgery was undertaken. The patient tolerated induction of anesthesia poorly and required urgent cardiopulmonary assistance. A right and left posteroinferior aneurysm (10 by 15 em.) was resected, the ventricular septal defect was repaired, and the ventriculotomies were closed. A saphenous vein graft was inserted into the left circumflex coronary artery (Fig. 3). There were no murmurs postoperatively and the patient was discharged on the fourteenth postoperative day taking digoxin. Apart from intermittent paroxysmal atrial flutter, he has had a satisfactory course on digoxin, a diuretic, and quinidine for the 11 months since his operation. CASE 3. A 71-year-old man entered a local hospital with an acute inferior myocardial infarction and advanced atrioventricular block. On the fourth hospital day he sustained a left hemiparesis; on the seventh day, the infarction extended; and on the tenth day a loud systolic murmur appeared. Left ventricular angiography revealed a posterior aneurysm and a ventricular septal defect (Table I). One month after infarction he underwent resection of the posterior infarct, closure of the ventricular septal defect, and double coronary bypass grafting. Postoperatively there were no murmurs. Cardiac output was excellent for 36 hours, during which time all ventilatory support was discontinued. Subsequently, malignant ventricular arrhythmias appeared which responded transiently to cardioversion and antiarrhythmic drugs. Despite a satis-
factory surgical repair and revascularization, the patient died of refractory ventricular arrhythmias 72 hours postoperatively.
Discussion
Advances in cardiopulmonary bypass technique and the development of devices to assist compromised circulation have led to an increasingly aggressive approach to the acute mechanical complications of myocardial infarction. Temporary circulatory assist devices have stabilized the condition of these patients preoperatively and have provided vital support during the low cardiac output states in the early postoperative interval. !I-12 The experience in these 3 patients, however, demonstrates that aggressive medical management of biventricular failure can forestall surgical treatment and enable cardiac catheterization to be successfully undertaken without the need of temporary circulatory assistance. When stabilization by such medical means is possible, the risk of surgical correction in the immediate postinfarction period can be reduced." 11, 13 There is difference of opinion concerning the optimal time for surgical intervention in such patients; previous reports recommend waiting from 6 weeks to 6 months after infarction.v" As in these 3 patients, when marginal compensation shows no further improvement on medical therapy or when critical deterioration occurs, prompt surgical intervention is required. Another important concept is the repair of all elements contributing to a compromise of cardiac function." 11. In Aorto-coronary bypass grafts for critically stenosed vessels supplying the remaining functional ventricular muscle, resection of the infarcted aneurysmal tissue, closure of the ventricular septal defect, and mitral valve replacement may be critical to successful management. Although correction of all of these pathological features enhances left ventricular performance,' 7. IS ventricular arrhythmias are not always successfully controlled, as in Case 3. In this patient, the anatomic problem was successfully corrected and the
Volume 70 Number 1 July, 1975
Surgical repair after acute myocardial infarction
hemodynamic outcome was satisfactory, but the man died due to severe ventricular arrhythmias. Patients with anterior or septal infarction associated with ventricular septal defect have a better chance of surviving after surgical repair than do those with posteroinferior infarctions and ventricular septal defect.2, 11 The posterior infarctions associated with acute ventricular septal defect are particularly lethal, both because infarctions of the ventricular septum and ventricular wall are more extensive and because the blood supply to the posterior papillary muscle is frequently compromised." The resultant severe acute mitral regurgitation superimposed on acute left ventricular injury frequently results in fatal left ventricular failure. Only ten posterior aneurysms were identified in one series of over 400 elective ventricular aneurysmectomies.w Since the patient with a posterior aneurysm frequently does not survive long enough for surgery to be undertaken, successful resection of posterior aneurysm is uncommon. Graham- reported operative deaths in 6 of 7 patients treated surgically for acute ventricular septal defect after posterior infarction. Daggett," in a series of 8 patients with inferior myocardial infarction and acute ventricular septal defect, used the intra-aortic balloon pump to support 5 of the patients preoperatively. Surgery resulted in closure of the ventricular septal defect in 4 of the 8 patients and in long-term survival in 3 of the 8 patients. The surgical technique outlined in Fig. 3 has resulted in satisfactory closure of the acute ventricular septal defect in all 3 patients. The total correction of all pathological lesions, resulting in long-term survival in 2 patients, underscores the need for early recognition and aggressive medical and surgical therapy when these mechanical defects complicate posterior infarctions. REFERENCES Sanders, R. J., Kern, W. H., and Blount, S. G.: Perforation of the Interventricular Septum Complicating Myocardial Infarction, Am. Heart J. 51: 736, 1956.
61
2 Graham, A. F., Stinson, E. B., Daily, P.O., and Harrison, D. C.: Ventricular Septal Defects After Myocardial Infarction, J. A. M. A. 225: 708, 1973. 3 Sanders, R. J., Neubuerger, K. D., and Ravin, A.: Rupture of Papillary Muscles: Recurrence of Rupture of Posterior Muscle in Posterior Myocardial Infarction, Chest 31: 316, 1957. 4 Cooley, D. A., Belmonte, B. A., Zeis, L. B., and Schnur, S.: Surgical Repair of Ruptured Interventricular Septum Following Acute Myocardial Infarction, Surgery 41: 930, 1957. 5 Austen, W. G., Sokol, D. M., DeSanctis, R. W., and Sanders, S. A.: Surgical Treatment of Papillary Muscle Rupture Complicating Myocardial Infarction, N. Engl. J. Med. 278: 1137, 1968. 6 Daicoff, G. R., and Rhodes, M. L.: Surgical Repair of Ventricular Septal Rupture and Ventricular Aneurysm, J. A. M. A. 203: 457, 1968. 7 Freeny, P. C., Schattenberg, T. T., Danielson, G. K., McGoon, D. c., and Greenberg, B. H.: Ventricular Septal Defect and Ventricular Aneurysm Secondary to Acute Myocardial Infarction, Circulation 43: 360, 1971. 8 Rawlins, M. D., Mendel, D., and Braimbridge, M. V.: Ventricular Septal Defect and Mitral Regurgitation Secondary to Myocardial Infarction, Br. Heart J. 34: 322, 1972. 9 Mundth, E. D., Buckley, M. J., Daggett, W. M., Sanders, C. A., and Austen, W. G.: Surgery for Complications of Myocardial Infarction, Circulation 45: 1279, 1972. 10 Buckley, M. J., Craver, J. M., Gold, H. K., Mundth, E. D., Daggett, W. M., and Austen, W. G.: Intra-aortic Balloon Pump Assist for Cardiogenic Shock After Cardiopulmonary Bypass, Circulation 47, 48: 90, 1973 (Suppl, III). 11 Buckley, M. J., Mundth, E. D., Daggett, W. M., Gold, H. K., Leinbach, R. C., and Austen, W. G.: Surgical Management of Ventricular Septal Defect and Mitral Regurgitation Complicating Acute Myocardial Infarction, Ann. Thorac. Surg. 16: 598, 1973. 12 Daggett, W. M., Mundth, E. D., Gold, H. K., Leinbach, R. C., Buckley, M. J., and Austen, W. G.: Early Repair of Ventricular Septal Defect Complicating Inferior Myocardial Infarction, Circulation 49, 50: 112, 1974 (Suppl, III). 13 Shumacker, H. B., Jr.: Suggestions Concerning Operative Management of Postinfarction Septal Defects. J. THORAC. CARDIOVASC. SURG. 64: 452, 1972. 14 Mallory, G. K., White, P. D., and Salcedo, S.: The Speed of Healing Myocardial Infarction: A Study of the Pathologic Anatomy in Two Cases, Am. Heart J. 18: 647, 1939.
62
Crosby et al.
15 Willman, V. L., Kaiser, G. C., and Barner, H. B.: Myocardial Infarction-Ventricular Septal Defect, Arch. Surg. 107: 275, 1973. 16 Barnhost, D. A.: Discussion of Willman, V. L., et al.l" 17 Ritter, E. R.: Intractable Ventricular Tachycardia Due to Ventricular Aneurysm With Surgical Care, Ann. Intern. Med, 71: 1155, 1969. 18 Herman, M. V., Heinle, R. A., Klein, M. D.,
The Journal of Thoracic and Cardiovascular Surgery
and Gorlin, R.: Localized Disorders in Myocardial Contraction Asynergy and Its Role in Congestive Heart Failure, N. Eng!. J. Med. 277: 222, 1967. 19 Heikkila, J.: Mitral Incompetence as a Complication of Acute Myocardial Infarction, Acta Med. Scand. (Suppl.) 475: 1, 1967. 20 Loop, F. D., Effler, D. B., Webster, J. S., and Groves, L. K.: Posterior Ventricular Aneurysms, N. Eng!. J. Med. 288: 237, 1973.