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Simple Geometrical Infarct Exclusion Technique With a Single Patch for Postinfarction Ventricular Septal Perforation
Simple Geometrical Infarct Exclusion Technique With a Single Patch for Postinfarction Ventricular Septal Perforation Toshiro Kobayashi, MD, Akihito Mikamo, MD, Ryo Suzuki, MD, Masanori Murakami, MD, Bungo Shirasawa, MD, and Kimikazu Hamano, MD Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University, Graduate School of Medicine, Yamaguchi, Japan
Six consecutive patients underwent emergency surgical repair of a postinfarction ventricular septal perforation. The principle of this technique is a simple three-dimensional repair with a nontailored square patch beforehand, which provides an adequate-sized pouch and prevents dehiscence of the patch being caused by excessive tension on the suture line. It also prevents a residual shunt. A single equine pericardium was sutured to the
viable muscle circumferentially around the infarcted area to be excluded, after which the free edge of the patch was tailored and sutured in a pouch configuration. This technique seems to provide satisfactory early results in the acute phase of myocardial infarction.
P
Under intra-aortic balloon pump driving, the average shock index (heart rate in beats per minute/systolic blood pressure in mm Hg) was 1.16 ⫾ 0.26 (0.8 to 1.6); therefore all 6 patients required emergency treatment [3].
Technique Patients Six consecutive patients underwent emergency surgery for a VSP within 1 week after the onset of an acute myocardial infarction (Tables 1a, 1b). There were 6 patients (2 women, aged 58 and 82 years; 4 men, aged 72 years [3 patients] and 71 years [1 patient]. All patients were admitted in cardiac failure (New York Heart Association functional class IV) after the ischemic event. All patients needed inotropic drug support and required intra-aortic balloon pump insertion. One patient had undergone percutaneous coronary intervention for a left anterior descending coronary artery lesion. Echocardiography confirmed an anterior rupture of the interventricular septum in 5 patients, and a posterior rupture in 1. Accepted for publication Aug 7, 2009. Address correspondence to Dr Hamano, Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University, Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, 755-8505, Japan; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Operative Technique The operation was performed by using a median sternotomy with cardiopulmonary bypass and mild systemic hypothermia with an arrest of the heart, using tepid blood cardioplegia. The defect was approached through a longitudinal left ventriculotomy in the infarcted area (approximately 1 to 2 cm away from the left anterior descending coronary artery in 5 patients, and from the right posterior descending artery in 1 patient with a posteroseptal infarction). The demarcation line between the infarction and the healthy myocardium was identified, and no infarcted tissue was excised. One side of a nontailored equine pericardium square was sutured to the viable muscle circumferentially around the infarcted area using running and interrupted mattress 3-0 polypropylene sutures that bordered the infarction and the healthy left ventricular septum and free wall (Fig 1). After suturing the patch to viable muscle, three sides of the patch were tailored and sewn in a pouch configuration, which was a little larger than and geometrically suited for the excluded ventricular volume (Fig 1). We then placed another small patch over the defect, using gelatinresorcin-formaldehyde (GRF) glue (Pharmacie Centrale; CHU Henri Mondor, Creteil, France). Closure was done in two layers, and the left ventriculotomy was closed with two felt strips (Fig 2). Finally, myocardial revascularization was done, if necessary. In the case of posterior postinfarction VSP, this surgical technique can be applied as previously described [4]. The 0003-4975/$36.00 doi:10.1016/j.athoracsur.2009.08.013
FEATURE ARTICLES
ostinfarction ventricular septal perforation (VSP) is a serious and life-threatening complication, which may be effectively repaired in the acute clinical phase by the infarction exclusion technique [1, 2]. However, the original infarction exclusion procedure presents a difficult technical decision concerning the size of the patch; if the two-dimensional patch is too small, excessive tension can be place on the suture line, resulting in dehiscence and a residual shunt. We describe our simple surgical technique for repairing a postinfarction VSP, which involves the creation of an adequate-sized pouch for infarction exclusion to minimize the residual shunt.
(Ann Thorac Surg 2010;89:2049 –52) © 2010 by The Society of Thoracic Surgeons
2050
HOW TO DO IT KOBAYASHI ET AL SIMPLE REPAIR OF A VSP
Ann Thorac Surg 2010;89:2049 –52
Table 1a. Patient Characteristics Age/Gender
Diagnosis
Risk Factors
Shock Indexa
Time Interval Onset of AMI to Operation (days)
1 2
58/Female 82/Female
Anteroseptal AMI, VSP Anteroseptal AMI, VSP
1.4 1.6
1 2
3 4
72/Male 72/Male
Anteroseptal AMI, VSP Anteroseptal AMI, VSP
1.3 1.1
2 5
5 6
72/Male 71/Male
Inferior AMI, VSP Anteroseptal AMI, VSP
HT HT DM Cerebral infarction HT DM HL HT DM
1.0 0.8
1 5
Case
a
Shock index ⫽ heart rate in beats per minute/systolic blood pressure in mm Hg. (Normal range, 0.5 to 0.7.)
AMI ⫽ acute myocardial infarction;
DM ⫽ diabetes mellitus;
HL ⫽ hyperlipidemia;
HT ⫽ hypertension;
VSP ⫽ ventricular septal perforation.
Table 1b. Additional Patient Characteristics Left Ventricular Ejection Fraction (%)
Qp/Qs
Coronary Angiography
1 2
40 50
5.5 Not measured
3 4 5
50 45 50
3.8 5.2 4.8
6
55
1.3
LAD #7 100% LAD #7 100%, Preoperative PCI to LAD #7 LAD #7 99%, D1 90% LAD #7 100% RCA #2 90%, LAD #6 90%, LCx #11 75% LAD #7 99%, RCA #13 99%
Case
FEATURE ARTICLES
D ⫽ diagonal branch; IABP ⫽ intra-aortic balloon pumping; LAD ⫽ left anterior descending coronary artery; ⫽ percutaneous coronary intervention; RCA ⫽ right coronary artery.
Fig 1. Repair of the ventricular septal perforation (anterior septum). (A) A patch of single equine pericardium was sutured to the viable muscle around the infarcted area, covering the infarcted left ventricular wall. On the septal and lower part of the intraventricular wall, the patch was secured with a 3-0 polypropylene running suture and reinforced with several interrupted mattress sutures. On the postero-inferior side, a Teflon felt patch (Kono Seisakusyo Co, Ltd, Tokyo, Japan) and several 3-0 polypropylene interrupted mattress sutures were brought from outside the heart to the free wall of the left ventricle inside the heart. (B) Schema of this procedure. (C) Both sides of the free edge of the patch were sutured to each other up from the suture lines in the muscle. The bottom of the patch was cut semicircularly and tailored into a pouch configuration. The pouch was larger than the excluded ventricular area. The two-dimensional patch was easily transformed into the three-dimensional pouch configuration. (D) Schema of this procedure.
Preoperative Cardiac Support IABP IABP IABP IABP IABP IABP
LCx ⫽ left circumflex artery;
PCI
Ann Thorac Surg 2010;89:2049 –52
HOW TO DO IT KOBAYASHI ET AL SIMPLE REPAIR OF A VSP
2051
operating room. Transthoracic echocardiography showed no major residual or recurrent shunt in 5 patients and a small residual shunt in 1 patient, which did not affect the hemodynamics. One patient died of colon cancer 3 months after the operation and the others were discharged from the hospital without any inotropic or mechanical support (Table 2).
Fig 2. Schema for cross-sectional imaging of this procedure. Another small patch was placed over the defect and secured with gelatinresorcin-formaldehyde (GRF) glue (Pharmacie Centrale, CHU Henri Mondor, Creteil, France). The ventriculotomy was closed using 2-0 polypropylene buttress sutures after placing a polyester felt strip (FPL 100; Matsuda Ika Kogyo, Tokyo, Japan) on either side of the incision, covering the free edge of the small patch over the defect, using GRF glue. (“xxx” indicates the part of the GRF glue application.)
left ventricle is entered posteriorly through an incision made parallel and adjacent to the posterior descending coronary artery. Nontailored equine pericardium is first sutured to the fibrous annulus of the mitral valve using interrupted mattress 3-0 polypropylene sutures with pledgets. The medial edge of the patch is then sutured to the noninfarcted muscle of the septum adjacent to the defect. Next, the lateral edge of the patch is sutured to the endocardium of the left ventricular free wall, adjacent to the posterior papillary muscle. This technique excludes all infarcted muscle from the left ventricular cavity. The following technique is similar to that used for an anterior VSP.
Results There was no operative death in our series and all patients were hemodynamically stable when they left the
Although the outcome of VSP has been improved remarkably by the infarction exclusion technique [1, 2], the shortcoming of the original procedure is the difficult technical decision concerning the size of the patch, because it necessitates the application of a two-dimensional patch on three-dimensional left ventricular geometry. As a result, a nongeometrical and too small a patch creates excessive tension on the suture line, resulting in patch dehiscence and a residual shunt. There are some reports that make up for this technical difficulty [5–7]. In these reports, the patch was tailored before it was sutured and it was attached to the left ventricle. Conversely, in our method, the patch was not tailored before being sutured and applied to the left ventricle, so we can tailor it freely to fit the left ventricular cavity. By using this technique, the surgeon can concentrate on the pitch and depth of the bites between the myocardium and the patch during suturing, without considering the final size of the patch. The length of the suture line is automatically determined by the size of the infarcted area to be excluded. The surplus area of the patch is cut and sewn according to the excluded left ventricular volume, so it is easy to make a new endocardial pouch, which is geometrically suited for, and a little larger than the excluded ventricular volume. Moreover, this technique can be applied similarly for a posterior VSP, with no geometrical distortion by exposure. Thereby, our technique resolves the original technical difficulties reported by some surgeons. This modified exclusion technique can theoretically prevent excessive tension on the suture line and subsequent dehiscence of the patch with a residual shunt. Moreover, to reinforce the VSP, we also placed the excised surplus patch over the VSP using GRF glue (Pharmacie Centrale), as described by Musumeci and colleagues [8]. The possible toxic effect of formaldehyde on the myocardium and the risk of contamination to the circulation was also
Table 2. Postoperative Results Case 1 2 3 4 5 6
Postoperative Complication None PM implantation (SSS) Colon cancer None None None
NYHA ⫽ New York Heart Association functional class;
Residual Shunt None None None Qp/Qs ⫽ 1.2 None None
Late Functional Status (NYHA)
Outcome
I II II I I I
Alive Alive Death (colon cancer) Alive Alive Alive
PM implantation ⫽ permanent pacemaker implantation;
SSS ⫽ sick sinus syndrome.
FEATURE ARTICLES
Comment
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HOW TO DO IT KOBAYASHI ET AL SIMPLE REPAIR OF A VSP
addressed by Musumeci and colleagues [8]; however, they did not observe any side effect of formaldehyde, and neither did we; therefore, we believe that the reinforcement using GRF glue is another surgical option for the repair of a VSP. Alternate glues, such as fibrin [9] and cyanoacrylate [10], may also be useful to adhere the patch to the septal wall because this additional patch is a supplemental option that is not essential for this technique. Theoretically, our modification may alleviate excessive restriction and late left ventricular expansion, protecting pouch configuration patch-plasty of the infarcted left ventricular wall. Our experience, although limited to 6 patients, demonstrates clearly that this technique is a feasible option for the early surgical management of this difficult group of patients. Thus, we conclude that this technique is simple and safe to perform in the acute phase of myocardial infarction.
References 1. David TE, Dale L, Sun Z. Postinfarction ventricular septal rupture: repair by endocardial patch with infarct exclusion. J Thorac Cardiovasc Surg 1995;110:1315–22.
Ann Thorac Surg 2010;89:2049 –52
2. Komeda M, Fremes SE, David TE. Surgical repair of postinfarction ventricular septal defect. Circulation 1990;82(5 Suppl): IV243–7. 3. Rady MY, Smithline HA, Blake H, Nowak R, Rivers E. A comparison of the shock index and conventional vital signs to identify acute, critical illness in the emergency department. Ann Emerg Med 1994;24:685–90. 4. Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB. Postinfarction ventricular septal defect. In: Cardiac Surgery. 3rd ed, vol 1. Pennsylvania: Churchill Livingston; 2003:456 –71. 5. Matsuda K, Oda T, Terai H, Hanyu M, Ban T. New surgical technique for repair of ventricular septal perforation. Ann Thorac Surg 1995;60:1430 –1. 6. Shibata T, Suehiro S, Ishikawa T, Hattori K, Kinoshita H. Repair of postinfarction ventricular septal defect with joined endocardial patches. Ann Thorac Surg 1997;63:1165–7. 7. Fujiwara H, Sugano T, Someya T. Repair of postinfarction ventricular septal rupture with a tailored, 3-dimensional patch. Tex Heart Inst J 2004;31:69 –71. 8. Musumeci F, Shukla V, Mignosa C, Casali G, Ikram S. Early repair of postinfarction ventricular septal defect with gelatin-resorcin-formol biological glue. Ann Thorac Surg 1996; 62:486 – 8. 9. Tabuchi N, Tanaka H, Arai H, et al. Double-patch technique for postinfarction ventricular septal perforation. Ann Thorac Surg 2004;77:342–3. 10. Lachapelle K, deVarennes B, Ergina PL, Cecere R. Sutureless patch technique for postinfarction left ventricular rupture. Ann Thorac Surg 2002;74:96 –101.
FEATURE ARTICLES
Six consecutive patients underwent emergency surgical repair of a postinfarction ventricular septal perforation. The principle of this technique is a simple three-dimensional repair with a nontailored square patch beforehand, which provides an adequate-sized pouch and prevents dehiscence of the patch being caused by excessive tension on the suture line. It also prevents a residual shunt. A single equine pericardium was sutured to the
viable muscle circumferentially around the infarcted area to be excluded, after which the free edge of the patch was tailored and sutured in a pouch configuration. This technique seems to provide satisfactory early results in the acute phase of myocardial infarction.
P
Under intra-aortic balloon pump driving, the average shock index (heart rate in beats per minute/systolic blood pressure in mm Hg) was 1.16 ⫾ 0.26 (0.8 to 1.6); therefore all 6 patients required emergency treatment [3].
Technique Patients Six consecutive patients underwent emergency surgery for a VSP within 1 week after the onset of an acute myocardial infarction (Tables 1a, 1b). There were 6 patients (2 women, aged 58 and 82 years; 4 men, aged 72 years [3 patients] and 71 years [1 patient]. All patients were admitted in cardiac failure (New York Heart Association functional class IV) after the ischemic event. All patients needed inotropic drug support and required intra-aortic balloon pump insertion. One patient had undergone percutaneous coronary intervention for a left anterior descending coronary artery lesion. Echocardiography confirmed an anterior rupture of the interventricular septum in 5 patients, and a posterior rupture in 1. Accepted for publication Aug 7, 2009. Address correspondence to Dr Hamano, Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University, Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, 755-8505, Japan; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Operative Technique The operation was performed by using a median sternotomy with cardiopulmonary bypass and mild systemic hypothermia with an arrest of the heart, using tepid blood cardioplegia. The defect was approached through a longitudinal left ventriculotomy in the infarcted area (approximately 1 to 2 cm away from the left anterior descending coronary artery in 5 patients, and from the right posterior descending artery in 1 patient with a posteroseptal infarction). The demarcation line between the infarction and the healthy myocardium was identified, and no infarcted tissue was excised. One side of a nontailored equine pericardium square was sutured to the viable muscle circumferentially around the infarcted area using running and interrupted mattress 3-0 polypropylene sutures that bordered the infarction and the healthy left ventricular septum and free wall (Fig 1). After suturing the patch to viable muscle, three sides of the patch were tailored and sewn in a pouch configuration, which was a little larger than and geometrically suited for the excluded ventricular volume (Fig 1). We then placed another small patch over the defect, using gelatinresorcin-formaldehyde (GRF) glue (Pharmacie Centrale; CHU Henri Mondor, Creteil, France). Closure was done in two layers, and the left ventriculotomy was closed with two felt strips (Fig 2). Finally, myocardial revascularization was done, if necessary. In the case of posterior postinfarction VSP, this surgical technique can be applied as previously described [4]. The 0003-4975/$36.00 doi:10.1016/j.athoracsur.2009.08.013
FEATURE ARTICLES
ostinfarction ventricular septal perforation (VSP) is a serious and life-threatening complication, which may be effectively repaired in the acute clinical phase by the infarction exclusion technique [1, 2]. However, the original infarction exclusion procedure presents a difficult technical decision concerning the size of the patch; if the two-dimensional patch is too small, excessive tension can be place on the suture line, resulting in dehiscence and a residual shunt. We describe our simple surgical technique for repairing a postinfarction VSP, which involves the creation of an adequate-sized pouch for infarction exclusion to minimize the residual shunt.
(Ann Thorac Surg 2010;89:2049 –52) © 2010 by The Society of Thoracic Surgeons
2050
HOW TO DO IT KOBAYASHI ET AL SIMPLE REPAIR OF A VSP
Ann Thorac Surg 2010;89:2049 –52
Table 1a. Patient Characteristics Age/Gender
Diagnosis
Risk Factors
Shock Indexa
Time Interval Onset of AMI to Operation (days)
1 2
58/Female 82/Female
Anteroseptal AMI, VSP Anteroseptal AMI, VSP
1.4 1.6
1 2
3 4
72/Male 72/Male
Anteroseptal AMI, VSP Anteroseptal AMI, VSP
1.3 1.1
2 5
5 6
72/Male 71/Male
Inferior AMI, VSP Anteroseptal AMI, VSP
HT HT DM Cerebral infarction HT DM HL HT DM
1.0 0.8
1 5
Case
a
Shock index ⫽ heart rate in beats per minute/systolic blood pressure in mm Hg. (Normal range, 0.5 to 0.7.)
AMI ⫽ acute myocardial infarction;
DM ⫽ diabetes mellitus;
HL ⫽ hyperlipidemia;
HT ⫽ hypertension;
VSP ⫽ ventricular septal perforation.
Table 1b. Additional Patient Characteristics Left Ventricular Ejection Fraction (%)
Qp/Qs
Coronary Angiography
1 2
40 50
5.5 Not measured
3 4 5
50 45 50
3.8 5.2 4.8
6
55
1.3
LAD #7 100% LAD #7 100%, Preoperative PCI to LAD #7 LAD #7 99%, D1 90% LAD #7 100% RCA #2 90%, LAD #6 90%, LCx #11 75% LAD #7 99%, RCA #13 99%
Case
FEATURE ARTICLES
D ⫽ diagonal branch; IABP ⫽ intra-aortic balloon pumping; LAD ⫽ left anterior descending coronary artery; ⫽ percutaneous coronary intervention; RCA ⫽ right coronary artery.
Fig 1. Repair of the ventricular septal perforation (anterior septum). (A) A patch of single equine pericardium was sutured to the viable muscle around the infarcted area, covering the infarcted left ventricular wall. On the septal and lower part of the intraventricular wall, the patch was secured with a 3-0 polypropylene running suture and reinforced with several interrupted mattress sutures. On the postero-inferior side, a Teflon felt patch (Kono Seisakusyo Co, Ltd, Tokyo, Japan) and several 3-0 polypropylene interrupted mattress sutures were brought from outside the heart to the free wall of the left ventricle inside the heart. (B) Schema of this procedure. (C) Both sides of the free edge of the patch were sutured to each other up from the suture lines in the muscle. The bottom of the patch was cut semicircularly and tailored into a pouch configuration. The pouch was larger than the excluded ventricular area. The two-dimensional patch was easily transformed into the three-dimensional pouch configuration. (D) Schema of this procedure.
Preoperative Cardiac Support IABP IABP IABP IABP IABP IABP
LCx ⫽ left circumflex artery;
PCI
Ann Thorac Surg 2010;89:2049 –52
HOW TO DO IT KOBAYASHI ET AL SIMPLE REPAIR OF A VSP
2051
operating room. Transthoracic echocardiography showed no major residual or recurrent shunt in 5 patients and a small residual shunt in 1 patient, which did not affect the hemodynamics. One patient died of colon cancer 3 months after the operation and the others were discharged from the hospital without any inotropic or mechanical support (Table 2).
Fig 2. Schema for cross-sectional imaging of this procedure. Another small patch was placed over the defect and secured with gelatinresorcin-formaldehyde (GRF) glue (Pharmacie Centrale, CHU Henri Mondor, Creteil, France). The ventriculotomy was closed using 2-0 polypropylene buttress sutures after placing a polyester felt strip (FPL 100; Matsuda Ika Kogyo, Tokyo, Japan) on either side of the incision, covering the free edge of the small patch over the defect, using GRF glue. (“xxx” indicates the part of the GRF glue application.)
left ventricle is entered posteriorly through an incision made parallel and adjacent to the posterior descending coronary artery. Nontailored equine pericardium is first sutured to the fibrous annulus of the mitral valve using interrupted mattress 3-0 polypropylene sutures with pledgets. The medial edge of the patch is then sutured to the noninfarcted muscle of the septum adjacent to the defect. Next, the lateral edge of the patch is sutured to the endocardium of the left ventricular free wall, adjacent to the posterior papillary muscle. This technique excludes all infarcted muscle from the left ventricular cavity. The following technique is similar to that used for an anterior VSP.
Results There was no operative death in our series and all patients were hemodynamically stable when they left the
Although the outcome of VSP has been improved remarkably by the infarction exclusion technique [1, 2], the shortcoming of the original procedure is the difficult technical decision concerning the size of the patch, because it necessitates the application of a two-dimensional patch on three-dimensional left ventricular geometry. As a result, a nongeometrical and too small a patch creates excessive tension on the suture line, resulting in patch dehiscence and a residual shunt. There are some reports that make up for this technical difficulty [5–7]. In these reports, the patch was tailored before it was sutured and it was attached to the left ventricle. Conversely, in our method, the patch was not tailored before being sutured and applied to the left ventricle, so we can tailor it freely to fit the left ventricular cavity. By using this technique, the surgeon can concentrate on the pitch and depth of the bites between the myocardium and the patch during suturing, without considering the final size of the patch. The length of the suture line is automatically determined by the size of the infarcted area to be excluded. The surplus area of the patch is cut and sewn according to the excluded left ventricular volume, so it is easy to make a new endocardial pouch, which is geometrically suited for, and a little larger than the excluded ventricular volume. Moreover, this technique can be applied similarly for a posterior VSP, with no geometrical distortion by exposure. Thereby, our technique resolves the original technical difficulties reported by some surgeons. This modified exclusion technique can theoretically prevent excessive tension on the suture line and subsequent dehiscence of the patch with a residual shunt. Moreover, to reinforce the VSP, we also placed the excised surplus patch over the VSP using GRF glue (Pharmacie Centrale), as described by Musumeci and colleagues [8]. The possible toxic effect of formaldehyde on the myocardium and the risk of contamination to the circulation was also
Table 2. Postoperative Results Case 1 2 3 4 5 6
Postoperative Complication None PM implantation (SSS) Colon cancer None None None
NYHA ⫽ New York Heart Association functional class;
Residual Shunt None None None Qp/Qs ⫽ 1.2 None None
Late Functional Status (NYHA)
Outcome
I II II I I I
Alive Alive Death (colon cancer) Alive Alive Alive
PM implantation ⫽ permanent pacemaker implantation;
SSS ⫽ sick sinus syndrome.
FEATURE ARTICLES
Comment
2052
HOW TO DO IT KOBAYASHI ET AL SIMPLE REPAIR OF A VSP
addressed by Musumeci and colleagues [8]; however, they did not observe any side effect of formaldehyde, and neither did we; therefore, we believe that the reinforcement using GRF glue is another surgical option for the repair of a VSP. Alternate glues, such as fibrin [9] and cyanoacrylate [10], may also be useful to adhere the patch to the septal wall because this additional patch is a supplemental option that is not essential for this technique. Theoretically, our modification may alleviate excessive restriction and late left ventricular expansion, protecting pouch configuration patch-plasty of the infarcted left ventricular wall. Our experience, although limited to 6 patients, demonstrates clearly that this technique is a feasible option for the early surgical management of this difficult group of patients. Thus, we conclude that this technique is simple and safe to perform in the acute phase of myocardial infarction.
References 1. David TE, Dale L, Sun Z. Postinfarction ventricular septal rupture: repair by endocardial patch with infarct exclusion. J Thorac Cardiovasc Surg 1995;110:1315–22.
Ann Thorac Surg 2010;89:2049 –52
2. Komeda M, Fremes SE, David TE. Surgical repair of postinfarction ventricular septal defect. Circulation 1990;82(5 Suppl): IV243–7. 3. Rady MY, Smithline HA, Blake H, Nowak R, Rivers E. A comparison of the shock index and conventional vital signs to identify acute, critical illness in the emergency department. Ann Emerg Med 1994;24:685–90. 4. Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB. Postinfarction ventricular septal defect. In: Cardiac Surgery. 3rd ed, vol 1. Pennsylvania: Churchill Livingston; 2003:456 –71. 5. Matsuda K, Oda T, Terai H, Hanyu M, Ban T. New surgical technique for repair of ventricular septal perforation. Ann Thorac Surg 1995;60:1430 –1. 6. Shibata T, Suehiro S, Ishikawa T, Hattori K, Kinoshita H. Repair of postinfarction ventricular septal defect with joined endocardial patches. Ann Thorac Surg 1997;63:1165–7. 7. Fujiwara H, Sugano T, Someya T. Repair of postinfarction ventricular septal rupture with a tailored, 3-dimensional patch. Tex Heart Inst J 2004;31:69 –71. 8. Musumeci F, Shukla V, Mignosa C, Casali G, Ikram S. Early repair of postinfarction ventricular septal defect with gelatin-resorcin-formol biological glue. Ann Thorac Surg 1996; 62:486 – 8. 9. Tabuchi N, Tanaka H, Arai H, et al. Double-patch technique for postinfarction ventricular septal perforation. Ann Thorac Surg 2004;77:342–3. 10. Lachapelle K, deVarennes B, Ergina PL, Cecere R. Sutureless patch technique for postinfarction left ventricular rupture. Ann Thorac Surg 2002;74:96 –101.
FEATURE ARTICLES