| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
J Thorac Cardiovasc Surg 2006;132:1238-1239
© 2006 The American Association for Thoracic Surgery
Brief Communication |
Department of Cardiothoracic Surgery, The Ohio State University, Columbus, Ohio.
Received for publication May 18, 2006; accepted for publication June 27, 2006. * Address for reprints: Michael S. Firstenberg, MD, Division of Cardiothoracic Surgery, N846 Doan Hall, 410 W. 10th Avenue, The Ohio State University, Columbus, OH 43210. (Email: msfirst{at}gmail.com).
Post-infarction ventricular septal defects (PI-VSDs) represent a catastrophic complication after acute myocardial infarctions. Despite advances in surgical and postoperative management, operative mortality is still 10% to 60%.1
Furthermore, little has been written describing the options in managing the severe and often biventricular failure that is associated with PI-VSD and that is a significant factor influencing postoperative morbidity and mortality. We describe a patient with complex PI-VSD who, despite appropriate and prompt surgical management, required biventricular mechanical assist devices (biVADs) as a bridge to recovery.
A 53-year-old man was admitted to an outside hospital with vague abdominal symptoms and a presumed diagnosis of acute cholecystitis. Severe hypotension and a new murmur shortly developed. Echocardiography revealed a large posteroinferior PI-VSD. After the patient was urgently transferred to our medical center, cardiac catheterization revealed a complete right coronary artery occlusion with critical left anterior descending coronary artery and ramus diseases. Because the patient was in profound cardiogenic shock requiring multiple high-dose pressors and intraaortic counter pulsation, he was taken urgently to the operating room. Intraoperatively, the patient's heart was diffusely erythematous, and there was a large inferior wall infarct, an akinetic right ventricle, and severe mitral regurgitation from a ruptured papillary muscle. Transesophageal echocardiology demonstrated a 4 x 4-cm posteroinferior VSD extending to the annulus of the mitral valve. After standard bicaval cannulation, cardiopulmonary bypass, and antegrade and retrograde cardioplegic arrest, an incision was made parallel to the posterior descending artery. The defect was closed with a large bovine pericardial patch with pledgeted sutures through healthy-appearing tissue. Coronary artery bypass grafting was performed in the diseased vessels. A mechanical mitral valve was inserted using standard techniques. Secondary to severe intraoperative right ventricular failure, a right ventricular assist device (Abiomed 5000, Abiomed Inc, Danvers, Mass) was placed. However, with increasing right ventricular assist device flows, left to right shunting across a residual VSD increased. Because of the perceived technical and physiologic difficulties associated with attempts at closure, combined with worsening left ventricular function, a left ventricular assist device (Abiomed 5000) was placed. The patient was stabilized and weaned from bypass. His initial intensive care unit course was unremarkable as he was rapidly extubated and weaned from pharmacologic support. After several months of aggressive rehabilitation, the patient underwent explantation of his biVAD and residual VSD closure. The patient tolerated this procedure well, and after pharmacologic optimization of his chronic heart failure he was transferred to an outpatient rehabilitation facility. At 18 months post-infarction, the patient was well.
PI-VSDs complicate up to 0.02% of myocardial infarctions.2 Despite advances in the surgical care of these moribund patients, operative mortality still approaches 50% with major risks, including cardiogenic shock, renal failure, right and/or left ventricular failure, size of VSD, posterior/inferior locations, and residual VSD.3 Management consists of VSD closure, coronary artery bypass grafting as needed, and aggressive postcardiotomy and end-organ support. Residual shunts are found in up to 40% of patients. Operative repair is associated with mortality greater than 60%,4 which has prompted interest in percutaneous closure, but the role of these procedures is still undefined.5 In our case, the implantation of a biVAD served as a bridge to recovery. By minimizing associated postoperative end-organ damage with cardiac support, we allowed for physiologic recovery so the residual VSD could be successfully closed and the impact of the massive myocardial infarction and associated heart failure could be minimized. Limitations include the need for multiple procedures (ie, device weaning/explant), aggressive anticoagulation in a high-risk patient, and meticulous follow-up.
Right ventricular support is critical after the acute volume and pressure overload of a PI-VSD. Recovery may be unpredictable and prolonged, necessitating long-term biventricular support. Short-term univentricular options, such as intraaortic balloon pumps, extracorporeal membrane oxygenation, or left ventricular assist devices, are limited in right ventricle failure and residual shunting. A total artificial heart precludes native cardiac recovery and obligates transplantation; nevertheless, this may be an option with the appropriate resources and experience.
Biventricular mechanical support, as demonstrated in this complex case, should be considered a useful tool as a bridge to recovery in patients with PI-VSDs.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
