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J Thorac Cardiovasc Surg 2008;136:233-234
© 2008 The American Association for Thoracic Surgery

Letter to the Editor

Reply to the Editor:

Luis R. Gerola

Gainesville, FL

I thank Dr Pocar for promoting a discussion about our article and technical proposition. In fact, the juxtaposition of the right free wall over the septum is not new and was applied for the first time by Boer and Boer in 1998;1Go they called it "septal stabilization."

The authors2,3Go cited by Dr Pocar made an intelligent association of 2 techniques, that is, septal stabilization1Go and infarction exclusion,4Go with good results.

In our study, we proposed the juxtaposition of both the right and left free walls over the septum, and this is the originality of the procedure. Perhaps it was not clear in our article, but the juxtaposition technique was proposed for anterior ventricular septal rupture, and for this reason we cited the anterior papillary muscle as a reference point to perform the left free wall juxtaposition with a lower risk of excessive left ventricular cavity reduction.

After this technique was applied in 4 patients with good results, posterior ventricular septal rupture was diagnosed in 1 patient with total occlusion of the right coronary artery. This patient had a clear posterior myocardial infarction and posterior ventricular septal rupture.

In this patient, we performed a ventriculotomy in the infarcted area in the posterior wall of the left ventricle. The juxtaposition of the free wall ventricles was done, juxtaposing the posterior free wall of the right ventricle with the posterior free wall of the left ventricle. Cava cannulation was performed, and the right atrium was opened to verify whether any stitch was accidentally in the posterior cusp of the tricuspid valve.

There is nothing controversial about applying the juxtaposition technique to treat posterior ventricular septal rupture. Of course, the anterior papillary muscle is not a reference point in the posterior region.

Although this technique can be used for posterior septal ventricular rupture, the juxtaposition of ventricular walls is more difficult and involves a minor area of juxtaposition.

As I said, we have observed only 1 case of posterior septal rupture, and since then, no patients with septal rupture have undergone operation. The real applicability of this technique for posterior rupture still remains to be defined.

Once again, we emphasize that the innovation of this technique is in the juxtaposition of both the right and left free walls over the septum, promoting the reinforcement of the ventricular septal rupture closure, exclusion of the infarcted area, and safety of ventricular cavity reduction.

I congratulate Dr Pocar and his team for the good surgical results obtained with their technique and thank you for the opportunity to clarify any doubts about our technical proposition.

References

  1. de Boer HD, de Boer WJ. Early repair of postinfarction ventricular septal rupture: infarct exclusion, septal stabilization and left ventricular remodeling. Ann Thorac Surg 1998;65:853-854.[Abstract/Free Full Text]
  2. Marimoto K, Taniguchi I, Miyasaka S, Aoki T, Kato I, Yamaga T. Infarction exclusion technique with transmural sutures for postinfarction ventricular septal rupture. Ann Thorac Cardiovasc Surg 2004;10:39-41.[Medline]
  3. Bayezid O, Turkay C, Golbasi I. A modified infarct exclusion technique for repair of postinfarction ventricular septal defect. Tex Heart Inst J 2005;32:299-302.[Medline]
  4. David TE, Dale L, Sun Z. Postinfarction ventricular septal rupture: repair by endocardial patch with infarct exclusion. J Thorac Cardiovasc Surg 1995;110:1315-1322.[Abstract/Free Full Text]




This Article
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Right arrow Myocardial infarction

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