| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
J Thorac Cardiovasc Surg 2008;136:234-235
© 2008 The American Association for Thoracic Surgery
Letter to the Editor |
Cattedra di Cardiochirurgia, Università degli Studi di Milano, IRCCS MultiMedica, Milano, Italy
To the Editor:
We congratulate Gerola and colleagues1
for the outstanding results reported with biventricular free wall juxtaposition to secure postinfarction ventricular septal rupture (VSR) patch repair and would like to add a few comments.
Although not previously described with respect to the left ventricular free wall, right free wall plication over the septum for additional reinforcement of patch repair is conceptually similar and not an entirely new idea.2,3 We used the latter approach in a 60-year-old man in whom a modified infarct exclusion operation was performed to repair an anterior VSR with associated oozing-type left ventricular anterior free wall rupture (
Figure 1). The patient showed triple-vessel coronary disease and acute left ventricular failure (ejection fraction, 30%) with cardiogenic shock and was brought to the operating room on mechanical ventilation and intra-aortic balloon counterpulsation 19 hours after the onset of acute myocardial infarction (AMI). This interval also corresponds to the average time between AMI and rupture in patients developing cardiogenic shock.4 Operation was completed with associated saphenous bypass grafting to the circumflex territory, and the postoperative course was free of major complications. At the 6-month follow-up, the ejection fraction increased to 48% and the patient was in New York Heart Association class I.
|
but this approach allows the patch to be anchored to noninfarcted muscle with transmural sutures, whereas nondelayed surgery reduces the obvious impact of prolonged low cardiac output, rendering immediate repair less hazardous. In this respect, the SHOCK trial investigators reported an in-hospital mortality of 87% among patients with the triad AMI-VSR-cardiogenic shock, including patients managed conservatively or judged too sick for surgery, which further suggests a beneficial role of an aggressive strategy. Conversely, the advantages of left ventricular free wall juxtaposition, as advocated by the authors, are less clear. AMI extends to the anterolateral free wall to a variable degree, whereas the risks of residual cavity restriction are difficult to predict. The level of the papillary muscles is suggested as the proximal limit for safe free wall juxtaposition. However, the technique has also been applied for posterior VSR in 1 patient. This sounds controversial given that posterior VSR usually relates to AMI in the right coronary territory and involves the posterobasal septum. It is possible that the authors repaired a VSR secondary to AMI in the distal territory of an extensively developed left anterior descending artery (ie, distal to the apex and thus along the inferior interventricular groove) with anteroseptal and distal inferior necrosis.
We fully concur that free wall juxtaposition is useful to ensure a secure patch repair, but the technique is most appealing for right ventricular noninfarcted muscle. This strategy may help to successfully perform VSR repair with a more aggressive timing.
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 |
