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Post mi vsd

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Post mi vsd

  1. 1. MODERATOR::::::::::::::DR.MADAN presented by:Dr.JYOTINDRA SINGH CASE STUDY A STUDY OF POST MI VSD REPAIR BY INFARCT EXCLUSIONTECHNIQUE WITH OR WITHOUT CONCOMITANT CABG Dr.RAMESH CHANDRA MISHRA, Dr. M AMARESH RAO, Dr.PRAGATIKAPOOR,DR.RAMAKRISHNA, Dr.JYOTINDRA SINGH, Nizams Institute of Medical Sciences, Department of Cardiothoracic surgery,Hyderabad
  2. 2. INTRODUCTION Post infarction VSD is a defect in the ventricular septum that results from rupture of acutely infarcted myocardium. In 1847,Latham first described a PMI-VSD,but not until 1923 it was described clinically by BRUNN. 1957-Cooley and colleagues first reported surgical repair of PMIVSD. Even though most MIs involve some portion of the septal area,Even though most MIs involve some portion of the septal area, ventricular septal rupture is rare.ventricular septal rupture is rare. It occurs in only 1 to 2% of patients with acute MI, and it causesIt occurs in only 1 to 2% of patients with acute MI, and it causes early death in about 5% of post-MI patients.early death in about 5% of post-MI patients.
  3. 3. INTRODUCTION Chronic heart failure, coronary artery disease, and previous MIChronic heart failure, coronary artery disease, and previous MI increase the likelihood that collateral circulation will beincrease the likelihood that collateral circulation will be developed, and so lower the likelihood of ventricular septaldeveloped, and so lower the likelihood of ventricular septal rupture.rupture. Anterior septal rupture is caused by anterolateral infarctionAnterior septal rupture is caused by anterolateral infarction when 32% of the left ventricle and 10% of the right ventriclewhen 32% of the left ventricle and 10% of the right ventricle were infarcted.were infarcted. Posterior septal rupture is caused by inferoseptal infarction,Posterior septal rupture is caused by inferoseptal infarction, which results from occlusion of the dominant right coronarywhich results from occlusion of the dominant right coronary artery and occurs in the proximal half of the posterior septumartery and occurs in the proximal half of the posterior septum when 21% of the left ventricle and 31% of the right ventriclewhen 21% of the left ventricle and 31% of the right ventricle were infarcted.were infarcted.
  4. 4. INTRODUCTION The most frequent complications of acquired VSD are rapidlyThe most frequent complications of acquired VSD are rapidly progressing congestive heart failure, cardiogenic shock,progressing congestive heart failure, cardiogenic shock, hemorrhage, pulmonary edema, renal insufficiency,andhemorrhage, pulmonary edema, renal insufficiency,and eventual multiple organ failure; with these complications,eventual multiple organ failure; with these complications, mortality approaches50%.mortality approaches50%.. Debate as to whether coronary artery bypass grafting(CABG)Debate as to whether coronary artery bypass grafting(CABG) should be undertaken along with closure of the VSD has beenshould be undertaken along with closure of the VSD has been ongoing.ongoing. The time intervals from infarct to rupture and from rupture toThe time intervals from infarct to rupture and from rupture to surgery were analysed.surgery were analysed.
  5. 5. INTRODUCTION This study evaluated our outcomes in today’s era ofThis study evaluated our outcomes in today’s era of percutaneous advances of postinfarction VSD closure.percutaneous advances of postinfarction VSD closure. Secondary purpose included an analysis of multivariateSecondary purpose included an analysis of multivariate predictors of in-hospital or 30-day mortality in this highriskpredictors of in-hospital or 30-day mortality in this highrisk population.population. We reviewed our 5 year experience at the Nizams InstituteWe reviewed our 5 year experience at the Nizams Institute with the treatment of postinfarction VSD rupturewith the treatment of postinfarction VSD rupture
  6. 6. Materials & Methods Between March 1997 and April 2012, a total of 26 patients withBetween March 1997 and April 2012, a total of 26 patients with a diagnosis of postinfarction VSD were operated at Nizamsa diagnosis of postinfarction VSD were operated at Nizams institute of medical science,Hyderabad.institute of medical science,Hyderabad. Of these, 20 patients underwent VSD repair with concomitantOf these, 20 patients underwent VSD repair with concomitant CABG procedure while 6 patients had VSD closure alone.CABG procedure while 6 patients had VSD closure alone. A preoperative transthoracic echocardiography andA preoperative transthoracic echocardiography and catheterization study was done in all patients.catheterization study was done in all patients. Besides counterpulsation with an intraaorticballoon pumpBesides counterpulsation with an intraaorticballoon pump (IABP), no other mechanical assist devices were used(IABP), no other mechanical assist devices were used
  7. 7. TABLE 1 .
  8. 8. 22 TABLE 2-VARIOUS RISK FACTORSTABLE 2-VARIOUS RISK FACTORS
  9. 9. TABLE 3-CATHETERISATION
  10. 10. TABLE 4-PATIENT PROFILE
  11. 11. SURGICAL TECHNIQUE Following full cardiological assessment including echocardiography and coronaryFollowing full cardiological assessment including echocardiography and coronary angiography,angiography, patients were operated on through a median sternotomy.patients were operated on through a median sternotomy. After cardiopulmonary bypass was established the septal rupture was approachedAfter cardiopulmonary bypass was established the septal rupture was approached through the infarcted area of myocardium.through the infarcted area of myocardium. TheVSD was then patched using Dacron patch or simply buttressed with suturesTheVSD was then patched using Dacron patch or simply buttressed with sutures alone.alone. The ventriculotomy was then closed using pledgeted Teflon strips to support theThe ventriculotomy was then closed using pledgeted Teflon strips to support the suture line, with exclusion of the infarcted myocardium.suture line, with exclusion of the infarcted myocardium. Concomitant CABG was done in 20 cases out of 26 patients.Concomitant CABG was done in 20 cases out of 26 patients. Bypass was discontinued after which inotropes and IABP were used when indicatedBypass was discontinued after which inotropes and IABP were used when indicated to stabilise the patient in the immediate postoperative periodto stabilise the patient in the immediate postoperative period
  12. 12. TABLE 5-POST OP DATA
  13. 13. RESULTS
  14. 14. RESULTS Overall, 26 patients underwent surgical repair for a post-infarct VSD in NizamsOverall, 26 patients underwent surgical repair for a post-infarct VSD in Nizams Institute of medical sciences during March 1997and April 2012.Institute of medical sciences during March 1997and April 2012. Table 1 shows the a total of 18 patients underwent simultaneous procedure.Table 1 shows the a total of 18 patients underwent simultaneous procedure. Mean duration between MI and appearance of VSD was 7.2 days while time gapMean duration between MI and appearance of VSD was 7.2 days while time gap between VSD appearance and operation was 27.2 days.18 patients had prebetween VSD appearance and operation was 27.2 days.18 patients had pre operative IABP insertion.operative IABP insertion. 10 patients underwent re exploration for post operative bleeding in Group A as10 patients underwent re exploration for post operative bleeding in Group A as compared to 6 patients in Group B.compared to 6 patients in Group B. Five patients in group A had permanent stroke.Five patients in group A had permanent stroke.
  15. 15. RESULTS Duration of post hospital stay in Group A was 10 days compared to 8 days in GroupDuration of post hospital stay in Group A was 10 days compared to 8 days in Group B(Table-5).B(Table-5). Post operative 2D-Echo revealed residual shunts in 5 cases while none of thePost operative 2D-Echo revealed residual shunts in 5 cases while none of the patients required reoperation .patients required reoperation . 15 out of 20 patients survived in Group A compared to 50 % mortality (3/6) in group15 out of 20 patients survived in Group A compared to 50 % mortality (3/6) in group B.In hospital mortality was 30.9% while 30 days mortality was 33%.B.In hospital mortality was 30.9% while 30 days mortality was 33%. Rate of posterior VSD mortality was higher 37.5% compared to 29% in anterior VSD.Rate of posterior VSD mortality was higher 37.5% compared to 29% in anterior VSD. There was 100% mortality in patients who underwent emergency surgery within 3There was 100% mortality in patients who underwent emergency surgery within 3 days after AMI while 100% survival was seen who underwent surgery after 3 weeksdays after AMI while 100% survival was seen who underwent surgery after 3 weeks of AMI .of AMI .
  16. 16. DISCUSSION The study aims to study a relatively recent population who underwent post MI VSD surgicalThe study aims to study a relatively recent population who underwent post MI VSD surgical repair to examine preoperative high risk factors, the effect of simultaneous CABG on mid-termrepair to examine preoperative high risk factors, the effect of simultaneous CABG on mid-term survival and to assess risk factors for in-hospital mortality.survival and to assess risk factors for in-hospital mortality. The question of whether to perform bypass grafts at the same time as the VSD closure hasThe question of whether to perform bypass grafts at the same time as the VSD closure has remained largely unresolved over recent years.remained largely unresolved over recent years. The safety of coronary angiography in these unstable patients has been a concern.It has beenThe safety of coronary angiography in these unstable patients has been a concern.It has been shown that up to 4.5% of these patients can deteriorate haemodynamically duringshown that up to 4.5% of these patients can deteriorate haemodynamically during catheterisation .catheterisation . In our experience, coronary angiography did not adversely affect the clinical state of the patientsIn our experience, coronary angiography did not adversely affect the clinical state of the patients in our population. Often, it was useful not only in providing information about the coronaryin our population. Often, it was useful not only in providing information about the coronary arteries but also provided the opportunity to site an IABP.arteries but also provided the opportunity to site an IABP.
  17. 17. DISCUSSION In the last few years, an upward trend has been occurring in the number of female patientsIn the last few years, an upward trend has been occurring in the number of female patients with post-MI VSD, and increased mortality among these patients.with post-MI VSD, and increased mortality among these patients. A change in frequency of VSD location has been occurring; in the past, rupture was more likelyA change in frequency of VSD location has been occurring; in the past, rupture was more likely to involve anterior region of the left anterior descending artery basin, whereas recent datato involve anterior region of the left anterior descending artery basin, whereas recent data shows predominance in the inferior–posterior region.shows predominance in the inferior–posterior region. Despite intervention, operative mortality for post-MI VSD repair remains high (from 20% toDespite intervention, operative mortality for post-MI VSD repair remains high (from 20% to 40% by several studies40% by several studies Our 30-day mortality rate was comparable at 33%.Our 30-day mortality rate was comparable at 33%. Preoperative status of the patient has a bearing on prognosis.Preoperative status of the patient has a bearing on prognosis. Poor ventricular function , deteriorating cardiovascular status [9], cardiogenic shock[10], inferiorPoor ventricular function , deteriorating cardiovascular status [9], cardiogenic shock[10], inferior MI [10,11], increasing age ,and inotrope requirements have all been shown to be associatedMI [10,11], increasing age ,and inotrope requirements have all been shown to be associated with a poor prognosis.with a poor prognosis.
  18. 18. DISCUSSION The development of shock is the most important predictor of survival. Persistence of class IVThe development of shock is the most important predictor of survival. Persistence of class IV cardiogenic shock inPVSD is associated with 100% mortality [12].cardiogenic shock inPVSD is associated with 100% mortality [12]. These findings are in line with our results concerning emergency operation. Worst results wereThese findings are in line with our results concerning emergency operation. Worst results were observed in patients with lack of improvement hemodynamic status in spite the useof an IABP.observed in patients with lack of improvement hemodynamic status in spite the useof an IABP. A longer time between AMI and surgery favoured survival. Time period from AMI to VSDA longer time between AMI and surgery favoured survival. Time period from AMI to VSD seems to be a significantfactor of survival.seems to be a significantfactor of survival. It is clear that the higher mortality in patients operated on early is also due to the seriousnessIt is clear that the higher mortality in patients operated on early is also due to the seriousness of hemodynamic conditions which do not allow any delay in surgical treatment.of hemodynamic conditions which do not allow any delay in surgical treatment. Higher mortality reported in posterior VSD can either be related to greater technical difficultiesHigher mortality reported in posterior VSD can either be related to greater technical difficulties associated with surgical repair or to a higher incidence of right ventricular failure [17,18associated with surgical repair or to a higher incidence of right ventricular failure [17,18 Chronic VSD is easier to repair since the septum is well scarred and the patch can be securelyChronic VSD is easier to repair since the septum is well scarred and the patch can be securely sutured .sutured .
  19. 19. LIMITATIONS The main limitation of this study is theretrospective nature of our work.The main limitation of this study is theretrospective nature of our work. Moreover, our study population was smaller than multi-centre studies.Moreover, our study population was smaller than multi-centre studies. However,our single centre observation study has comparatively a relativeHowever,our single centre observation study has comparatively a relative large number of patients undergoing aPVSD reconstruction between 2007large number of patients undergoing aPVSD reconstruction between 2007 and 2012.and 2012. Thus, this study has the strength to show intuitional experiences in patientsThus, this study has the strength to show intuitional experiences in patients undergoing a PVSD reconstruction over a long periodundergoing a PVSD reconstruction over a long period..
  20. 20. REFERENCESREFERENCES 1.Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors,angiographic patterns, and1.Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors,angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction.outcomes in patients with ventricular septal defect complicating acute myocardial infarction. Circulation 2000;101:27–32.Circulation 2000;101:27–32. 2. Prêtre R, Rickli H, Ye Q, Benedikt P, TurinaMI. Frequency of collateral blood flow in the2. Prêtre R, Rickli H, Ye Q, Benedikt P, TurinaMI. Frequency of collateral blood flow in the infarct-related coronary artery inrupture of the ventricular septum after acute myocardialinfarct-related coronary artery inrupture of the ventricular septum after acute myocardial infarction. Am J Cardiol 2000;85:497–9.infarction. Am J Cardiol 2000;85:497–9. 3. David TE: Operative management of postinfarction ventricular septal defect. Semin Thorac3. David TE: Operative management of postinfarction ventricular septal defect. Semin Thorac Cardiovasc Surg 1995, 7:208-13.Cardiovasc Surg 1995, 7:208-13. 4. Hill JD, Stiles QR: Acute ischemic ventricular septal defect. Circulation 1989, 79(6 Pt 2):I112-4. Hill JD, Stiles QR: Acute ischemic ventricular septal defect. Circulation 1989, 79(6 Pt 2):I112- I115.I115. 5. Labrousse L, Choukroun E, Chevalier JM, Madonna F, Robertie F.Surgery for post infarction5. Labrousse L, Choukroun E, Chevalier JM, Madonna F, Robertie F.Surgery for post infarction ventricular septal defect (VSD): riskfactors for hospital death and long term results. Eur Jventricular septal defect (VSD): riskfactors for hospital death and long term results. Eur J Cardiothorac Surg 2002;21:725–31Cardiothorac Surg 2002;21:725–31 6. AndersonDR,Adams S,BhatA, Pepper JR. Post-infarction ventricular septal defect: the6. AndersonDR,Adams S,BhatA, Pepper JR. Post-infarction ventricular septal defect: the importance of site of infarction and cardiogenic shock on outcome. Eur J Cardiothorac Surgimportance of site of infarction and cardiogenic shock on outcome. Eur J Cardiothorac Surg 1989;3:554–7.1989;3:554–7. 7. Muehrcke DD, Daggett WM, Buckley MJ, Akins CW, HilgenbergAD, AustenWG. Post7. Muehrcke DD, Daggett WM, Buckley MJ, Akins CW, HilgenbergAD, AustenWG. Post infarction ventricularinfarction ventricular
  21. 21. HELLO– ANY QUESTIONSHELLO– ANY QUESTIONS Please share, I’ll appreciate all of your advice THANK YOU
  22. 22. THANK YOU
  23. 23. STATISTICS

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