This case study examines outcomes of 26 patients who underwent surgical repair of a post-myocardial infarction ventricular septal defect (PMIVSD) over a 15-year period. 20 patients underwent defect closure with concomitant coronary artery bypass grafting (CABG), while 6 had defect closure alone. In-hospital mortality was 30.9%, with higher mortality seen in those with cardiogenic shock, posterior defects, and surgery over 3 weeks after infarction. 15 of the 20 patients who had CABG survived, compared to 3 of the 6 who had defect closure alone. Residual shunts occurred in 5 patients but did not require reoperation. Predictors of poor prognosis included cardiogenic shock, timing of surgery, and total

1. CASE STUDY
A STUDY OF POST MI VSD REPAIR BY INFARCT
EXCLUSION TECHNIQUE WITH OR WITHOUT
CONCOMITANT CABG
Presented by – Dr. Jyotindra Singh

2. INTRODUCTION
In the era before reperfusion therapy, septal rupture
complicated 1-3 % of acute myocardial infarctions.
Among the 41,021 patients in (GUSTO-I) trial, VSD was
suspected in 140 patients (0.34 %)
Chronic heart failure, coronary artery disease, and previous MI
lower the likelihood of ventricular septal rupture.
SHOCK Trial
– Rupture occurred at median of 16 hours after
infarction

3. Natural History
Post MI VSD Without Surgery
– 25% died within 24hrs
– 50% died within one week
– 65% died within 2 weeks
– 80% died within 4 weeks
– 7% lived longer than one year
HEROICS TRIAL

4. AIMS
Objective: Our primary aim was to evaluate the effect of
concomitant coronary artery bypass grafting (CABG) on post
operative results and also to identify prognostic indicators.
The time intervals from infarct to rupture and from rupture to
surgery were analysed.
This study evaluated our outcomes in today’s era of
percutaneous advances of postinfarction VSD closure.
Secondary purpose included an analysis of multivariate
predictors of in-hospital or 30-day mortality in this high risk
population.

5. Materials & Methods
Between March 1997 and April 2012, a total of 26 patients with
a diagnosis of postinfarction VSD were operated at Nizams
institute of medical science,Hyderabad.
Of these, 20 patients underwent VSD repair with concomitant
CABG procedure while 6 patients had VSD closure alone.
A preoperative transthoracic echocardiography and
catheterization study was done in all patients.
Counterpulsation with an intraaorticballoon pump (IABP), was
used in 18 out of 26 patients.

6. PATIENT PROFILE
0
5
10
15
20
CABG +VSD
VSD REPAIR
20
6
GROUP A-CABG+VSD CLOSURE
GROUP B- VSD REPAIR ALONE

7. TABLE 1
.
FEMALES
Column2
Column1
0
5
10
15
GROUP A GROUP B
8
4
12
2
PATIENT DETAILS CABG+ VSD CLOSURE VSD CLOSURE ONLY
Number of patients 20 6
AGE in years (Mean) 64(52-72.1) 61(49-68)
SEX(Female) 8/20 4/6
BMI 25.2 25.4
SMOKER 7/20 3/6
NYHA CLASS IV (%) 42% 26%

8. TABLE 2- RISK FACTORS
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
MI%
Grp-A
MI%
GRP-
B
55
30
2
RISK FACTORS GROUP A GROUP B
Previous MI % 55.2 30
Hypertension % 56.0 36.1
Hypercholestremia
%
50.3 17.4
Diabetes % 57.5 10.4
Renal dysfunction 11.4 11.5
Respiratory distress 28.2 21.3
CCF % 75.3 52.2

9. CATHETERISATION DETAILS
VESSELS INVOLVED
0
10
20
30
40
50
60
70
80
GROUP A
GROUP B
35
72
46
35
19
3
SINGLE
DOUBLE
TRIPLE

10. INVOLVED INFARCTED ARTERY
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
GROUP A GROUP B
LAD, 54.2
LAD, 62.2
45.8
37.8
Series 3
RCA
LAD

11. TABLE 3-CATHETERISATION

12. PRE OPERATIVE PATIENT PROFILE
ANTERIOR VSD 18
POSTERIOR VSD 8
PA mean (mm Hg) 34+/- 8
L-R shunt (ml) 56+/-20%
Time interval AMI-VSD (d) 7.2 ( 1 - 12 d)
Time interval VSD-OP (d) 27.2 ( 3 - 55d)
Time interval AMI-OP (d) 30 +/- 15days
IABP pre OP 18
Pre OP intubation 3
Pre OP thrombolysis 3
Pre OP cardiac Shock 6
TABLE 4-PATIENT PROFILE
0
2
4
6
8
10
12
14
16
18
18
8
PATIENT
PROFILE

13. OPERATIVE TECHNIQUE
A median sternotomy is performed
If concomitant coronary artery bypass is planned, the Vein graft or Internal
mammary artery was dissected at this point.
The pericardium is opened and the heart inspected for evidence of transmural
infarction.
Single or double venous cannulation can be used, with standard aortic cannulation
and full cardiopulmonary bypass is begun

14. OPERATIVE TECHNIQUE
An anterolateral left ventriculotomy
is made through the area of
infarction.
Stay sutures can be placed
through the edges of the
ventriculotomy to maintain an open
visual field.
The interventricular septum, area
of infarction, and site of rupture are
visualized.
The necrotic portion of the septum
is inspected .

15. Operative technique
A DACRON patch is brought onto the field
and first sewn to the basal and posterior
septum behind the defect using 3-0
polypropylene in a continuous running
fashion.
Sutures must be placed far from the infarct in
healthy muscle.
The patch is then sewn with full thickness
sutures to the anterolateral ventricular free
wall beyond the area of infarction, carefully
avoiding the muscle.
This completes closure of the left ventricular
chamber excluding the defect and infarcted
septum and ventriculotomy from the high
pressures generated by the left ventricle

16. Operative technique
Excess patch is trimmed off and the
ventriculotomy is closed using Teflon
strips sewn onto the ventricular wall
using interrupted full thickness
horizontal mattress sutures of 3-0
polypropylene .
The sutures are then tied, closing the
ventriculotomy .
This first row of sutures
reapproximates the muscle and
secures the Teflon to it.
A second double running layer is
placed incorporating the Teflon strips
and upper muscle layers to provide
strain relief and seal gaps.
.

17. POST-OP COMPLICATIONS
10
5
10
20
25
56
0
16 16
33
0
0
5
10
15
20
25
30
35
group a
group b
Column1

18. TABLE 5-POST OP DATA
GROUP A GROUP B
I A B P (%) 64% 73%
Duration of intra aortic balloon pump 46 (24-72) 26 (24-48)
Duration of inotrope support (h) 48 (24-96) 28 (24-48)
Re-exploration for bleeding (%) 10 6
Permanent stroke (%) 5 6
Permanent pacemaker (%) 10 16
Atrial fibrillation (%) 20 16.6
Renal failure (%) 25 33.3
Tracheostomy (%) 5 0
ICU (Days) 5 (4-8) 4 (4-6)
Post-operative length of stay (Days) 10 (6-12) 8 (7-10)

19. Patient outcome- Mortality rates
33.33
25
100
100
33
30.9
0 20 40 60 80 100 120
Anterior VSD
Posterior VSD
Emergency surgery -mortality
Surgery after 3 weeks-survival
30 days mortality
Hospital mortality
Series 3
Series 2
Series 1

20. GROUP A & GROUP B
MORTALITY
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
GROUP A
GROUP B
15
3
5
3

21. RESULTS

22. TO SUM UP
26 patients underwent surgical repair for a PMIVSD in NIMS during
March 1997and April 2012.
The number of female patients with PMIVSD- 12/26
Majority of the cases were single and double vessel diseases .
Mean duration between MI and appearance of VSD was 7.2 days (1-12 days) .
Time gap between VSD appearance and operation was 27.2 days.( 3- 55 days)
15 out of 20 patients survived in Group A compared to (3/6) in group B.
In hospital mortality was 30.9% while 30 days mortality was
33%.

23. RESULTS
The mortality of urgent repair within 3 days of intractable cardiogenic shock was
100% while 100% survival was seen who underwent surgery after 3 weeks of AMI .
Renal failure was the major cause of morbidity and mortality in post operative period.
Postoperative hospital stay in Group A was 10 days compared to 8 days in Group B.
Post operative 2D-Echo revealed residual shunts in 5 cases while none of the
patients required reoperation .
Predictors of poor prognosis included -cardiogenic shock,
-timing of surgery
- total occlusion of infarct related artery,
-Posterior versus anterior post-MI VSD
- poor preoperative (NYHA) status

24. Follow up
8 patients out of 26 died within 1 month of surgery.
5 patients were lost in serial follow up.
13 patients were followed up for 1 to 60months (mean 25 ).3 patients died from non
cardiac causes.
4 patients had pacemaker implantation within one month of surgery.
Of the patients, 92% were in NYHA class 1, and 8% in class 2.
4 patients had ventricular ectopics- not clinically significant or any sudden death.
5 patients had residual shunts not requiring surgery.
We did not find patients developing pulmonary hypertension late after surgery.
Pulmonary pressure neither diminished, nor progressed during follow-up.

25. Our experience/ Discussion
Poor preoperative indicators./ Outcomes of thrombolysis. (TACTICS TRIAL )
Rising trend of female patients and increased mortality in this group.
The safety of coronary angiography in these unstable patients.
Timing of surgery
Anterior vs Posterior VSD mortality.
High mortality rate- Is it acceptable??
Follow up strategy/ Residual shunts

27. Study profile, success rate, and outcome.
Thiele H et al. Eur Heart J 2009;30:81-88
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2008. For permissions please email: journals.permissions@oxfordjournals.org

28. Follow up
.Actuarial survival at 5 years for most recent series
generally ranges between 40% and 60%
Gaudiani et al
- 40 % over all hospital mortality rate
– 88% of hospital survivors were alive at 5 years
– 74% of survivors in NYHA functional class I and 21% of
survivors in class II
Davies et al
– 5-, 10-, and 14-year survivals of 69%, 50%, and 37%
– 82% patients were in NYHA functional class I or II

29. RESULTS

30. How to deal with residual shunt?
Residual Lt.  Rt. shunt
– Reported in up to 28% of
survivors
– Associated with high mortality
– Intra-operative TEE useful in
early detection and correction if
deemed necessary
– attributable to the
Reopening of a closed defect
Presence of an overlooked
VSD
Development of a new septal
perforation during the early
postoperative period

31. How to deal with residual shunt
Repair through Right
Atrium with Right
Thoracotomy on beating
heart technique
Reason:
 Redo surgery is complex
 High mortality and morbidity
Transcatheter closure
with the Amplatzer
septal occluder

32. REFERENCES
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infarct-related coronary artery inrupture of the ventricular septum after acute myocardial
infarction. Am J Cardiol 2000;85:497–9.
3. David TE: Operative management of postinfarction ventricular septal defect. Semin Thorac
Cardiovasc Surg 1995, 7:208-13.
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infarction ventricular

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