Presentation for students

1. HRISTO RAHMAN 11/04/20
MECHANICAL COMPLICATIONS OF
CORONARY ARTERY DISEASE

2. 1. LEFT VENTRICULAR ANEURYSM
2. VENTRICULAR SEPTAL DEFECT
3. LEFT VENTRICULAR FREE WALL
RUPTURE
4. ISCHAEMIC MITRAL REGURGITATION

3. MECHANICAL COMPLICATIONS OF CORONARY ARTERY DISEASE
LEFT VENTRICULAR ANEURYSM
• POST-INFARCTION LV ANEURYSM IS WELL-DELINEATED TRANSMURAL FIBROUS
SCAR, VIRTUALLY DEVOID OF MUSCLE, IN WHICH CHARACTERISTIC TRABECULAR
PATTERN OF THE INNER SURFACE OF THE WALL HAS BEEN REPLACED BY
SMOOTH FIBROUS TISSUE
• IN SUCH AREAS, THE LV WALL IS UNUSUALLY THIN, AND BOTH INNER AND OUTER
SURFACES BULGE OUTWARD
• DURING SYSTOLE, THE INVOLVED LV WALL SEGMENTS ARE AKINETIC (WITHOUT
MOVEMENT) OR DYSKINETIC (PARADOXICAL MOVEMENT)
• JOHNSON ET AL. DEFINED ANEURYSM AS A LARGE SINGLE AREA OF INFARCTION
(SCAR) THAT CAUSES THE LV EJECTION FRACTION TO BE PROFOUNDLY
DEPRESSED (APPROX. 35%)

4. • INCIDENCE OF LV ANEURYSM
AFTER AMI HAS BEEN DECLINING
BECAUSE OF EARLY
INTERVENTIONAL THERAPIES
• 90% OF LV ANEURYSMS ARE
RESULT OF TRANSMURAL MI
SECONDARY TO ACUTE
OCCLUSION OF LAD
• PATIENTS DEVELOP ANEURYSM
(PSEUDOANEURYSM) AS EARLY
AS 48 HOURS AFTER MI
• MOST PATIENTS DEVELOP LV
ANEURYSMS WITHIN WEEKS
• APPROX. 2/3 OF PATIENTS WHO
DEVELOP LV ANEURYSM REMAIN
ASYMPTOMATIC
• 10-YEAR SURVIVAL RATE:
• - 90% FOR ASYMPTOMATIC
PATIENTS;
• - 50% FOR SYMTOMATIC
PATIENTS

5. RISK OF THROMBEMBOLISM IS
LOW
LONG-TERM ANTICOAGULATION IS
NOT RECOMMENDED UNLESS
THERE IS MURAL THROMBUS
MOST COMMON CAUSES OF
DEATH ARE:
-1. ARRHYTHMIAS (>40%);
-2. CHF (>30%);
-3. RECURRENT MI (>10%)

6. • DIAGNOSIS:
• -1. ECHOCARDIOGRAPHY;
• -2. THALLIUM IMAGING OR PET -
USEFUL IN DETERMINING THE
EXTENT OF ANEURYSM AND
VIABILITY OF ADJACENT
REGIONS
• INDICATIONS:
• -1. PATIENT SCHEDULED TO
UNDERGO CABG FOR
SYMTOMATIC CAD;
• -2. CONTAINED RUPTURE OF
FALSE ANEURYSM;
• -3. PATIENT WITH
THROMBEMBOLIC EVENT EVEN
DESPITE ANTICOAGULATION

8. SURGICAL REPAIR OR RESECTION
OF LV ANEURYSM IN CONJUNCTION
WITH CABG RESULTS IN:
-1. ANGINA RELIEF;
-2. RESOLUTION OF HF SYMPTOMS
* FOR MOST PATIENTS
5-YEAR
POSTOPERATIVE
SURVIVAL RATE - 60-
80%

9. LINEAR REPAIR OF LV ANEURYSM
SURGICAL VENTRICULAR RESTORATION
• SURGICAL RESECTION OF ANEURYSM AND RECONSTRUCTION OF NATIVE
VENTRICULAR GEOMETRIC SHAPE
• CPB WITH CARDIOPLEGIC ARREST/WITHOUT CARDIOPLEGIC ARREST IF
AORTIC VALVE IS COMPETENT
• ANEURYSM IS USUALLY RECOGNISED BY PARADOXICAL MOVEMENT OF THE
WALLS COMPARED WITH THE REST OF VIABLE LV MYOCARDIUM

10. LINEAR REPAIR
OF ANTERIOR LV
ANEURYSM

11. PATCH REPAIR OF LV ANEURYSM
SURGICAL VENTRICULAR RESTORATION
• SURGICAL RESECTION OF ANEURYSM AND RECONSTRUCTION OF NATIVE
VENTRICULAR GEOMETRIC SHAPE
• CPB WITH CARDIOPLEGIC ARREST/WITHOUT CARDIOPLEGIC ARREST IF AORTIC
VALVE IS COMPETENT
• ANEURYSM IS USUALLY RECOGNISED BY PARADOXICAL MOVEMENT OF THE
WALLS COMPARED WITH THE REST OF VIABLE LV MYOCARDIUM
• ANEURYSM IS OPENED, AND A PURSE-STRING FONTAN STITCH IS PLACED AT THE
JUNCTION OF THE VIABLE AND NON-VIABLE MYOCARDIUM
• DACRON OR BOVINE PERICARDIAL PATCH IS USED TO EXCLUDE ANEURYSM, AND
THE ANEURYSM IS CLOSED OVER THE PATCH

12. PATCH REPAIR OF ANTERIOR LV
ANEURYSM

13. MECHANICAL COMPLICATIONS OF CORONARY ARTERY DISEASE
VENTRICULAR SEPTAL DEFECT (VSD)
• POST-INFARCTION VENTRICULAR SEPTAL DEFECT (VSD) IS AN OPENING IN THE
VENTRICULAR SEPTUM RESULTING FROM RUPTURE OF ACUTELY INFARCTED
MYOCARDIUM
• OCCURS IN LESS THAN 1% OF PATIENTS AND IS ASSOCIATED WITH ACUTE LAD
OCCLUSION
• MORE COMMON IN MEN THAN IN WOMEN (3:2)
• VSD IS TYPICALLY MANIFESTED WITHIN 2-4 DAYS AFTER MI
• STILL CONSIDERED ACUTE VSD OCCURS IN THE FIRST 6 WEEKS AFTER MI
• DEFECT IS USUALLY APPROX. 1-2 CM. IN SIZE

14. • VSD IS USUALLY LOCATED IN
ANTERIOR OR APICAL ASPECT OF
THE VENTRICULAR SEPTUM
• IN 25% OF AFFECTED PATIENTS,
POSTERIOR VSD CAUSED BY
INFERIOR WALL MI DUE TO
OCCLUSION OF THE RCA
• FULL-THICKNESS MI IS
PREREQUISITE FOR VSD
FORMATION
• NEW LOUD SYSTOLIC MURMUR
AFTER MI
• ECHOCARDIOGRAPHY:
• -1. SIZE;
• -2. LOCATION;
• -3. DEGREE OF L2R SHUNT
• RIGHT-SIDED HEART
CATHETERISATION:
• - INCREASED O2 SATURATION IN
RV AND PULMONARY ARTERY

15. APPROX. 60% OF PATIENTS WITH
POSTINFARCTION VSD HAVE
SIGNIFICANT CAD IN UNRELATED
VESSEL
MORTALITY RATE IN UNTREATED
PATIENTS IS HIGH:
- 25% DIE WITHIN 24 HOURS FROM
REFRACTORY HF
PATIENTS WITH
POSTINFARCTION VDS SHOULD
UNDERGO IMMEDIATE LEFT-
SIDED HEART
CATHETERISATION TO
CHARACTERISE:
-1. DEGREE OF CAD;
-2. MAGNITUDE OF LV
DYSFUNCTION;
-3. DETECT ANY MITRAL
INSUFFICIENCY

16. VENTRICULAR SEPTAL DEFECT
SURGICAL REPAIR
• PATIENTS SHOULD BE TREATED EARLY WITH CLOSURE OF THE DEFECT AND
CONCOMITANT CABG
• 75% SURVIVAL RATE IN THE ABSENCE OF REFRACTORY HF AND
HAEMODYNAMIC INSTABILITY
• INFARCT EXCLUSION TECHNIQUE IS USED TO REPAIR VSD

17. ONE OF THE MOST TECHNICALLY CHALLENGING PROCEDURES IN CARDIAC
SURGERY
INFARCT EXCLUSION TECNIQUE IN VSD REPAIR
• LV IS OPENED LONGITUDINALLY ON THE INFARCT AND THE DEFECT EVALUATED
• MULTIPLE VSDs MAY BE PRESENT AND NECROTIC MYOCARDIUM IS DEBRIDED TO
VIABLE TISSUE
• PROSTHETIC DACRON OR BOVINE PERICARDIAL PATCH IS SUTURED TO LV SIDE
OF THE SEPTAL DEFECT AND BROUGHT OUT THROUGH VENTRICULOTOMY,
WHERE IT IS INCORPORATED INTO THE CLOSURE
• IN THIS METHOD, POSTERIOR ASPECT OF THE PATCH IS THUS ANCHORED TO THE
REMNANT VIABLE SEPTUM, AND ANTERIOR ASPECT IS INCORPORATED WITH THE
FREE VENTRICULAR WALL, FORMING THE NEO-INTERVENTRICULAR SEPTUM
• FELT STRIPS ARE USED TO BUTTRESS THE CLOSURE

18. INFARCT EXCLUSION TECHNIQUE IN VSD
REPAIR WITH PATCH FORMING NEO-
VENTRICULAR SEPTUM

19. INFARCT EXCLUSION TECHNIQUE IN ANTERIOR
VSD REPAIR WITH PATCH FORMING NEO-
VENTRICULAR SEPTUM

20. INFARCT EXCLUSION TECHNIQUE WITH ENDOCARDIAL
PATCH REPAIR OF ANTERIOR VSD

21. APICAL LV ANEURYSM AND APICAL VSD REPAIR
TECHNIQUE
CARDIAC APEX AMPUTATION AND
REPAIR

22. POSTERIOR VSD REPAIR
TECHNIQUE

23. POSTERIOR VSD ENDOCARDIAL PATCH REPAIR TECHNIQUE

24. IN BOTH GROUPS OF SURGICALLY
TREATED PATIENTS, AND WITH
TRANS-CATHETER CLOSURE,
TEMPORARY CIRCULATORY
SUPPORT CAN BE LIFE-SAVING:
-1. ECMO;
-2. VENTRICULAR-ASSIST DEVICE
(LVAD)
TRANS-CATHETER
CLOSURE OF POST-
INFARCTION VSD

25. MECHANICAL COMPLICATIONS OF CORONARY ARTERY DISEASE
ISCHAEMIC MITRAL REGURGITATION
• MITRAL REGURGITATION DUE TO ISCHAEMIC HEART DISEASE (IMR) IS MITRAL
REGURGITATION CAUSED BY ISCHAEMIC HEART DISEASE. THIS ENTITY MUST
NOT BE CONFUSED WITH MITRAL REGURGITATION FROM OTHER CAUSES
THAT COEXIST WITH ISCHAEMIC HEART DISEASE
• APPROX. 40% OF PATIENTS WHO SUSTAIN AMI DEVELOP CHRONIC IMR,
DETECTABLE BY ECHOCARDIOGRAPHY
• IN 3-4% OF CASES THE DEGREE OF MR IS MODERATE OR SEVERE

26. MECHANICAL COMPLICATIONS OF CORONARY ARTERY DISEASE
CHRONIC ISCHAEMIC MITRAL REGURGITATION
• ISCHAEMIC PAPILLARY MUSCLE DYSFUNCTION AND LV DILATATION
ASSOCIATED WITH MITRAL ANNULAR DILATATION AND RESTRICTION OF
POSTERIOR MITRAL LEAFLET
• THE OPERATION FOR CHRONIC IMR - ON ELECTIVE BASIS:
• CABG + MVP (PROSTHETIC RING)

27. E T I O L O G Y
I S C H A E M I C M I T R A L R E G U R G I T A T I O N
• CHRONIC ISCHAEMIC MR
IS CAUSED BY:
• COMBINATION OF:
• - RESTRICTED MOVEMENT OF
P2 & P3 SCALLOPS OF
POSTERIOR MITRAL VALVE
LEAFLET (PML) DUE TO
VENTRICULAR DILATATION
DISPLACING PAPILLARY
MUSCLES;
• - FUNCTIONAL DILATATION OF
MITRAL VALVE ANNULUS
C O M B I N A T I O N O F :
T Y P E I I I B + T Y P E I
R E S T R I C T E D
C L O S U R E
+
N O R M A L L E A F L E T
M O T I O N

29. E T I O L O G Y
I S C H A E M I C M I T R A L R E G U R G I T A T I O N
• ACUTE
ISCHAEMIC MR
IS USUALLY
CAUSED BY:
• - INFARCTED;
• - RUPTURED;
• - NON-RUPTURED
PAPILLARY
MUSCLE
T Y P E I I
E X C E S S
L E A F L E T
M O T I O N

30. MECHANICAL COMPLICATIONS OF CORONARY ARTERY DISEASE
ACUTE ISCHAEMIC MITRAL REGURGITATION
• PAPILLARY MUSCLE NECROSIS AND RUPTURE CAUSED BY
OCCLUSION OF OVERLYING EPICARDIAL ARTERIES THAT
GIVE RISE TO THE PENETRATING VESSELS, SUPPLYING
THE PAPILLARY MUSCLES
• POSTEROMEDIAL PAPILLARY MUSCLE IS AFFECTED 3-6
TIMES MORE OFTEN THAN ANTEROLATERAL PAPILLARY
MUSCLE, AND EITHER THE ENTIRE TRUNK OF THE
MUSCLE OR ONE OF THE HEADS TO WHICH CHORDAE
ATTACH MAY PARTIALLY OR TOTALLY RUPTURE

31. MITRAL PAPILLARY MUSCLE BLOOD
SUPPLY
Papillary muscles:
1. Anterolateral papillary muscle
(ALPM - anterolateral papillary
muscle):
- The ALPM has a single head and
receives its blood supply from the
circumflex coronary artery (LCx);
2. Postromedial papillary muscle
(PMPM):
- The PMPM usually has multiple
(usually 3) and receives its blood
supply from the right coronary
artery (RCA).

32. • PROMPT SURGICAL INTERVENTION
PROVIDES BEST CHANCE FOR
SURVIVAL
• PREDICTORS OF IN-HOSPITAL
MORTALITY:
• -1. CHF:
• -2. MULTIVESSEL CAD;
• -3. RENAL FAILURE
• EMERGENT SURGICAL
TREATMENT:
• CABG + MVR (PROSTHETIC VALVE)
• MITRAL REPAIR SHOULD NOT BE
ATTEMPED BECAUSE IT MAY NOT
BE FEASIBLE IN PAPILLARY
MUSCLE RUPTURE AND REQUIRES
PROLONGING CROSS-CLAMP TIME-
NOT RECOMMENDED IN ACUTE
CASES
• IN-HOSPITAL MORTALITY IN ACUTE
CASES - 50%

33. COMCOMITANT MITRAL VALVE REPLACEMENT & ANTERIOR LV ANEURYSM
REPAIR

34. OPERATIONS ON PATIENTS WITH
ACUTE MECHANICAL
COMPLICATIONS FROM MI ARE
CHALLENGING

35. HRISTO RAHMAN 11/04/20
SURGEONS HAVE
TO ANTICIPATE AND
BE PREPARED FOR
PLACEMENT OF LV
ASSIST DEVICE IF
PATIENT CANNOT
BE SEPARATED
FROM CPB