This study evaluated outcomes of 26 patients who underwent surgical repair of post-myocardial infarction ventricular septal defect (VSD) at Nizams Institute of Medical Sciences between 1997-2012. 20 patients underwent VSD repair with concomitant coronary artery bypass grafting, while 6 had VSD closure alone. The mean time between MI and VSD appearance was 7.2 days, and between VSD appearance and surgery was 27.2 days. Overall in-hospital mortality was 30.9% and 30-day mortality was 33%. Patients who underwent emergency surgery within 3 days of MI had 100% mortality, while those operated on after 3 weeks had 100% survival. Concomitant CABG during VSD repair was associated with lower

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. 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. 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. 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. 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. 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. TABLE 1
.

8. 22
TABLE 2-VARIOUS RISK FACTORSTABLE 2-VARIOUS RISK FACTORS

9. TABLE 3-CATHETERISATION

10. TABLE 4-PATIENT PROFILE

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. TABLE 5-POST OP DATA

13. RESULTS

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. 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. 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. 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. 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. 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..

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24. STATISTICS