Surgical Technique
Repair of Postinfarction Ventricular Septal Rupture with a Tailored, 3-Dimensional Patch
Hitoshi Fujiwara, MD Takahiko Sugano, MD Takeshi Someya, MD
We modified the technique of patch repair for postinfarction ventricular septal rupture by beginning with a larger-than-needed circular patch and later trimming it into a 3dimensional patch to match the size of the exclusion area. This technique makes it easier to determine the optimal size for the patch, and the completed 3-dimensional shape fits well inside of the left ventricle. (Tex Heart Inst J 2004;31:69-71)
F
or the repair of postinfarction ventricular septal rupture, the infarct exclusion method with use of an endoventricular patch is very effective.1-3 This technique is intended to protect the area of acutely damaged myocardium. Accordingly, optimal sizing and complete lining inside the infarct area are crucial. We began using this technique in 1994 in patients who had an acute ventricular septal rupture; however, we had some difficulty in determining the optimal patch size. Therefore, we decided to try sewing a larger circular patch at the beginning of the procedure and trimming the surplus later to make a 3-dimensional patch.
Surgical Technique
Key words: Bioprosthesis; cardiac surgical procedures/ methods; equine patch, pericardial/transplantation; heart rupture, postinfarction/surgery; heart ventricle; human; methods; myocardial infarction/ complications/surgery From: Department of Cardiovascular Surgery, Musashino Red Cross Hospital, Musashino-shi, Tokyo, 180-8610, Japan Address for reprints: Hitoshi Fujiwara, MD, Musashino Red Cross Hospital, 1-26-1 Kyonan, Musashino-shi, Tokyo, 180-8610, Japan E-mail:
[email protected] © 2004 by the Texas Heart ® Institute, Houston
Texas Heart Institute Journal
The basic concept of our technique is to construct a dome-shaped patch from the lower part of a cone as shown in Figure 1. The base of the cone is created from part of the circumference of a large circle (Fig. 1A). Then the top part of the cone is discarded, and the remaining top edge is sewn so that the patch becomes a dome (Fig. 1B). The operation is performed with the patient on cardiopulmonary bypass either during cardiac arrest or on a beating heart. A circular patch of approximately 10 cm in diameter is prepared. Typically, we use glutaraldehyde-preserved equine pericardium that is commercially available (Edwards Lifesciences Corporation; Irvine, Calif ). Its size is 10 cm square, and we trim it into a 10-cm-diameter circle before use. Since the area required for the repair is about half of this circle, a roughly semicircular patch of similar size will suffice. A ventriculotomy is made parallel to the left anterior descending coronary artery, through which the left ventricular cavity is inspected. The patch is sewn to the margin of the intact myocardium. The surgeon starts a 2-0 or 3-0 polypropylene running suture at the base of the heart and proceeds toward the apex on both the septal wall posterior to the rupture site and the lateral wall anterior to the anterior papillary muscle (Figs. 2A and 3A). The suture line is extended approximately halfway around the circular patch, according to the size of the area to be excluded. When the needles of the double-armed suture meet at the apex of the left ventricle, the suture is carefully tightened and tied (Fig. 3B). Then the surplus area is cut so that the height of the patch is similar to the distance between the suture line and the line of the ventriculotomy (Figs. 2B and 3C). The cut edge of the patch is sewn longitudinally into a 3-dimensional patch, which looks like a shallow dome (Figs. 2C and 3D). Reinforcing mattress sutures are added along the suture line if needed. The left ventricular incision is then closed over the patch with a 3-0 polypropylene suture, buttressed with strips of Teflon felt.
Patients and Results Since 1998, we have operated on 9 patients who had ventricular septal rupture after acute anteroseptal myocardial infarction. There were 3 women and 6 men, and their Tailoring a 3-D Patch for Postinfarction Ventricular Rupture
69
average age was 74 years. Generally, early repair was attempted, but a delay up to a few days was allowed for control of congestive heart failure. All patients were placed on intra-aortic balloon pumping (IABP) immediately upon the diagnosis of ventricular septal rupture; repair was performed an average of 2.5 days after diagnosis. The onset of septal rupture was difficult to ascertain, because 6 of the patients already had a systolic murmur on arrival at the hospital. The estimated interval between the onset of acute myocardial infarction (expressed as onset of chest pain or discomfort) and the repair of the ventricular septal rupture ranged from 2 to 14 days (average, 7.1 days). We used an equine pericardial patch in 7 patients and a Dacron patch in 2 patients. All 9 patients tolerated the surgery; however, 2 patients died postoperatively despite a successful operation. One of these patients died of sepsis 7 days after surgery, and the
A
B
Fig. 1 The concept of the tailor-made 3-dimensional patch is as follows: A) approximately half of a circle is used to make a cone. The area to be used (a) is automatically determined by the length of the suture line; B) the height is adjusted about halfway up the cone (arrow). The top portion is discarded, and the lower portion is sutured closed.
A
C
B
Fig. 2 Steps in the patch repair: A) a relatively large circular patch (P) is sewn from the base of the heart toward the apex; B) then the surplus is trimmed off, and the opening at the top of the remaining portion is closed so that the volume occupied by the patch fits that of the area to be excluded; C) the 3-dimensional patch (P) posterior to the septal rupture (R) is completed as shown. The myocardial incision is then closed over the patch.
70
Tailoring a 3-D Patch for Postinfarction Ventricular Rupture
other died of chronic respiratory failure 108 days after surgery. At the postoperative evaluation, 6 patients had no residual shunt detected by echocardiography. In the other 3 patients, a small residual shunt was detected: 1 patient experienced hypertensive episodes up to 200 mmHg during the early postoperative period, and the systolic murmur was detected a few days thereafter. All 3 patients with a residual shunt remained hemodynamically stable, and none required further repair. The 7 survivors were discharged from the hospital in good condition without any sign of heart failure.
Discussion Endoventricular patch repair has been found to be valuable for treatment of left ventricular aneurysm and postinfarction ventricular septal rupture,4 because this type of repair maintains the geometry of the left ventricle. In the original procedure, an oval-shaped patch was used. This procedure presented a difficult technical decision concerning the size of the patch that should be used in the acute phase of ventricular septal rupture, when the left ventricle is not yet distended (in most cases). If the 2-dimensional patch is too small, it can distort the original left ventricular geometry and decrease the ventricular volume. A better alternative might be a 3-dimensional repair, as described herein. The inner part of the left ventricle is normally a conical structure with tubular walls, or a revolving ellipse. Therefore, it would seem logical to cover the ruptured part of the ventricle with a patch of a similar configuration. Two technical modifications in endoventricular patch repair have been reported. Matsuda and colleagues5 advocated the use of a porcine pericardium tailored in a conical shape. Their methods provided good surgical visibility for suturing, but the size of the cone had to be determined beforehand. Shibata and co-authors6 described a technique with 2 bovine pericardial patches joined to make a single pouch. Our concept is similar to theirs with regard to the method of choosing the size of the patch; the difference is that we use a single patch. Surgeons using our method can concentrate on the pitch and depth of the bites between the myocardium and the patch as they begin suturing, without considering the final size of the patch. In so doing, the surgeon can achieve a better fit between the patch and the possibly friable myocardium. The length of the suture line is automatically determined by the size of the area to be excluded. For the repair of an anterior septal rupture, we have empirically chosen a circular patch of 10 cm in diameter. Since the final size of the dome-like patch becomes approximately 3.5 × 6 cm, about half the circumference of the circle is used along Volume 31, Number 1, 2004
Fig. 3 Intraoperative photographs viewed from the right side of the patient: A) the circular patch is being sewn to the myocardium; B) after the suture line on the myocardium is completed, C) the height of the patch is determined, and the surplus is removed; D) the top opening of the patch has been sewn longitudinally.
the suture line. The surplus area of the patch is removed according to the distance between the ventriculotomy and the suture line. When the remaining portion is sewn, a 3-dimensional patch is formed. The surgeon can modify the volume included by the patch at the time of trimming. This process minimizes changes in the left ventricular geometry. In conclusion, our technique for ventricular septal repair in cases of acute myocardial infarction is highly reproducible, and it enables surgeons to make a more appropriately sized patch than was previously possible.
5. Matsuda K, Oda T, Terai H, Hanyu M, Ban T. New surgical technique for repair of ventricular septal perforation. Ann Thorac Surg 1995;60:1430-1. 6. Shibata T, Suehiro S, Ishikawa T, Hattori K, Kinoshita H. Repair of postinfarction ventricular septal defect with joined endocardial patches. Ann Thorac Surg 1997;63:1165-7.
References 1. Cooley DA. Repair of the difficult ventriculotomy. Ann Thorac Surg 1990;49:150-1. 2. Komeda M, Fremes SE, David TE. Surgical repair of postinfarction ventricular septal defect. Circulation 1990;82(5 Suppl):IV243-7. 3. David TE, Dale L, Sun Z. Postinfarction ventricular septal rupture: repair by endocardial patch with infarct exclusion. J Thorac Cardiovasc Surg 1995;110:1315-22. 4. Cooley DA, Frazier OH, Duncan JM, Reul GJ, Krajcer Z. Intracavitary repair of ventricular aneurysm and regional dyskinesia. Ann Surg 1992;215:417-24.
Texas Heart Institute Journal
Tailoring a 3-D Patch for Postinfarction Ventricular Rupture
71
