‘Double patch and glue’ technique for early repair of posterior post-infarction ventricular septal defect
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《血管的通路杂志》
Department of Cardio-Vascular Surgery, Hpital Haut-Levèque, Bordeaux Heart University Hospital, Avenue de Magellan, F. 33 604 Bordeaux-Pessac, France
Abstract
A surgical procedure that reduces the recurrence of post-infarction posterior ventricular septal defects is described. This technique is based on a double ventriculotomy without an infarctectomy, the use of two patches, and glue, which is applied between the two patches. Excellent results have been obtained in 18 consecutives patients with this simple and reliable technique.
Key Words: Post-infarction cardiac complications; Coronary disease
1. Introduction
Post-infarction ventricular septal defects (VSD) remain a surgically challenging procedure with a high rate of mortality and morbidity, which is attributable in part to the recurrence of the VSD. The recurrence is predominantly due to the friable post-infarction tissue combined with the difficulty of the surgical approach, especially for posterior VSD, and the complex morphology of the rupture. We present here a successful modified Daggetts's [1] technique that employs a double ventriculotomy, two patches, and glue, which is applied between the patches (Fig. 1). This modification allows the formation of a new solid septum. In our experience this method has been useful and effective for decreasing post operative recurrence of posterior, as well as anterior VSD, which consequently reduced surgical mortality [2].
2. Method
Patients were operated on via a median sternotomy with extracorporeal circulation and moderate hypothermia (28 to 33 °C). The cardiopulmonary bypass was established between both caval veins (with caval tapes) and the ascending aorta. Antegrade cold cardioplegia and topical cooling were used for myocardial protection. All operations were performed from 1 to 6 days (mean: 3.1 days) after the septal defect occurred.
The posterior face of the heart is exposed by lifting up the inferior caval vein tape and the apex of the heart with a pledget-stitch. The first ventriculotomy is performed on the right ventricle in the infarct area, getting as close as possible and parallel to the posterior descending artery. Once the exact position of the VSD and the septum is confirmed (Fig. 2A), then make the second incision through the other ventricle, parallel to the first one and as near as possible to the septum (Fig. 2B).
A Dacron patch is widely positioned over the VSD via each ventriculotomy, and sutured to the other patch with a continuous 3-0 polypropylene suture. Thus, each patch is used as a support for the suture on the other. Once the suture is finished, glue (GRF has been replaced since 1997 by Bioglue) is placed between the two patches to reinforce necrotic myocardium septal tissue, which is not resected (Fig. 2C).
Lastly, the ventriculotomies are closed using the usual technique of buttressing the suture lines with Teflon strips. Ideally the closure is done without tension, or reduction of ventricular cavities, which may require a prosthetic Dacron patch. Therefore, we prefer using the external part of the two patches for support of this suture, like a butterfly's wings, with two strips of felt reinforced by glue (in an endocardial and epicardial position) and interrupted U stitches (Fig. 2D). No VSD recurrence occurs in this series [2].
3. Comment
Despite the improvements in surgical techniques, closure of acute posterior post-infarction VSD is associated with a high incidence of failure and subsequent mortality due to the recurrence of the defect, which occurs in 10–25% of patients [3].
A few technical aspects regarding the described procedure need to be pointed out. The double patch technique with the glue is performed without an infarctectomy. Therefore, it avoids additional detrimental damage to the septum or the ventricular wall. Each patch makes the suturing easier and less prone to tear than pledgets, as performed in the classic Daggett's technique [1], because each patch is used as a support for the suture on the other. Another role for the second patch is to hold the glue. This permits the glue to homogenize, thus reinforcing and maintaining the friable septal tissue, which becomes dense and solid. Lastly, the patches are sutured very far from the necrosis. This excludes the main part of the infarcted septum, but also allows the glue to build a new septum ‘en bloc’ that is less prone to tear.
Difficulties in operative exposition and repair are usually advanced to explain the increased operative mortality of posterior VSD localization. The absence of VSD recurrence, confirms that the double ventriculotomy allows a better visualization of the surgical field with an easier and more reliable surgical repair. Since the right ventriculotomy is achieved through an infarcted area, any detrimental effect of the procedure on function remains hypothetical, and long-term follow-up [2] confirms this point.
The infarct exclusion method described by David [4] was also useful in reducing postoperative recurrence. However, we believe that even though it is distant from the infarcted tissue, a single continuous suture appears less safe than a trans-septal suture buttressed on both sides by the patches.
In our experience, the absence of recurrence in 18 consecutive patients with post-infarction posterior VSD treated with the double patch and glue technique could be an explanation for the observed decrease in mortality (7/18 patients) since this technique was first used. In the absence of any long-term detrimental effects, this technique can be recommended for the early repair of posterior post-infarction VSD.
References
Madsen JC, Dagget WM. Repair of post infarction ventricular septal defects. Semin Thorac Cardiovasc Surg 1998; 10:117–127.
Labrousse L, Choukroun E, Chevalier JM, Madonna F, Robertie F, Merlico F, Coste P, Deville C. Surgery for post infarction ventricular septal defect: risk factors for hospital death and long term results. Eur J Cardiothorac Surg 2002; 21:725–732.
Deja MA, Szostek J, Widenka K, Szafron B, Spyt TJ, Hickey MS, Sosnowski AW. Post infarction ventricular septal defect – can we do better. Eur J Cardiothoracic Surg 2000; 18:194–201.
David TE, Armstrong S. Surgical repair of post-infarction ventricular septal defect by infarct exclusion. Semin Thorac Cardiovasc 1998; 10:105–110.(Louis Labrousse, Laurent )
Abstract
A surgical procedure that reduces the recurrence of post-infarction posterior ventricular septal defects is described. This technique is based on a double ventriculotomy without an infarctectomy, the use of two patches, and glue, which is applied between the two patches. Excellent results have been obtained in 18 consecutives patients with this simple and reliable technique.
Key Words: Post-infarction cardiac complications; Coronary disease
1. Introduction
Post-infarction ventricular septal defects (VSD) remain a surgically challenging procedure with a high rate of mortality and morbidity, which is attributable in part to the recurrence of the VSD. The recurrence is predominantly due to the friable post-infarction tissue combined with the difficulty of the surgical approach, especially for posterior VSD, and the complex morphology of the rupture. We present here a successful modified Daggetts's [1] technique that employs a double ventriculotomy, two patches, and glue, which is applied between the patches (Fig. 1). This modification allows the formation of a new solid septum. In our experience this method has been useful and effective for decreasing post operative recurrence of posterior, as well as anterior VSD, which consequently reduced surgical mortality [2].
2. Method
Patients were operated on via a median sternotomy with extracorporeal circulation and moderate hypothermia (28 to 33 °C). The cardiopulmonary bypass was established between both caval veins (with caval tapes) and the ascending aorta. Antegrade cold cardioplegia and topical cooling were used for myocardial protection. All operations were performed from 1 to 6 days (mean: 3.1 days) after the septal defect occurred.
The posterior face of the heart is exposed by lifting up the inferior caval vein tape and the apex of the heart with a pledget-stitch. The first ventriculotomy is performed on the right ventricle in the infarct area, getting as close as possible and parallel to the posterior descending artery. Once the exact position of the VSD and the septum is confirmed (Fig. 2A), then make the second incision through the other ventricle, parallel to the first one and as near as possible to the septum (Fig. 2B).
A Dacron patch is widely positioned over the VSD via each ventriculotomy, and sutured to the other patch with a continuous 3-0 polypropylene suture. Thus, each patch is used as a support for the suture on the other. Once the suture is finished, glue (GRF has been replaced since 1997 by Bioglue) is placed between the two patches to reinforce necrotic myocardium septal tissue, which is not resected (Fig. 2C).
Lastly, the ventriculotomies are closed using the usual technique of buttressing the suture lines with Teflon strips. Ideally the closure is done without tension, or reduction of ventricular cavities, which may require a prosthetic Dacron patch. Therefore, we prefer using the external part of the two patches for support of this suture, like a butterfly's wings, with two strips of felt reinforced by glue (in an endocardial and epicardial position) and interrupted U stitches (Fig. 2D). No VSD recurrence occurs in this series [2].
3. Comment
Despite the improvements in surgical techniques, closure of acute posterior post-infarction VSD is associated with a high incidence of failure and subsequent mortality due to the recurrence of the defect, which occurs in 10–25% of patients [3].
A few technical aspects regarding the described procedure need to be pointed out. The double patch technique with the glue is performed without an infarctectomy. Therefore, it avoids additional detrimental damage to the septum or the ventricular wall. Each patch makes the suturing easier and less prone to tear than pledgets, as performed in the classic Daggett's technique [1], because each patch is used as a support for the suture on the other. Another role for the second patch is to hold the glue. This permits the glue to homogenize, thus reinforcing and maintaining the friable septal tissue, which becomes dense and solid. Lastly, the patches are sutured very far from the necrosis. This excludes the main part of the infarcted septum, but also allows the glue to build a new septum ‘en bloc’ that is less prone to tear.
Difficulties in operative exposition and repair are usually advanced to explain the increased operative mortality of posterior VSD localization. The absence of VSD recurrence, confirms that the double ventriculotomy allows a better visualization of the surgical field with an easier and more reliable surgical repair. Since the right ventriculotomy is achieved through an infarcted area, any detrimental effect of the procedure on function remains hypothetical, and long-term follow-up [2] confirms this point.
The infarct exclusion method described by David [4] was also useful in reducing postoperative recurrence. However, we believe that even though it is distant from the infarcted tissue, a single continuous suture appears less safe than a trans-septal suture buttressed on both sides by the patches.
In our experience, the absence of recurrence in 18 consecutive patients with post-infarction posterior VSD treated with the double patch and glue technique could be an explanation for the observed decrease in mortality (7/18 patients) since this technique was first used. In the absence of any long-term detrimental effects, this technique can be recommended for the early repair of posterior post-infarction VSD.
References
Madsen JC, Dagget WM. Repair of post infarction ventricular septal defects. Semin Thorac Cardiovasc Surg 1998; 10:117–127.
Labrousse L, Choukroun E, Chevalier JM, Madonna F, Robertie F, Merlico F, Coste P, Deville C. Surgery for post infarction ventricular septal defect: risk factors for hospital death and long term results. Eur J Cardiothorac Surg 2002; 21:725–732.
Deja MA, Szostek J, Widenka K, Szafron B, Spyt TJ, Hickey MS, Sosnowski AW. Post infarction ventricular septal defect – can we do better. Eur J Cardiothoracic Surg 2000; 18:194–201.
David TE, Armstrong S. Surgical repair of post-infarction ventricular septal defect by infarct exclusion. Semin Thorac Cardiovasc 1998; 10:105–110.(Louis Labrousse, Laurent )