post-infarction ventricular septal rupture and free wall rupture

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Post-infarction Ventricular Septal Rupture and Free Wall Rupture 서서서서서서 서서서서서서 서서서

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Post-infarction Ventricular Septal Rupture and Free Wall Rupture. 서울삼성병원 성균관대학교 김욱성. History of VSR. Latham First described at autopsy in 1845 Cooley First successful surgical repair in a patient after 9 weeks through RVtomy after VSR in 1956 Heimbecker,Allen,Woodwark,Iben - PowerPoint PPT Presentation

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Page 1: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Post-infarction Ventricular Septal Rupture and Free Wall

Rupture

서울삼성병원성균관대학교

김욱성

Page 2: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

History of VSR

LathamFirst described at autopsy in 1845

CooleyFirst successful surgical repair ina patient after 9 weeks throughRVtomy after VSR in 1956

Heimbecker,Allen,Woodwark,IbenSurgery for acute phase in the late1960s

Page 3: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

General Statistics

Incidence1-2% of AMI and 0.2% in thrombolytic era

5% of early deaths after MIMale : Female = 3 : 21 vessel (64%), 2 vessels (7%), 3 vessels

(29%)

Disease progressAverage time from infarction to rupture : 2 ~ 4 days (a few hours ~ 2 weeks)

: closer to 1 day in thrombolytic eraChronic VSR : more than 4 ~ 6 weeks

Page 4: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Pathogenesis

Hyaline degeneration Fragmentation Enzymatic digestion Fissure formation Septal rupture

VSR : AMI = 26% : 15% (LV wall)Simple, complexSingle, multiple (5-11%)

Page 5: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Pathophysiology

Heart failureSize of infarctionMagnitude of Lt. to Rt. shunt

Anterior septal rupture LV dysfunction

Posterior septal ruptureRV dysfunction

Page 6: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Pathophysiology

Page 7: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Diagnosis

History of AMI

Physical Examination and Monitoring

New systolic murmurAbrupt deterioration in hemodynamics

Imaging StudiesEcho: Gold standardCoronary angiographyLV catheterization : Not recommended

Page 8: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Natural Course

25% of pts : Died within first 24 hrs

50% of pts : Died within 1 week

65% of pts : Died within 2 week

80% of pts : Died within 4 week

7% of pts : Lived longer than 1 yr

Page 9: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Preoperative Management

IABPCardiac outputLt. to Rt. shuntCoronary Perfusion

MedicationsInotropicsDiureticsVasodilators (?)

Page 10: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Unusual Reference for IABP

Post-infarction ventricular septal defect: delayed closure

with prolonged mechanical circulatory support

Baillot et al. Ann Thorac Surg. 1983 Feb;35(2):138-42

: Surgery after IABP support for 19-25 days in 3 patients

Page 11: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Goal of Surgery

Exclusion or removal of infarcted myocardium

Elimination of Lt. to Rt. shunt

Page 12: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Resection of Infarcted Myocardium

Page 13: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Double Patch Repair of VSR

Balkanay et al. Tex Heart Inst J 2005;32:43-6

Page 14: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Double Patch Technique

MMCTS (April 25, 2005)

Page 15: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Infarction Exclusion

Page 16: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Repair of VSR with 3D Patch

Page 17: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Double Patch Technique

Page 18: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Infarct Exclusion Technique

Page 19: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Surgical Techniques

Three Patch Technique

Page 20: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Surgical Techniques

Three Patch Technique

Page 21: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Repair through Rt. Atrium

Massetti et al. (J Thorac Cardiovasc Surg 2000;119:784-9)

Page 22: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Closure of VSR on Beating Heart

Piotr Siondalski, Interactive CardioVascular and Thoracic Surgery 6 (2007) 160–162

Page 23: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Weaning from CPB

Bleeding

Low cardiac outputIABPMilrinone

RV failure (especially posterior VSR)Volume loadingInotropicsPGE-1NO gas

VAD

Page 24: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Free wall Rupture

Page 25: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

History of Free wall Rupture

William HarveyFirst described the free wall ruptu

re of the heart after AMI in 1647

Hatcher, FitzGibbon, MontegutFirst successful repairs in early 1

970s

Page 26: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Incidence

11% of AMI (VSR x 10)

Elderly women, first infarction, within 5 days

Ant. > Lat.

Simple versus complex (50:50)

Page 27: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Pathogenesis and Pathophysiology

Transmural MI

Infarct expansionAcute regional thinning and dilatation of infarct zone

Systemic HT, lack of collateral

After extensive hemorrhagic transformation of AMI

Page 28: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Pathogenesis and Pathophysiology

AcuteDeath in a few minutes

SubacuteSmaller tear, temporarily sealed by clot or fibrinous pericardial adhesions

Chronic False aneurysm

Page 29: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Diagnosis

Clinical picture of pericardial tamponade

EchocardiographyEffusion thickness > 10mmEcho-dense masses in the effusionVentricular wall defect

Page 30: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Natural History

Subacute Median survival : 8 Hours

Page 31: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Surgical Technique

Epicardial patching Direct suture

Debridement and patch closure

Infarct exclusion

Prêtre R, Ann Thorac Surg 2000;69:1342-5

Page 32: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Sutureless Tech.

Page 33: Post-infarction Ventricular Septal Rupture and Free Wall Rupture

Thank Youfor Your Attention!