Early Repair of Postinfarction Ventricular Septal Defects: Technical Issues

Abstract

Successfull repair of ventricular septal defects (VSDs) at the acute stage of myocardial infarction still remains a surgical challenge. On the basis of 18 years of experience encompassing more than 100 patients, we have found, however, that strict adherence to some fundamental technical principles can result in decreased operative mortality. These principles include: (1) meticulous attention to intraoperative myocardial preservation, (2) a transinfarction approach to the VSD, (3) liberal trimming of the necrotic tissue which surrounds the margins of the infarct to ensure firm anchoring of the patch used for closing the defect, (4) generous use of prosthetic material for closure of the ventriculotomy to reduce tension, and subsequent bleeding, at the suture lines, and (6) buttressing of suture lines with strips of Teflon felt and, whenever necessary, reinforcement with biological glue to prevent stitches from cutting through friable muscle. The issue of additional coronary artery bypass grafting remains unsettled. In our experience, only those arteries supplying a significant muscle mass in jeopardy are considered for revascularization. In addition to these technical factors, early operation in hemodynamically unstable patients and routine postoperative support with intra-aortic balloon pumping have emerged as critical determinants of early outcome.