Skip to main content
Log in

Postinfarction ventricular septal rupture: can we improve clinical outcome of surgical repair?

  • Current Topics Review Article
  • Published:
General Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

Abstract

Postinfarction ventricular septal rupture (VSR) is a lethal structural complication following acute myocardial infarction (AMI). Surgical repair of VSR was first reported in 1957 by Cooley. Since then, many methods have been introduced, variously using right and/or left ventriculotomy. Daggett used infarctectomy and septal reconstruction via left ventriculotomy, reporting 52 % operative mortality when repair was attempted within 21 days, but only 7 % when done after 3 weeks. Komeda and David described single pericardial patch infarct exclusion without infarctectomy through a left ventriculotomy in 1990. It seemed conceptually simple, and became a standard technique. Modifications of that technique and development of other methods have been reported by many surgeons. Nonetheless, recent clinical outcomes of surgical repairs demonstrated operative mortality from 19 to 81 %. Predictors for poor survival include cardiogenic shock, the need for repair within 7 days after AMI, posterior VSR and shunt recurrence. Reasons for poor outcomes after surgical repair of VSR include preoperative cardiogenic shock, the unclear boundary between infarction and viable myocardium in the acute phase, and frequent shunt recurrence. Surgical complications such as bleeding from an LV incision and low output syndrome are significant concerns as well. We propose that the fundamental requirements for VSR closure include a sufficiently large patch securely fixed on the LV side of the septum, minimal damage to LV function, and simplicity of technique. Our “extended sandwich patch technique” fulfills those requirements, and has yielded improved outcomes without shunt recurrence, even within 7 days following onset, and for posterior VSR.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Oyamada A, Queen FB. Spontaneous rupture of the interventricular septum following acute myocardial infarction with some clinicopathological observation on survival in five cases. Presented at the first Pan-Pacific Pathological Congress, Tripler US Army Hospital, Honolulu, HI, Oct 12, 1961.

  2. Arnaoutakis GJ, Zhao Y, George TJ, Sciortino CM, McCarthy PM, Conte JV. Surgical repair of ventricular septal defect after myocardial infarction: outcomes from the society of thoracic surgeons national database. Ann Thorac Surg. 2012;94:436–44.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Latham PM. Lectures on subjects connected with clinical medicine comprising diseases of the heart, vol. 2. London: Longman Rees; 1845. p. 168–74.

    Google Scholar 

  4. Cooley DA, Belmonte BA, Zeis LB, Schnur S. Surgical repair of ruptured interventricular septum following acute myocardial infarction. Surgery. 1957;41:930.

    CAS  PubMed  Google Scholar 

  5. Payne WS, Hunt JC, Kirklin JW. Surgical repair of ventricular septal defect due to myocardial infarction. Report of a case. JAMA. 1963;183:603–5.

    Article  CAS  PubMed  Google Scholar 

  6. Iben AB, Pupello DF, Stinson EB, Shumway NE. Surgical treatment of postinfarction ventricular septal defects. Ann Thorac Surg. 1969;8:252.

    Article  CAS  PubMed  Google Scholar 

  7. Kitamura S, Mendez A, Kay JH. Ventricular septal defect following myocardial infarction: experience with surgical repair through a left ventriculotomy and review of literature. J Thorac Cardiovasc Surg. 1971;61:186.

    Google Scholar 

  8. Javid H, Hunter JA, Naiafi H, Dye WS, Julian OC. Left ventricular approach for the repair of ventricular septal perforation and infarctectomy. J Thorac Cardiovasc Surg. 1972;63:14–24.

    CAS  PubMed  Google Scholar 

  9. Filgueira JL, Battistessa SA, Estable H, Lorenzo A, Cassinelli M, Scola R. Delayed repair of an acquired posterior septal defect through a right atrial approach. Ann Thorac Surg. 1986;42:208–9.

    Article  CAS  PubMed  Google Scholar 

  10. Daggett WM, Guyton RA, Mundth ED, Buckley MJ, McEnany MT, Gold HK, Leinbach RC, Austen WG. Surgery for post-myocardial infarct ventricular septal defect. Ann Surg. 1977;186:260–71.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Muehrcke DD, Daggett WM Jr, Buckley MJ, Akins CW, Hilgenberg AD, Austen WG. Postinfarct ventricular septal defect repair: effect of coronary artery bypass grafting. Ann Thorac Surg. 1992;54:876–82.

    Article  CAS  PubMed  Google Scholar 

  12. Komeda M, David TE, Fremes SE. Surgical repair of postinfarction ventricular septal defect. Circulation. 1990;82(Suppl):IV243–7.

    CAS  PubMed  Google Scholar 

  13. 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.

    Article  CAS  PubMed  Google Scholar 

  14. David TE, Armstrong S. Surgical repair of postinfarction ventricular septal defect by infarct exclusion. Semin Thorac Cardiovasc Surg. 1998;10:105–10.

    Article  CAS  PubMed  Google Scholar 

  15. Seguin JR, Frapier JM, Colson P, Chaptal PA. Fibrin sealant for early repair of acquired ventricular septal defect. J Thorac Cardiovasc Surg. 1992;104:748–51.

    CAS  PubMed  Google Scholar 

  16. Musumeci F, Shukla V, Mignosa C, Casali G, Ikram S. Early repair of postinfarction ventricular septal defect with gelatin-resorcin-formol biological glue. Ann Thorac Surg. 1996;62:486–8.

    Article  CAS  PubMed  Google Scholar 

  17. Passage J, Jalali H, Tam RK, Harrocks S, O’Brien MF. BioGlue surgical adhesive—an appraisal of its indications in cardiac surgery. Ann Thorac Surg. 2002;74:432–7.

    Article  PubMed  Google Scholar 

  18. Tashiro T, Todo K, Haruta Y, Yasunaga H, Shibano R, Kawara T. Extended endocardial repair of postinfarction ventricular septal rupture: new operative technique—modification of the Komeda-David operation. J Card Surg. 1994;9:97–102.

    Article  CAS  PubMed  Google Scholar 

  19. 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.

    Article  CAS  PubMed  Google Scholar 

  20. Imagawa H, Takano S, Shiozaki T, Ryugou M, Shikata F, Kawachi K. Two-patch technique for postinfarction inferoposterior ventricular septal defect. Ann Thorac Surg. 2009;88:692–4.

    Article  PubMed  Google Scholar 

  21. Tabuchi N, Mizuno T, Kuriu K, Toyama M. Double patch technique for repairing postinfarction ventricular septal defect. Jpn J Thorac Cardiovasc Surg. 2001;49:264–6.

    Article  CAS  PubMed  Google Scholar 

  22. Tanaka H, Hasegawa S, Sakamoto T, Sunamori M. Postinfarction ventricular septal perforation repair with endoventricular circular patch plasty using double patches and gelatin-resorcinol-formaldehyde biological glue. Eur J Cardiothorac Surg. 2001;19:945–8.

    Article  CAS  PubMed  Google Scholar 

  23. Sugimoto T, Yoshii S, Yamamoto K, Sakakibara K, Iida Y, Uehara A, Mishima T, Kasuya S. A modified infarct exclusion technique: triple-patch technique for postinfarction ventricular septal perforation. J Thorac Cardiovasc Surg. 2008;135:702–3.

    Article  PubMed  Google Scholar 

  24. Kobayashi T, Mikamo A, Suzuki R, Murakami M, Shirasawa B, Hamano K. Simple geometrical infarct exclusion technique with a single patch for postinfarction ventricular septal perforation. Ann Thorac Surg. 2010;89:2049–52.

    Article  PubMed  Google Scholar 

  25. Ito T, Hagiwara H, Maekawa A, Yamazaki T. Finite element analysis regarding patch size, stiffness, and contact condition to the endocardium in surgery for post infarction ventricular septal rupture. Gen Thorac Cardiovasc Surg. 2013;61:632–9.

    Article  PubMed  Google Scholar 

  26. Ichihara T, Asakura T, Ishida H, Sakai Y, Yasuura K. The investigation of surgical procedures for post infarcted ventricular septal defects: a comparison between Daggett and David method. Kyobu Geka. 1998;51:1110–3.

    CAS  PubMed  Google Scholar 

  27. Ito T, Hagiwara H, Maekawa A. Entire septal patch technique for postinfarction ventricular septal rupture. Ann Thorac Surg. 2000;70:273–4.

    Article  CAS  PubMed  Google Scholar 

  28. Ito T, Hagiwara H, Maekawa A. Early and late results of entire septal patch technique for post infarction ventricular septal rupture. Gen Thorac Cardiovasc Surg. 2012;60:475–9.

    Article  PubMed  Google Scholar 

  29. Hirotani T, Nakamichi T. A modified infarct exclusion technique for a post-infarction ventricular septal defect. Ann Thorac Cardiovasc Surg. 2002;8:281–5.

    PubMed  Google Scholar 

  30. Isoda S, Imoto K, Uchida K, Hashiyama N, Yanagi H, Tamagawa H, Takanashi Y. Sandwich technique via right ventricle incision to repair postinfarction ventricular septal defect. J Card Surg. 2004;19:149–50.

    Article  CAS  PubMed  Google Scholar 

  31. Usui A, Murase M, Maeda M, Tomita Y, Murakami F, Teranishi K, Koyama T, Ito T, Abe T. Sandwich repair with two sheets of equine pericardial patch for acute posterior post-infarction ventricular septal defect. Eur J Cardiothorac Surg. 1993;7:47–9.

    Article  CAS  PubMed  Google Scholar 

  32. Skillington PD, Davies RH, Luff AJ, Williams JD, Dawkins KD, Conway N, Lamb RK, Shore DF, Monro JL, Ross JK. Surgical treatment for infarct-related ventricular septal defects. Improved early results combined with analysis of late functional status. J Thorac Cardiovasc Surg. 1990;99:798–808.

    CAS  PubMed  Google Scholar 

  33. Prêtre R, Ye Q, Grünenfelder J, Lachat M, Vogt PR, Turina MI. Operative results of “repair” of ventricular septal rupture after acute myocardial infraction. Am J Cardiol. 1999;84:785–8.

    Article  PubMed  Google Scholar 

  34. Prêtre R, Ye Q, Grünenfelder J, Zund G, Turina MI. Role of myocardial revascularization in postinfarction ventricular septal rupture. Ann Thorac Surg. 2000;69:51–5.

    Article  PubMed  Google Scholar 

  35. 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 Cardiothorac Surg. 2000;18:194–201.

    Article  CAS  PubMed  Google Scholar 

  36. Labrousse L, Choukroun E, Chevalier JM, Madonna F, Robertie F, Merlico F, Coste P, Deville C. Surgery for post infarction ventricular septal defect (VSD): risk factors for hospital death and long term results. Eur J Cardiothorac Surg. 2002;21:725–31.

    Article  CAS  PubMed  Google Scholar 

  37. Cerin G, Di Donato M, Dimulescu D, Montericcio V, Menicanti L, Frigiola A, De Ambroggi L. Surgical treatment of ventricular septal defect complicating acute myocardial infarction. Experience of a north Italian referral hospital. Cardiovasc Surg. 2003;11:149–54.

    Article  CAS  PubMed  Google Scholar 

  38. Lundblad R, Abdelnoor M, Geiran OR, Svennevig JL. Surgical repair of postinfarction ventricular septal rupture: risk factors of early and late death. J Thorac Cardiovasc Surg. 2009;137:862–8.

    Article  PubMed  Google Scholar 

  39. Maltais S, Ibrahim R, Basmadjian AJ, Carrier M, Bouchard D, Cartier R, Demers P, Ladouceur M, Pellerin M, Perrault LP. Postinfarction ventricular septal defects: towards a new treatment algorithm? Ann Thorac Surg. 2009;87:687–92.

    Article  PubMed  Google Scholar 

  40. Fukushima S, Tesar PJ, Jalali H, Clarke AJ, Sharma H, Choudhary J, Bartlett H, Pohlner PG. Determinants of in-hospital and long-term surgical outcomes after repair of postinfarction ventricular septal rupture. J Thorac Cardiovasc Surg. 2010;140:59–65.

    Article  PubMed  Google Scholar 

  41. Menon V, Webb JG, Hillis LD, Sleeper LA, Abboud R, Dzavik V, Slater JN, Forman R, Monrad ES, Talley JD, Hochman JS. Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries in cardiogenic shock? J Am Coll Cardiol. 2000;36(3 Suppl A):1110–6.

    Article  CAS  PubMed  Google Scholar 

  42. Crenshaw BS, Granger CB, Birnbaum Y, Pieper KS, Morris DC, Kleiman NS, Vahanian A, Califf RM, Topol EJ. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (global utilization of streptokinase and TPA for occluded coronary arteries) trial investigators. Circulation. 2000;101:27–32.

    Article  CAS  PubMed  Google Scholar 

  43. Barker TA, Ramnarine IR, Woo EB, Grayson AD, Au J, Fabri BM, Bridgewater B, Grotte GJ. Repair of post-infarct ventricular septal defect with or without coronary artery bypass grafting in the northwest of England: a 5-year multi-institutional experience. Eur J Cardiothorac Surg. 2003;24(6):940–6.

    Article  CAS  PubMed  Google Scholar 

  44. Jeppsson A, Liden H, Johnsson P, Hartford M, Rådegran K. Surgical repair of post infarction ventricular septal defects: a national experience. Eur J Cardiothorac Surg. 2005;27:216–21.

    Article  PubMed  Google Scholar 

  45. Moreyra AE, Huang MS, Wilson AC, Deng Y, Cosgrove NM, Kostis JB, MIDAS Study Group (MIDAS 13). Trends in incidence and mortality rates of ventricular septal rupture during acute myocardial infarction. Am J Cardiol. 2010;106:1095–100.

    Article  PubMed  Google Scholar 

  46. Kuwano H, Amano J, Yokomise H. Thoracic and cardiovascular surgery in Japan during 2010: annual report by the Japanese association for thoracic surgery. Gen Thorac Cardiovasc Surg. 2012;60:680–708.

    Article  PubMed  Google Scholar 

  47. Amano J, Kuwano H, Yokomise H. Thoracic and cardiovascular surgery in Japan during 2011: annual report by the Japanese association for thoracic surgery. Gen Thorac Cardiovasc Surg. 2013;61:578–607.

    Article  PubMed  Google Scholar 

  48. Committee for Scientific Affairs, The Japanese Association for Thoracic Surgery, Masuda M, Kuwano H, Okumura M, Amano J, Arai H, Endo S, Doki Y, Kobayashi J, Motomura N, Nishida H, Saiki Y, Tanaka F, Tanemoto K, Toh Y, Yokomise H. Thoracic and cardiovascular surgery in Japan during 2012: annual report by the Japanese association for thoracic surgery. Gen Thorac Cardiovasc Surg. 2014;62:734–64.

    Article  Google Scholar 

  49. Holzer R, Balzer D, Amin Z, Ruiz CE, Feinstein J, Bass J, Vance M, Cao QL, Hijazi ZM. Transcatheter closure of postinfarction ventricular septal defects using the new Amplatzer muscular VSD occluder: results of a US Registry. Catheter Cardiovasc Interv. 2004;61:196–201.

    Article  PubMed  Google Scholar 

  50. Costache VS, Chavanon O, Bouvaist H, Blin D. Early Amplatzer occluder closure of a postinfarct ventricular septal defect as a bridge to surgical procedure. Interact Cardiovasc Thorac Surg. 2007;6:503–4.

    Article  PubMed  Google Scholar 

  51. Thiele H, Kaulfersch C, Daehnert I, Schoenauer M, Eitel I, Borger M, Schuler G. Immediate primary transcatheter closure of postinfarction ventricular septal defects. Eur Heart J. 2009;30:81–8.

    Article  PubMed  Google Scholar 

  52. Michel-Behnke I, Ewert P, Koch A, Bertram H, Emmel M, Fischer G, Gitter R, Kozlik-Feldman R, Motz R, Kitzmüller E, Kretschmar O, Investigators of the Working Group Interventional Cardiology of the German Association of Pediatric Cardiology. Device closure of ventricular septal defects by hybrid procedures: a multicenter retrospective study. Catheter Cardiovasc Interv. 2011;77:242–51.

    Article  PubMed  Google Scholar 

  53. Sathananthan J, Ruygrok P. Evolution in the management of postinfarct ventricular septal defects from surgical to percutaneous approach: a single-center experience. J Invasive Cardiol. 2013;25:339–43.

    PubMed  Google Scholar 

  54. Calvert PA, Cockburn J, Wynne D, Ludman P, Rana BS, Northridge D, Mullen MJ, Malik I, Turner M, Khogali S, Veldtman GR, Been M, Butler R, Thomson J, Byrne J, MacCarthy P, Morrison L, Shapiro LM, Bridgewater B, de Giovanni J, Hildick-Smith D. Percutaneous closure of postinfarction ventricular septal defect: in-hospital outcomes and long-term follow-up of UK experience. Circulation. 2014;129:2395–402.

    Article  PubMed  Google Scholar 

  55. Zornoff LA, Skali H, Pfeffer MA, Sutton MSJ, Rouleau JL, Lamas GA, Plappert T, Rouleau JR, Moyé LA, Lewis SJ, Braunwald E, Solomon SD, SAVE Investigators. Right ventricular dysfunction and risk of heart failure and mortality after myocardial infarction. J Am Coll Cardiol. 2002;39:1450–5.

    Article  PubMed  Google Scholar 

  56. Anavekar NS, Skali H, Bourgoun M, Ghali JK, Kober L, Maggioni AP, McMurray JJ, Velazquez E, Califf R, Pfeffer MA, Solomon SD. Usefulness of right ventricular fractional area change to predict death, heart failure, and stroke following myocardial infarction (from the VALIANT ECHO study). Am J Cardiol. 2008;101:607–12.

    Article  PubMed  Google Scholar 

  57. Antoni ML, Scherptong RW, Atary JZ, Boersma E, Holman ER, van der Wall EE, Schalij MJ, Bax JJ. Prognostic value of right ventricular function in patients after acute myocardial infarction treated with primary percutaneous coronary intervention. Circ Cardiovasc Imaging. 2010;3:264–71.

    Article  PubMed  Google Scholar 

  58. Asai T, Hosoba S, Suzuki T, Kinoshita T. Postinfarction ventricular septal defect: right ventricular approach-the extended “sandwich” patch. Semin Thorac Cardiovasc Surg. 2012;24:59–62.

    Article  PubMed  Google Scholar 

  59. Hosoba S, Asai T, Suzuki T, Nota H, Kuroyanagi S, Kinoshita T, Takashima N, Hayakawa M. Mid-term results for the use of the extended sandwich patch technique through right ventriculotomy for postinfarction ventricular septal defects. Eur J Cardiothorac Surg. 2013;43:e116–20.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We thank Mr. Piers Vigers for reviewing our manuscript.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Tohru Asai.

Ethics declarations

Conflict of interest

The author has no conflict of interest.

Additional information

This review was submitted at the invitation of the editorial committee.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Asai, T. Postinfarction ventricular septal rupture: can we improve clinical outcome of surgical repair?. Gen Thorac Cardiovasc Surg 64, 121–130 (2016). https://doi.org/10.1007/s11748-015-0620-1

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11748-015-0620-1

Keywords

Navigation