How I would do my anterior VSD Closure John V. Conte, MD Professor Of Surgery Johns Hopkins University School Of Medicine Baltimore, Maryland Good afternoon. I was asked to describe how I would like my post infarction VSD repaired.
Disclosures No relevant financial relationships related to this presentation I personally have no relevant financial relationships to disclose.
Anterior Infarct = LAD Infarct It Depends!! Anterior Infarct = LAD Infarct Incidence 1-2% after acute MI Present 2-7 days post-infarction Treatment Surgical Closure
What does it depend on ? Size of Infarct Definition of Infarct Borders Smaller, well defined VSD’s do exist More distal the better Coronary artery anatomy LAD size Right coronary dominance Comfort level with different techniques Pre-op condition
Preop Optimization Hemodynamic stability ECMO? Inotropes? IABP? Diuresis? Intubation? ECMO? Primary reason to establish hemodynamic stability Allowing tissue to “stabilize”/”firm up” questionable Myocardial edema the rule for weeks To be truly beneficial in stable pts ECMO durations would be long
Catheter Based Repair
Gore Starflex® NMT Medical Cardiofix® Starway Medical Amplatzer®AGA Medical
When would I want Catheter based repair ? Cardiogenic Shock Not a candidate for surgery Very few individuals have significant experience Technically challenging catheter based procedure
Two Basic Surgical Approaches Patch Technique Exclusion technique
Operative Approach & Considerations Bicaval cannulation Percutaneous femoral venous Antegrade & retrograde cardioplegia Construct Grafts first Open through infarct Minimal debridement Repair VSD Unclamped in many cases If it moves its alive and will hold sutures
Anterior Infarction
Anterior Ventriculotomy
Anterior Ventriculotomy Ventriculotomy thru infarct Assess full extent of infarct Important for closure Note papillary muscle location Visualize how a patch or exclusion would be situated.
Anterior Ventriculotomy Minimal debridement or maniipulation of infarcted tissue Assess suture placement Decide which technique
Exclusion Technique
Exclusion Technique Key Concept: Large, ill defined VSD Two Major advantages Sutures in healthy / non-infarcted tissue Patch / Infarcted septum / anterior wall not exposed to systemic pressures Key Concept: You are creating new septum / medial wall for Left Ventricle
Patch placement Deep bites thru good tissue Continuous or Interrupted Interrupted more flexible Sutures can be placed External to Internal Large needle Bulky pledgets Do not undersize patch Imperative to oversize
Patch placement
Patch placement
Patch placement Area close to valves can be tricky Additional reinforcing sutures helpful Trim patch as you go and at end
Patch Completion
Patch Completion Clamp off LV vent off to deair Additional pledgeted sutures Bioglue is your friend Out of systemic circulation
Ventriculotomy Closure
Anterior Wall Closure
Two Patch Technique
Patch Technique Limit to small, well defined infarcts Avoids conduction system Avoids large patch with associated thromboembolic risks
Patch Technique – Septal patch Deep bites Oversize patch LV pressure helps keep patch in place
Patch Technique – Septal patch
Septal Patch Suture Considerations
Anterior Patch Closure
Post Op Care Biventricular pacing Inotropes Dys-synchrony and heart block common Inotropes Inhaled pulmonary vasodilators IABP “mandatory” ECMO can be helpful
Summary Patch Technique Exclusion Technique Smaller, well defined infarcts Hemodynamically stable Large, ill defined infarcts Hemodynamically unstable or CHF