1. 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.

2. Disclosures
No relevant financial relationships related to this presentation
I personally have no relevant financial relationships to disclose.

3. 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

4. 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

5. 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

6. Catheter Based Repair

7. Gore
Starflex® NMT Medical
Cardiofix® Starway Medical
Amplatzer®AGA Medical

8. 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

9. Two Basic Surgical Approaches
Patch Technique
Exclusion technique

10. 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

11. Anterior Infarction

12. Anterior Ventriculotomy

13. 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.

14. Anterior Ventriculotomy
Minimal debridement or maniipulation of infarcted tissue
Assess suture placement
Decide which technique

15. Exclusion Technique

16. 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

17. 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

18. Patch placement

19. Patch placement

20. Patch placement Area close to valves can be tricky
Additional reinforcing sutures helpful
Trim patch as you go and at end

21. Patch Completion

22. Patch Completion Clamp off LV vent off to deair
Additional pledgeted sutures
Bioglue is your friend
Out of systemic circulation

23. Ventriculotomy Closure

24. Anterior Wall Closure

25. Two Patch Technique

26. Patch Technique Limit to small, well defined infarcts
Avoids conduction system
Avoids large patch with associated thromboembolic risks

27. Patch Technique – Septal patch
Deep bites
Oversize patch
LV pressure helps keep patch in place

28. Patch Technique – Septal patch

29. Septal Patch
Suture Considerations

30. Anterior Patch Closure

31. Post Op Care Biventricular pacing Inotropes
Dys-synchrony and heart block common
Inotropes
Inhaled pulmonary vasodilators
IABP “mandatory”
ECMO can be helpful

32. Summary Patch Technique Exclusion Technique
Smaller, well defined infarcts
Hemodynamically stable
Large, ill defined infarcts
Hemodynamically unstable or CHF