1. Post MI Ventricular Septal Defects Nick Tehrani, MD

2. Overview VSD Complicates 1-2% of cases of acute myocardial infarction. First successful correction reported by Cooley in 1957.

3. Overview High mortality despite various improvements in therapy 30 day mortality- 74% 1 year mortality- 78% GUSTO analysis, Crenshaw et al, Circ. 1/2000

4. Overview Relative Improvement in survival due to Earlier diagnosis Earlier flow restoration More aggressive surgical intervention

5. Overview Incidence declining due to: Earlier restoration of flow, preventing transmural MI More aggressive BP control post MI

6. Overview Predictors of VSD Advanced age, Anterior location of infarction, Female sex, No history of smoking Per GUSTO analysis Thrombolysis after 12 hours also suggested as a predisposing factor.

7. Overview Average time to rupture 2-4 days Range: few hours  2 weeks Time course may be accelerated by thrombolysis, possible related to intramyocardial hemorrhage

8. Overview Coronary anatomy and VSD Post MI VSDs more commonly associated with 100% occlusion of the infarct related artery This was observed in all of our patients

9. Anatomy of VSDs Two types of VSD Simple: through and through defect usually located anteriorly Complex: serpentiginous dissection tract remote from the primary septal defect- most commonly an inferior VSD Patient BG had such a presentation

10. Transesophageal Echocardiogram of Complex VSD

11. Angiography

12. Anatomy of VSDs Antro-apical septal rupture Comprise approximately 60-80% of cases LAD occlusion is always the culprit

13. Anatomy of VSDs Posterior septal rupture Approximately 20-40% of cases Occlusion of Dominant RCA => extensive RV infarction Dominant LCX (Less common), RV mostly spared

14. Anatomy of VSDs Multiple defects (5-11% of cases) Secondary to infarct extension Evolve within days of each other

15. Anatomy of VSDs Our series Antro-apical septum Three of four cases Posterior septum One of four cases

16. Pathophysiology Antero-apical septal rupture Tamponade Secondary RV failiure due to acute volume overload

17. Pathophysiology Posterior septal rupture Commonly complicated by MR Shunt reversal due to elevated RVEDP

18. Diagnosis Loud/harsh pansystolic murmur Within the first week post AMI Best heard at Lt. Lower sternal border Less loud at the apex Associated with a palpable thrill Depending on the location, may radiate to the axilla mimicking MR

19. Diagnosis Up to 50% of patients experience chest pain associated with the development of murmur CHF and shock often associated with the development of murmur

20. Diagnosis Color Flow Doppler 100% sensitive and specific in differentiating VSD from acute MR Site of septal rupture correctly identified in 41 of 42 patients One of our 4 patients had had a negative TTE earlier in the day, and no apparent homodynamic changes prior to the catheterization later that day Smyllie et. Al. 1990 JACC

21. Diagnosis Earlier diagnosis and surgical intervention, may be due to greater availability of Echocardiography at peripheral centers.

22. Diagnosis Need for cardiac catheterization 2/3 of the patients have multivessel coronary artery disease Decreased operative mortality and improved late survival has been shown in patients with multivessel disease Cardiogenic shock not a deterrent to Cath =>Coronary angiography should be performed

23. Diagnosis

24. Pre-Operative Management Hemodynamic stabilization so as to minimize peripheral organ compromise Reduce Systemic vascular resistance, and thus, the left-to-right shunt Maintain or improve coronary artery blood flow Maintain cardiac output and arterial pressure to ensure peripheral organ perfusion =>IABP

25. Timing of Surgery Controversial (in the past) Non-randomized studies showing: Early repair, 40% - 50% mortality Late repair (past 3 weeks), 10% mortality => Aggressive Medical management aimed at delaying surgical intervention

26. Timing of Surgery Short-coming of the argument Patients with less sever hemodynamic compromise, more likely to survive the acute phase without need for prompt surgery: Lower pre-op risk =>Better outcome

27. Timing of Surgery Short-coming of the argument Patients with greater hemodynamic compromise, and more severe insult: Higher pre-op risk =>Worse outcome

28. Timing of Surgery Surgery should be performed soon after diagnosis in most patients Patients is cardiogenic shock should be operated on immediately after anigography Hemodynamically stable patients should have surgery on an urgent basis

29. Operative Technique Classical approach to antero-septal rupture Infarctectomy, and Reconstruction of the ventricular septum with Dacron patches

30. Operative Technique Classical approach to infro-posterior rupture Infarctectomy, and Reconstruction of infroposterior VSD, Reconstruction Reconstruction free wall with Dacron patches.

31. Outcome In a review of 139 cases reported in the literature prior to 1977 Six month survival without surgical intervention was less than 10%. Kirklin, Churchill Livingston 1993

32. Outcome Predictors of early mortality per multivariable logistic regression analysis in a series of 22 patients DM Elevated RA pressure (RV involvement/IMI) Absence of intraoperative IABP

33. Outcome Predictors of early mortality per GUSTO analysis Advanced age Inferior location of MI

34. Outcome In patients with cardiogenic shock mortality reported to be the highest Posterior VSD (IMI) is another factor strongly associated with poor surgical outcome due to Difficulty of exposure, and Frequent concomitant infarction of the postero- medial papillary muscle Compilation from 6 series from the late 80s

35. Outcome David, in a series of 44 patients reported no difference between mortality rates for the posterior and anterior VSD using the Exclusion technique

36. Exclusion Technique Exclusion technique LV excluded from the infarcted muscle using a bovine pericardial patch sutured to the healthy peri-infarct endocardium No infarctectomy is performed RV is undisturbed Better RV function preservation May help support the posteromedial papillary muscle

37. Exclusion technique

38. Outcome Residual Lt.  Rt. shunt Reported in up to 28% of survivors Associated with high mortality Intra-operative TEE useful in early detection and correction if deemed necessary Seen in one of our patients. Patient was treated medically

39. Residual VSD

40. Post-Op state Dialysis Commonly required in patients in shock Not required by either of our two survivors Prolonged ventilatory support Residual or recurrent VSD Reoperation may be necessary depending on the shunt size and hemodynamics

41. Clinical Profile of our Patients