Successful early repair of acquired ventricular septal defect after myocardial infarction.

Abstract

Successful repair of an acquired ventricular septal defect following myocardial infarction was first reported in 1962. Recently Barnard and Kennedy (1965) have reviewed 14 patients with post-infarction ventricular septal defect in whom surgical closure was attempted; 7 survived more than 6 weeks after operation. They found that those whose defects were closed 5 weeks or more after infarction survived the operation, but that those requiring emergency operation soon after infarction died. The best long-term results were obtained in those whose operations were delayed 3 months or more. However, more than 90 per cent of all patients die within a year of septal rupture, and most of these die within 2 months (Sanders, Kern, and Blount, 1956). It is clear that surgical repair should be considered in all patients who have a hemodynamically significant shunt through an acquired ventricular septal defect; ideally this should be done at least 6 and preferably 12 weeks after infarction, but, in view of the very high early mortality on medical treatment, nothing can be lost by attempting closure at an earlier stage if the patient is deteriorating.The following report concerns a patient in whom the defect was successfully repaired 27 days after infarction, and 20 days after the presumed time of septal rupture. Case ReportA man, aged 52, had left-sided chest pain, with nausea and sweating, on September 10, 1965. On September 17, he was more breathless and had a fainting episode; on this occasion his doctor heard a loud pracordial systolic murmur for the first time.On admission to the Whittington Hospital on September 20 under the care of Dr. T. St M. Norris, he was pale and sweating with a regular tachycardia and a raised venous pressure. The blood pressure was 120/100 453 mm. Hg. The heart was not clinically enlarged but a loud pansystolic murmur with thrill was loudest in the fourth left intercostal space near the sternum. There were bilateral basal rales, and a chest x-ray film showed pulmonary venous congestion with a small right pleural effusion. The electrocardiogram showed a recent posterior myocardial infarct. The diagnosis of ruptured interventricular septum was made; he improved at first on routine medical treatment, but signs of right-sided heart failure increased, and he was transferred to the London Chest Hospital on September 28 for consideration of surgical repair.At this time he was orthopnceic, and had signs of congestive cardiac failure with raised jugular venous pressure (10 cm.), enlarged tender liver, and cedema of both ankles. The pulse was rapid (110/min.) and the blood pressure 130/100 mm. Hg. The murmur and thrill were unchanged. He had several carious teeth and gross gingival infection. The chest x-rayfilm showed no cardiac enlargement (CTR 48%); there was severe pulmonary congestion with bilateral hilar and basal clouding and small pleural effusions. The electrocardiogram showed normal sinus rhythm; Q waves, slightly raised ST segments, and inverted T waves in leads II, III, aVF, V6, and V7 indicated...

Optimal management of acute ventricular septal rupture

“…This process of ''unnatural selection'' was first expressed in the literature nearly 40 years ago by Honey and his colleagues from the London Chest Hospital. 16 Some time later, from the same institution, Norell and colleagues reported a series of 55 consecutive patients who had presented with ventricular septal rupture and which they divided into two temporal groups. 12 Of the first group of 26 patients up to 1982, who were managed with delayed surgery, two had only minimal haemodynamic abnormality and did not go forward to operation.…”

Protocol-based Surgical Intervention to Manage Ventricular Septal Rupture from a Tier Two City

“…Even though repair on a fibrosed myocardium is technically easier compared to an acutely inflamed myocardium, the authors of the present study strongly believe that this should never be a reason to put the patients to trial. It is because of this major glitch that these strategies were aptly labeled as a technique of “unnatural selection” by Honey et al [ 10 ] .…”

Rupture of the ventricular septum from myocardial infarction: Haemodynamic response to surgical treatment

“…at rest was due to left ventricular failure which, in this case, clearly resulted from the volume overload as well as from the poor ischaemic myocardium. Honey, Belcher, Hasan, and Gibbons (1967) have emphasized the importance of assessing left ventricular function in these cases before deciding on management, but it may be difficult to separate the role of the left-to-right shunt from that of the primary myocardial disease in causing the failure. Clearly, left ventricular angiocardiography would provide valuable information about the size of the defect, but this was deliberately not done at the first investigation as the patient was breathless when lying at an angle of 450 on the catheter table.…”

“…Persistence or re-opening of a small ventricular septal defect is not uncommon after surgery for a lesion due to rupture following myocardial infarction (Cooley, Belmonte, Zeis, and Schnur, 1957;Proudfit, Tapia, McCormack, and Effier, 1959;Honey et al, 1967). However, even reducing the shunt clearly helps recovery, and the possibility of re-opening the defect should not prevent surgery even in the most ill patients.…”