Daijiworld Media Network - Mangalore
with inputs from Dr Sunil Deshpande
Chief Operating Officer

• Successful Surgery for Post Infraction Ventricular Septal Rupture (VSR)

Mangalore, Jan 12: Prabhakar Maindan (53), male,  from Bengre in the city,  was admitted to one of the private hospitals in the city with a severe heart attack (MI).

A coronary angiogram revealed 100% Block in LAD. The patient had developed Ventricular Septal Defect during the course in hospital. He had hypotension (BP 80 Systolic) commonly known as low BP and renal failure (Creatinine 3.4), he was brought to KMC Hospital for further management.

Dr Narashimha Pai, cardiologist of KMC Hospital, stabilized the patient in ICU with the help of the Nephrology team. Intra-aortic balloon pump was inserted to maintain blood pressure. Once patient was stabilized patient was referred to Dr Sujeeth Suvarna and his team for emergency surgical intervention as VSR was large (19 mm) and mortality was high without surgical procedure.

Dr Sujeeth Suvarna, cardio-thoracic surgeon of KMC Hospital, shifted the patient to OT and following which Dr Rammoorthy, cardiac anesthetist, gave general anesthesia. Cardiopulmonary bypass was initiated and the patient was cooled to 26°C and the heart was protected using intermittent antegrade cold blood cardioplegia. The ventricular septal rupture was inspected by opening the left ventricular wall.  The ruptured ventricular septal wall, approximately the size of a rupee coin, was seen in the antero apical position.

This was repaired using a synthetic gortex patch using intermittent and semi continuous plegetted sutures. The defect was then tested for any leaks prior to double plegetted suturing of the opened left ventricular lateral wall incision wound. Following this, the patient was re-warmed and weaned off cardiopulmonary bypass machine and transferred into cardiac ICU on inotropic and IABP support in a critical stable condition. The patient was extubated and IABP and inotropic support was stopped after 24v hours.

One third of patients with fatal acute myocardial infarction have left ventricular rupture. Most of the ventricular ruptures occur in the free wall of the left ventricle and these are usually fatal. In approximately 15% to 20% of the cases the rupture occurs in the interventricular septum 2-8 days after an infarction and unless surgically treated, most of these patients die of severe congestive cardiac failure within hours to days

Operation for post infarction rupture of the inter-ventricular septum is reportedly associated with high operative mortality when done during the acute phase of the myocardial infarction. Operative procedures to correct acute septal rupture have consisted of infarctectomy and reconstruction of the septum and ventricular walls with one or more Dacron fabric patches. Septal exclusion with bovine pericardium and closure of the left ventriculotomy with pledget or felt, use of surgical glue has also been described

Each year in the UK since 1988, an average of 165 patients have undergone surgical repair of inter-ventricular septal rupture complicating myocardial infarction (cardiac surgical registry of the Society of Cardiothoracic Surgeons of Great Britain and Ireland). From each surgeon’s viewpoint this operation is a rare event. Given that there are now some 200 consultant cardiac surgeons in the UK, the current workload averages out at less than one case per surgeon per year.

Without surgery only 80 % of the patients survive the first 24 hours and only 50 % the first week. Less than 30% survive 2 weeks and only 10 % to 20% more than 4 weeks. The risk is greater immediately following MI and this reduces gradually afterwards.

There are two types of septal rupture Anterior (60%) this is common and posterior (40%) which is rare and more serious. The risk of death during surgery is more than 40 to 50 % during surgery.

• Summary of features of postinfarction VSR
• Occurrence is typically 3-8 days after an MI
• The sites of rupture are the anterior septum (60%) and the posterior septum (40%)
• The most consistent finding is a murmur
• In the differential diagnosis, exclude mitral regurgitation from papillary muscle rupture
• Diagnosis is confirmed with the aid of echocardiography and the presence of a left-to-right shunt.
  Catheterization results help determine the extent of CAD
• Of patients treated without surgery, 90% die
• Surgery must be emergent, even if the patient is stable
• All VSRs are closed with a patch and associated coronary artery bypass grafting
• The surgical mortality rate for anterior defects is 30-40% and for posterior defects is 60% to 80%.

The details were revealed to the media at a press conference in the city. Chief operating officer of KMC Hospitals, Mangalore, Dr Sunil Deshpande appreciated the efforts taken by Dr Narashimha Pai and team, Dr Sujith and team for giving new life to the patient

Dr Sujeeth Suvarna, Dr Narashimha Pai, Dr. Padmanabha Kamath, Dr. Madhava Kamath were present in the conference. Prashant S Desai proposed the vote of thanks.