A New Surgical Technique for Post-Myocardial Infarction Ventricular Septal Rupture with Hemodynamic Instability
Ventricular septal rupture (VSR) is a rare but life-threatening complication of acute myocardial infarction (AMI). Despite advances in medical and surgical interventions, VSR remains associated with high mortality rates, particularly in patients with hemodynamic instability. Emergent surgical repair is the only definitive treatment for survival; however, the perioperative mortality rate is exceptionally high in the early phase. Elective surgery, often performed in relatively stable patients, has shown improved outcomes but may be influenced by survival bias, as it excludes patients with early hemodynamic instability who are at higher risk of mortality. This study introduces a novel surgical technique, termed Surgical Repair Combining an Occluder and a Patch (SurCOP), designed to address the challenges of repairing VSR in hemodynamically unstable patients during the acute phase.
Background and Clinical Significance
VSR occurs when the septal wall of the heart ruptures following an AMI, leading to a left-to-right shunt and hemodynamic compromise. The condition is associated with significant morbidity and mortality, particularly in patients who develop hemodynamic instability. Traditional surgical repair techniques, such as the David infarct exclusion method, involve the use of large patches to close the rupture site. However, these methods are often complicated by residual shunts, which are a major risk factor for poor outcomes. Percutaneous transcatheter closure has emerged as an alternative, but it is primarily suitable for small VSRs in the sub-acute or chronic phase and is associated with high mortality in advanced cases.
The SurCOP technique was developed to overcome these limitations by combining the use of a patent ductus arteriosus (PDA) occluder with a bovine pericardial patch. This approach aims to provide a stable and effective closure of the rupture site while minimizing the risk of residual shunts and myocardial tearing.
Surgical Technique: SurCOP
The SurCOP technique involves a series of carefully orchestrated steps to ensure precise and stable closure of the VSR. The procedure is performed via a median sternotomy under general anesthesia, with cardiopulmonary bypass and moderate systemic hypothermia for myocardial protection. The rupture site is accessed through a longitudinal left ventriculotomy in the infarcted area, approximately 1 to 2 cm away from the left anterior descending coronary artery.
After debriding the surrounding necrotic myocardium (excluding the myocardium immediately surrounding the VSR), a T-shaped PDA occluder (Cardi-O-Fix, Starway Medical Technology, Beijing, China) is placed directly through the ventriculotomy incision. The cylindrical part of the occluder fills the rupture site, while the aortic retention disc faces the left ventricular (LV) side. The disc is fixed to the surrounding septal myocardium at the 3, 6, 9, and 12 o’clock positions using mattress sutures with gaskets. A bovine pericardial patch, trimmed to be slightly larger than the occluder, is then applied to cover the aortic retention disc and continuously sutured to the adjacent myocardium. Finally, the ventricular incision is closed with sutures buttressed on felt strips and reinforced with surgical glue.
Clinical Application and Outcomes
Between August 2017 and May 2019, nine patients with hemodynamically unstable VSR underwent the SurCOP procedure. The patients were closely monitored for hemodynamic status, urine output, creatinine levels, liver enzymes, and blood lactate levels. Preoperative management included volume expansion, vasopressors, inotropes, and additional therapies to prevent or treat multi-organ dysfunction syndrome. In cases of clinical deterioration, immediate intervention was initiated, including intra-aortic balloon pumping (IABP), non-invasive positive pressure ventilation, or extracorporeal membrane oxygenation (ECMO).
Preoperatively, three patients required inotropic support, six patients were sustained with IABP, and one patient received both IABP and ECMO. Eight patients underwent SurCOP within 14 days of VSR diagnosis, while one patient underwent the procedure on day 23. The VSR was located in the apical area in five patients, the anterior area in two patients, and the posterior area in two patients. The mean size of the VSR was 15.0 mm (range: 14.5–20.0 mm). The PDA occluder sizes ranged from 16/18 to 24/26, and the patch was trimmed accordingly. Additional procedures, such as coronary artery bypass grafting (CABG), ventricular aneurysm resection, and tricuspid annuloplasty, were performed as necessary.
Postoperatively, three patients required continued IABP support, and two patients needed continuous renal replacement therapy (CRRT). Two patients died: one at 7 days post-surgery and one at 44 days post-surgery. Neither death was attributed to low cardiac output syndrome (LCOS). The remaining seven patients demonstrated excellent outcomes, with a 30-day mortality rate of 11.1% (1/9). The overall mortality rate during the follow-up period (up to 187 days, interquartile range: 70–550 days) was 22.2% (2/9).
Advantages of the SurCOP Technique
The SurCOP technique offers several advantages over traditional surgical methods. The combination of a PDA occluder and a bovine pericardial patch provides a double fixation mechanism that ensures stability under high LV pressure gradients, reducing the risk of residual shunts and myocardial tearing. The occluder can be precisely released without enlarging the rupture or damaging the fragile myocardium, while the patch reinforces the closure and prevents device dislocation or valve impingement. Additionally, the technique allows for debridement of necrotic myocardium and secure closure of the ventriculotomy, further enhancing its effectiveness.
Limitations and Future Directions
The primary limitation of this study is the small sample size, which is inherent to the rarity of VSR. However, the preliminary results demonstrate the safety, feasibility, and efficacy of the SurCOP technique in managing hemodynamically unstable VSR. Future studies with larger cohorts and longer follow-up periods are needed to validate these findings and further refine the technique. Feedback from other surgeons who adopt this method will be invaluable in improving outcomes for patients with VSR.
Conclusion
The SurCOP technique represents a significant advancement in the surgical management of post-myocardial infarction VSR, particularly in hemodynamically unstable patients. By combining a PDA occluder with a bovine pericardial patch, this method provides a stable and effective closure of the rupture site, reducing the risk of residual shunts and improving patient outcomes. The technique is safe, easy to manipulate, and offers a promising alternative to traditional surgical and percutaneous approaches. Continued research and collaboration among surgeons will be essential to further enhance the prognosis of patients with this life-threatening condition.
doi.org/10.1097/CM9.0000000000001442
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