Decision-making and surgery results in postinfarction ventricular septal rupture

Objectives: Postinfarction ventricular septal defect (VSD) remains a surgical challenge because it is technically difficult to reconstruct the septum during the acute phase of transmural myocardial infarction, and it is a relatively uncommon operative procedure. Design and Methods: Thirty patients underwent surgical repair of a postinfarction ventricular septal defect from 1992 to 2003. 26 of the patients were in New York Heart Association functional class IV, and 9 of them – in cardiogenic shock when operated on. There were 19 females and 11 males with a mean age of 68 ± 9.5 years. The VSD was anterior in 16 patients and posterior – in 14 patients. We used operative techniques that evolved from infarctectomy and reconstruction of the septum with Dacron patches to pericardial patch exclusion of the left ventricle and left ventricular volume reconstruction. This was accomplished by suturing a single Dacron patch to the healthy endocardium surrounding the infarcted muscle. Results: Six patients died perioperatively, whereas the surgical mortality rate was 20%. Nineteen patients underwent coronary artery bypass grafting. Four patients developed recurrent VSD; one patient died and one patient underwent surgical closure of a defect. There were 14 survivors at 36 months of follow-up: 50% of patients were in functional class II, and 50% – in functional class III. Four patients died at a remote period. Conclusions: Decision on terms of surgical intervention was made individually for each patient. Patch closure of the ventricular septal rupture, remodelling of the left ventricle and selective myocardial revascularisation provided acceptable results.