Ventricular Septal Defect and Left Ventricular Aneurysm After Acute Myocardial Infarction

doi:10.4236/ss.2011.24038

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Surgical Science, 2011, 2, 175-176

doi:10.4236/ss.2011.24038 Published Online June 2011 (http://www.SciRP.org/journal/ss)

Ventricular Septal Defect and Left Ventricular Aneurysm

after Acute Myocardial Infarction

Kasra Azarnoush, Mario Manca, Andrea Innorta, Lionel Camilleri

CHU Clermont-Ferrand, Service de Chirurgie Cardiaque, Clermont-Ferrand, France

E-mail: [email protected]

Received January 14, 2011; revised April 27, 2011; accepted April 29, 2011

Abstract

The combination of an acute ventricular septal defect (VSD) and left ventricular aneurysm (LVA) is a rare,

life-threatening complication which usually occurs within the first week following acute myocardial infarct-

tion (AMI). We describe the case of an apical VSD and LVA in a 77-year-old diabetic and dyslipidemic

male patient after anterior AMI. The patient was an active smoker and had a history of chronic obstructive

pulmonary disease, arterial hypertension and atrial fibrillation. The patient underwent ventriculotomy for

VSD repair using a large equine pericardial patch followed by intraventricular patch remodelling of the LVA.

He was discharged 2 months after surgery and underwent a successful hip replacement 10 months later.

Keywords: Endoventricular Patch Remodelling, Myocardial Infarction, Ventricular Aneurysm, Ventricular

Septal Defect

1. Introduction

Acute ventricular septal defects (VSDs) usually occur

within the first week of acute myocardial infarction

(AMI) [1]. These defects have an incidence of 1% - 3%

[2] and are associated with high mortality if not diag-

nosed early and adequately managed [3].

Left ventricular aneurysms (LVAs) are more common,

with a reported incidence of 3.5% - 5% [4]. However, the

true incidence of LVAs is unknown because there is no

well-established definition of LVA and because of

time-dependant left ventricular remodelling with late

LVA occurrence [5]. LVAs have been associated with

myocardial free wall rupture, congestive heart failure,

left ventricular thrombus formation and ventricular tach-

yarrhythmias [3]. Acute VSD combined with LVA is

uncommon and usually occurs within the first week of

AMI.

2. Case Report

A 77-year-old diabetic and dyslipidemic male patient

suffered an anterior AMI. The patient was an active

smoker with a history of chronic obstructive pulmonary

disease, arterial hypertension and atrial fibrillation.

On day 1 he was referred to our hospital with symp-

toms of acute heart failure and renal dysfunction

(creatinine clearance 30 ml/min; estimated with the

Cockroft & Gault equation). Doppler-echocardiography

revealed an apical VSD, without valve disease, plus an

antero-apical LVA; the patient had an ejection fraction of

50% and pulmonary arterial systolic pressure of 70 mmHg.

Coronarography revealed occlusion of the anterior in-

terventricular artery and right coronary artery stenosis.

Preoperative Euroscore (standard Euroscore = 20, lo-

gistic Euroscore = 86.46%) graded the patient as high

risk.

The patient underwent surgery using typical bicaval

cannulation for the cardiopulmonary bypass circuit,

maintaining a blood temperature of 37˚C with warm

blood cardioplegia.

The antero-apical LVA was visible when the pericar-

dium was opened. Revascularization was performed with

a saphenous graft to the right coronary artery and a

skeletonized and pedicled left internal thoracic artery

graft to the interventricular artery.

A 6 cm long left ventriculotomy was performed paral-

lel to the interventricular artery (Figure 1) for VSD re-

pair. The VSD had a diameter of 1.5 cm with irregular

and weak edges (Figure 2). The VSD was covered with

a large equine pericardial patch fastened with U stitches

and the fragile apical portion of the septum was rein-

forced with Bioglue (CryoLife Inc., Georgia, USA).

The LVA was then repaired by intraventricular patch

176 K. AZARNOUSH ET AL.

Figure 1. Antero-apical ventriculotomy parallel to the in-

terventricular artery, opening the left ventricular aneu-

rysms.

Figure 2. Ventricular septal defect with irregular and weak

edges, close to the apical area.

remodelling (Hemapatch Intervascular, La Ciotat, France),

excluding the apex and septal patch from the ventricular

cavity (Video 1). Sutures were reinforced with Bioglue

(CryoLife Inc., Georgia, USA). The residual cavity be-

tween the patch and sutured edges of the ventriculotomy

was filled with Tissucol glue (Baxter Healthcare, Vienna,

Austria).

The patient was discharged 2 months after surgery and

was admitted to the orthopaedic surgery department for a

septic hip prosthesis 10 months later.

3. Discussion

The combination of an acute VSD and anterior LVA is a

rare, life-threatening complication of AMI. Surgical

treatment is technically demanding, with poor results due

to the fragility of the infarcted myocardial tissue. The

endoventricular patch remodelling procedure used in our

patient is a useful approach, allowing a direct view for

VSD patch implantation and aneurysm exclusion. The

risk of residual interventricular communication is con-

sidered to be reduced by this double exclusion of infarct-

ted myocardium. This technical procedure appears to be

feasible, even in high risk patients.

4. References

[1] B. S. Crenshaw, et al., “Risk Factors, Angiographic Pat-

terns, and Outcomes in Patients with Ventricular Septal

Defect Complicating Acute Myocardial Infarction. Gust o- I

(Global Utilization of Streptokinase and TPA for Oc-

cluded Coronary Arteries) Trial Investigators,” Circula-

tion, Vol. 101, No. 1, 2000, pp. 27-32.

[2] S. Pohjola-Sintonen, J. E. Muller, P. H. Stone, et al.,

“Ventricular Septal and Free Wall Rupture Complicating

Acute Myocardial Infarction: Experience In The Multi-

center Investigation Of Limitation Of Infarct Size,” Ameri-

can Heart Journal, Vol. 117, No. 4, 1989, pp. 809-818.

doi:10.1016/0002-8703(89)90617-0

[3] Y. Birnbaum, M. C. Fishbein, C. Blanche, et al., “Ven-

tricular Septal Rupture after Acute Myocardial Infarc-

tion,” The New England Journal of Medicine, Vol. 347,

No. 18, 2002, pp. 1426-1432.

doi:10.1056/NEJMra020228

[4] M. H. Dubnow, H. B. Burchell and J. L. Titus, “Postin-

farction Ventricular Aneurysm. A Clinicomorp hologic and

Electrocardiographic Study of 80 Cases,” American Heart

Journal, Vol. 70, No. 6, 1965, pp. 753-760.

doi:10.1016/0002-8703(65)90331-5

[5] V. Dor, et al., “Endoventricular Patch Reconstruction of

Ischemic Failing Ventricle. A Single Center with 20 Years

Experience. Advantages of Magnetic Resonance Imaging

Assessment,” Heart Fail Reviews, Vol. 9, No. 4, 2004, pp.

269-286. doi:10.1007/s10741-005-6804-5