Successful Redo Post Infarction VSD Repair + CABG Surgery

Dr. Pavan Kumar, Dr. S Borkar, Dr. D Kulkarni, Dr. Amit Modi, Dr Prasad C, Dr. N Kothari, Dr. P.S Sanzgiri.

Department Of CardiacSurgery, Cardiology & Cardiac Anaesthesiology.

A 50 year old male patient, Mr. Ram Avatar Ram, an operated case of patch closure of post infarct VSD with CABG [ Single graft of RSVG to OM ) done elsewhere in Mumbai 3 months back was admitted to Lilavati Hospital on 6th Novembr’2003 with symptoms and signs suggestive of gross Congestive Cardiac Failure.

CLINICAL FEATURES:

The patient had Gr. II pansystolic murmur in the Lt. 4th, 5th Intercostals space. The patient’s blood pressure was 100 / 60 mmHg. The diuretic requirement was Injectable Lasix 60mg. ( 6th ) hrly with Tab. Aldactone 25mg ( 12 ) hrly.

INVESTIGATIONS :

Chest X-Ray revealed gross cardiomegaly with pulmonary edema.

ECG had changes showing old Anterior wall Infarct.

2D Echo showed a large VSD of 14mm at the apex with severe pulmonaryhypertension.

The LVEF was 30%.Coronary angiography done by Dr P Sanzgiri showed totally occluded LAD with no distal formation, 100% blocked Circumflex and the saphenous vein graft to OM showed 99% stenosis at distal Anastomosis. The OM was of good quality and caliber. LV angiography showed a VSD jet in the Apical region. LVEF was 30 – 35 %.

OPERATIVE PROCEDURE :

After proper antifailure treatment, the patient was taken for surgery on November 12th,2003 . Dobutamine infusion 7mic/kg/ min was started. BP was 100/ 70mm Hg. The Lt. femoral artery was isolated, looped and kept ready. Redo sternotomy was done. Fibrous adhesions over aorta, SVC, IVC and RA, RV was freed. A systolic thrill was felt over the RV.After heparinisation Aorta and bicaval cannulation was done and patient was put on cardiopulmonary bypass.Adhesions over L.Ventricle were freed. Scar of previous surgery present over the LV apex and the previous saphenous vein graft was also seen. Cross clamp applied and cardoplegia given. LV was opened though the previous incision. Dacron patch was seen in situ. There was a separate VSD inferior to this patch. This VSD ( 8mm x 8mm ) was closed with 3 – 0 prolene pledgetted horizontal mattress sutures ( 3 sutures) .Left ventriculotomy closed. Reverse saphenous vein grafting of the OM done. Deairing done

Patient was gradually weaned off cardiopulmonary bypass with Dobutamine infusion of 7mic / kg/min. Patient was shifted to surgical ICCU with stable hemodynamics .

Post operative recovery was uneventful and patient was discharged on seventh post operative day. Patient followed up in the OPD on 15th post operative day and did not have any complaints.

REVIEW OF LITERATURE

Post infarct VSD is serious complication of myocardial infarction with 90% of patients dying before two months in published series .They occour in 1 - 2 % of cases of myocardial infarction and appear from 2 – 3 days upto 2 weeks of post infarction period. Early death is very common.

Urgent surgical repair is the only treatment option available . These patients usually require IABP support.

Early mortality post repair is very high ( 35% ) , 50% of them die because of congestive cardiac failure , 10% have sudden death and 5% die because of cerebrovascular accidents.

CONCLUSION

The VSD in this case was probably a missed VSD during previous surgery or post infarct VSD which has given way later.

This complex operation can be performed successfully with the use of latest technology and proper understanding of the pathology.