Post MI VSD

PowerPoint Presentation: 

Dr.M.Azam Shah Post Graduate Resident CCU III Punjab Institute Of Cardiology Lahore Pakistan

BIODATA: 

BIODATA Mehar Angez Sultana W\O Rehmat Ali 58 years Iqbal Town Lahore Housewife Admission: ER November 22,2011

PRESENTING COMPLAINTS: 

PRESENTING COMPLAINTS Exertional Shortness Of Breath 1 Month Mild Chest Discomfort Chest Tightness 1 Hour Severe Shortness of Breath

HOPI: 

HOPI SOB was gradual in onset and pregressed to Dyspnoa at rest (Grade IV) Associated with Mild chest discomfort and generalized weakness… Denied any H\O chest pain or pain in Lt. arm.

HOPI…: 

HOPI… Condition deteriorated 1 hour back when she suddenly developed severe breathlessness associated with chest tightness and sweating.

Systemic Review: 

Systemic Review GIT Nausea and Decreased Appetite CNS NAD Musculoskeletal Bodyaches and Generalized weakness

Past History: 

Past History Non Diabetic Non Hypertensive No H\O other Illness in past

Personal History: 

Personal History Housewife Non smoker Married with 3 Daughters and 2 sons

Family History: 

Family History Father was Diabetic One younger sister died of IHD at the age of 40 Drug History Nil

GPE: 

GPE Pallor +ve Jaundice -ve Clubbing -ve Thyroid -ve JVP Raised P.Edema -ve Pulse Not Palpable Bp Not Recordable RR 20 Temp Afebrile

Systemic Examination: 

Systemic Examination CVS Holosystolic Murmur,Best heard over LPS area, radiating across precordium ass e thrill JVP Raised Respiratory system NVB with Basal crepts GIT NAD CNS NAD

Diagnosis: 

Diagnosis Recent STEMI (Anteroseptal) complicated by Ventricular Septal Rupture with Cardiogenic Shock

Postinfarction VSD: 

Postinfarction VSD

INCIDENCE: 

INCIDENCE In the era before reperfusion therapy, septal rupture complicated 1-3 % of acute myocardial infarctions. Among the 41,021 patients in (GUSTO-I) trial, VSD was suspected in 140 patients ( 0.34 %) Thus, reperfusion therapy has decreased the incidence of septal rupture.

RISK FACTORS: 

RISK FACTORS Advanced Age Female sex Absence of Smoking Hypertension Size of Infarct RV Involvement

Overview: 

Overview Average time to rupture is 2-4 days Range: few hours  2 weeks Time course may be accelerated by thrombolysis, possiblly related to intramyocardial hemorrhage SHOCK Trial Rupture occurred at median of 16 hours after infarction

Diagnosis: 

Diagnosis Clinical Echocardiography Left heart catheterization with coronary angiography Swan-Ganz catheter oxygen saturation step-up between the right atrium and pulmonary artery in VSD (>9%) Qp/Qs range from 1.4:1 to greater than 8:1 and roughly correlate with the size of the defect

Anatomy of VSDs: 

Anatomy of VSDs Two types of VSD Simple : through and through defect usually located anteriorly Complex : serpentiginous dissection tract remote from the primary septal defect- most commonly an inferior VSD

CLASSIFICATION: 

CLASSIFICATION Becker and van Mantgem classified the free-wall rupture into three types, which are also relevant to ventricular septal rupture Type I Have an abrupt tear in the wall without thinning Type II Infarcted myocardium erodes before rupture occurs and is covered by a thrombus Type III Marked thinning of the myocardium, secondary formation of an aneurysm, and perforation in the central portion of the aneurysm

Natural History : 

Natural History Post MI VSD Without Surgery 25% died within 24hrs 50% died within one week 65% died within 2 weeks 80% died within 4 weeks 7% lived longer than one year

PowerPoint Presentation: 

Hemodynamics

PowerPoint Presentation: 

SEPTAL RUPTURE LEFT-TO-RIGHT SHUNT RIGHT VENTRICULAR VOLUME OVERLOAD, INCREASED PULMONARY BLOOD FLOW LEFT VENTRICULAR SYSTOLIC FUNCTION DETERIORATES SYSTOLIC PRESSURE DECLINES LEFT-TO-RIGHT SHUNTING DECREASES FRACTION OF THE SHUNT DIMINISHES

ANGIOGRAPHIC FINDINGS: 

ANGIOGRAPHIC FINDINGS VSR is likely to be associated with total occlusion of the infarct-related artery. In the GUSTO-I study, total occlusion of the infarct-related artery was documented in 57% of patients

ANGIOGRAPHIC FINDINGS: 

ANGIOGRAPHIC FINDINGS Some studies have found that septal rupture is associated with Multivessel coronary artery disease 1 High prevalence ( 54 % ) of single-vessel disease among patients with ventricular septal rupture 2 Collaterals are less often evident in patients with ventricular septal rupture 1 Radford MJ, Johnson RA, Daggett WM Jr, et al. Ventricular septal rupture:a review of clinical and physiologic features and an analysis of survival. Circulation 1981;64:545-53. 2 Skehan JD, Carey C, Norrell MS, de Belder M, Balcon R, Mills PG.Patterns of coronary artery disease in post-infarction ventricular septal rupture. Br Heart J 1989;62:268-72

SHOCK Trial: 

SHOCK Trial

Medical Management: 

Medical Management Measures are temporary,Time buying coz abrupts detrioration can occur. Oxygen IABP Inotropic support Diuretics Nitroprusside Decrease shunting Increase CO Cause Hypotension Not given with derranged RFTs

Timing of Surgery: 

Timing of Surgery Surgery should be performed soon after diagnosis in most patients Patients is cardiogenic shock should be operated on immediately after anigography

PowerPoint Presentation: 

Denton Arthur Cooley First successful human heart transplant First successful artificial heart implant First successful Post MI VSD Repair Poineer of Exclusion Technique

Operative Technique: 

Operative Technique Classical approach to Antero-septal rupture Infarctectomy, and Reconstruction of the ventricular septum with Dacron patches

Operative Technique: 

Operative Technique Classical approach to Infro-posterior rupture Infarctectomy, and Reconstruction of infroposterior VSD, Reconstruction free wall with Dacron patches.

Exclusion Technique: 

Exclusion Technique Exclusion technique LV excluded from the infarcted muscle using a bovine pericardial patch sutured to the healthy peri-infarct endocardium No infarctectomy is performed RV is undisturbed Better RV function preservation May help support the posteromedial papillary muscle

Operative Mortality and Risk Factors for Death : 

Operative Mortality and Risk Factors for Death Additional risk factors for early and late death Left main coronary artery disease Previous myocardial infarction Renal dysfunction Right heart failure The mortality of patients with an anterior VSD and a posterior VSD was 29.6% vs 42.8%

Outcome: 

Outcome Residual Lt.  Rt. shunt Reported in up to 28% of survivors Associated with high mortality Intra-operative TEE useful in early detection and correction if deemed necessary attributable to the Reopening of a closed defect Presence of an overlooked VSD Development of a new septal perforation during the early postoperative period

PowerPoint Presentation: 

OPTIONS

1: 

1 Conservative Management 1) spontaneous closure 2) Stable patients 3) Small Shunts

2: 

2 Repair through Right Atrium with Right Thoracotomy on beating heart technique Reason: Redo surgery is complex High mortality and morbidity

3: 

3 Transcatheter closure with the Amplatzer septal occluder

PowerPoint Presentation: 

THANKS

CLASSIFICATION: 

CLASSIFICATION Becker and van Mantgem classified the free-wall rupture into three types, which are also relevant to ventricular septal rupture Type I Have an abrupt tear in the wall without thinning Type II Infarcted myocardium erodes before rupture occurs and is covered by a thrombus Type III Marked thinning of the myocardium, secondary formation of an aneurysm, and perforation in the central portion of the aneurysm

Diagnosis: 

Diagnosis Clinical Color flow Doppler mapping Left heart catheterization with coronary angiography Swan-Ganz catheter oxygen saturation step-up between the right atrium and pulmonary artery in VSD (>9%) Qp/Qs range from 1.4:1 to greater than 8:1 and roughly correlate with the size of the defect

Diagnosis: 

Diagnosis Pre-OP left heart catheterization with coronary angiography ? To know associated coronary artery disease, left ventricular wall motion, and specifics of valvular dysfunction to plan surgery 60% at least one vessel disease It is time consuming contribute to both the mortality and morbidity of these already compromised patients

Diagnosis: 

Diagnosis Post MI VSD VS. MR Swan-Ganz catheter oxygen saturation step-up between the right atrium and pulmonary artery in VSD (>9%) Qp/Qs range from 1.4:1 to greater than 8:1 and roughly correlate with the size of the defect Classic giant V-waves in the pulmonary artery wedge pressure trace in MR

Diagnosis: 

Diagnosis Post MI VSD VS. MR Color flow Doppler mapping Smyllie et al reported a 100% specificity and 100% sensitivity to differentiate VSD from acute severe MR following acute MI Correctly demonstrated the site of septal rupture in 41 of 42 patients

PowerPoint Presentation: 

These residual defects are easily diagnosed with the aid of color-flow Doppler investigations. Residual VSDs may be attributable to the reopening of a closed defect, the presence of an overlooked VSD, or the development of a new septal perforation during the early postoperative period. Reoperation is required for closure of such residual defects when the Qp-to-Qs ratio is greater than 2. When these VSDs are small and asymptomatic, a conservative approach may be recommended because spontaneous closure can occur.

PowerPoint Presentation: 

Denton Arthur Cooley First successful human heart transplant First successful artificial heart implant First successful Post MI VSD Repair Poineer of Exclusion Technique