heart,journal, clinical ventricular aneurysm infarction · british heart,journal, i970, 32,...

British Heart,Journal, I970, 32, 863-866.

Clinical features and repair of ventricularseptal defect and left ventricular aneurysmcomplicating myocardial infarction

A. D. Heath, A. M. Harris, and M. P. WrightFrom Departments of Cardiology and Thoracic Surgery, St. George's Hospital, London S.W.i

A 52-year-old man developed a ventricular septal defect and ventricular aneurysm after myo-cardial infarction. The two defects were repaired through the left ventricular aneurysm usinghypothermic techniques. Only two similar cases have been previously reported.

Myocardial infarction is frequently compli-cated by the development of ventricularlesions, the commonest being a ventricularaneurysm followed by ventricular septal defectand ruptured papillary muscles. These ac-quired lesions are all amenable to surgicalrepair, and this has become more common inrecent years.The first successful repair of an acquired

ventricular aneurysm was made by Beck inI944 using a fascia lata graft to plicate theaneurysm. Acquired ventricular septal defectwas first surgically repaired by Cooley et al.(1957) using cardio-pulmonary bypass andhypothermia. Subsequently similar acquiredlesions were corrected surgically on manyoccasions, but not until I962 were both de-fects repaired at the same operation. This casereport describes the successful repair of anacquired ventricular septal defect and leftventricular aneurysm through the left ven-tricular aneurysm.

Case reportAn exhibition erector, a man of 52, was admittedto St. George's Hospital, London, on 4 Novem-ber I967. Thirty-six hours previously he had suf-fered a sudden attack of vomiting, followed bydyspnoea and central chest pain which radiatedthrough to the back. For several months he hadexperienced angina of effort.On examination he was breathless at rest, with

central cyanosis. Pulse I28/minute regular, jugulo-venous pressure + 6 cm. water, blood pressure120/85 mm. Hg.The heart sounds were normal, but there was

a loud pansystolic murmur at the left sternal edge.There were bilateral basal crepitations, the liverwas firm and palpable, but there was no peripheraloedema.

The electrocardiogram (Fig. I) showed aninferior infarct, and the chest x-ray (Fig. 2a)showed some cardiac enlargement and bilateralpulmonary oedema.On the evening of admission he became shocked

and there was wide splitting of the second soundin the pulmonary area, the systolic murmur waslouder, and there was a pericardial rub. The diag-nosis was thought to be either mitral incompetencefrom a ruptured chorda or ventricular septal de-fect as a result of an acute myocardial infarct.

Bed-rest and conservative management withdigoxin and diuretics produced a good responseand over the next three weeks there was steadyimprovement though the pansystolic murmurpersisted and the second heart sound was widelysplit in expiration (Fig. 3a).By 5 December plans had been made for his

discharge to await cardiac catheterization in oneto two months, but that morning he developedacute left ventricular failure which respondedrapidly to intravenous frusemide and morphine.It was now felt that he should undergo immediatecardiac catheterization with a view to surgicalcorrection of his myocardial lesion.

Cardiac catheterization and angiocardiographywere performed on 8 December. A torrential left-to-right shunt was demonstrated by serial bloodsamples at ventricular level and the pulmonaryartery pressure was 50/25 mm. Hg, pulmonarycapillary mean pressure was I6 mm. Hg, andthe left ventricular end-diastolic pressure was 5mm. Hg. Biplane Elema angiogram, with injec-tion of contrast medium into the left ventricle,showed the mitral valve to be competent, andconfirmed the left-to-right shunt at ventricularlevel (Fig. 2b). The diaphragmatic surface of theleft ventricle was seen to move paradoxically onx-ray screening, indicating a ventricular aneurysm.Median sternotomy was started shortly after thecardiac investigation was completed. Athin fibrousaneurysm was seen over the diaphragmatic sur-face of the left ventricle and there was a coarse

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864 Heath, Harris, and Wright

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FIG. i Above. Pre-opegram showing Q waves i?V5-V6. Below. Electroc(IO months after operatior,change from the pre-oper

F I G. 2 a Pre-operative ocardiac enlargement andcongestion.FI G. 2b Elema angiogrAngioconray into the leftshowing simultaneous filliright ventricles through tidefect and an inferior leftF I G. 2c Chest x-ray obafter operation showing asize and normal lung field

b67 thrill palpable anteriorly over the septum whichaVR aVL aVF could be abolished by local pressure.Right and left heart bypass circuits were estab-

\~ %lished without an oxygenator, and the blood wascooled to 140 C. by heat exchanger in the linereturned to the femoral artery.

V4 V5vS The pumps were stopped and the still heart wasdislocated forwards to expose the aneurysm. The

~ _ fibrous area was incised towards the apex of theheart, and on examining the interior of the leftventricle a low septal defect was found communi-cating by multiple holes with the trabeculae ofthe right ventricle. Repair was effected with Tery-lene sutures tied over Teflon felt buttresses. After

aVR aVL aV F excision of the thinned ventricular aneurysm, theventricle was similarly repaired with sutures tiedover Teflon felt buttresses.

Cardiac bypass was re-established, after 5 Iminutes of circulatory arrest. Rewarming wascontinued for 72 minutes. The heart was defibril-

V4 Vs. Vb lated by a single shock.After operation intermittent positive pressure

NN- \, L \ via endotracheal tube was continued for I2 hours.The heart sounds were normal and there were nomurmurs.

There was patchy basal pneumonia in the early,rative electrocardio- post-operative period, and tracheostomy was per-i leads II, III, aVF, formed on the sth day to facilitate bronchialardiogram recorded aspiration. Good progress was made and then showing very little tracheostomy tube was removed on the Iith day.ative recording. Four weeks after operation he was ambulant. His

chest was clear and there were no signs of failure.Maintenance therapy with digoxin, frusemide andpotassium, and warfarin was continued for 6

chest x-rays showing months and then tailed off. He took his own dis-chestox-rays showong charge against medical advice on i Januarypulmonary venous I968.He has been seen at intervals in out-patients,

'am with injection of though a rather erratic attender, and 22 monthsventricular cavity, later he is well and working with only occasional

ing of the left and chest pain after exertion.The electrocardiogram recorded IO monthshze ventricular septal after operation shows very little change from thetventricular aneurysm. pre-operative recording (Fig. i). The chest x-rayxtained io months (Fig. 2c) and phonocardiogram (Fig. 3b) werereduction in heart normal.

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Repair of acquired ventricular septal defect and left ventricular aneurysm 865

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F IG . 3 a Pre-operative external phonocardio-gram showing the pansystolic murmur and widesplitting of the second heart sound. The timeintervals are 0O2o and o0o4 sec. PA, pulmon-ary area; TA, tricuspid area; HF, high fre-quency; i, first heart sound; 2, second heartsound; A2, aortic component; P2, pulmonarycomponent; CAR, external carotid pulse;INSP, inspiration; L2, lead II of electrocardio-gram.

DiscussionCollis et al. (I962) described the repair of a

ventricular septal defect and left ventricularaneurysm in a man of 59. A similar procedurewas performed in I965 by Taylor et al., whocorrected the two defects in a 47-year-oldman. Both these operations were performedusing profound hypothermia and access tothe ventricular septal defect via the left ven-tricle, which thus permitted coincident ex-cision of the ventricular aneurysm.

After myocardial infarction, the incidenceof ventricular septal defect is about I per cent(Lee, Cardon, and Slodki, I962) and of ven-tricular aneurysm about I5 per cent (Schlich-ter, Hellerstein, and Katz, 1954). Figures forthe occurrence of both defects in the sameheart can be derived from Schlichter et al.(I954): of I02 patients with ventricularaneurysm, 3 per cent had a coexisting ven-tricular septal defect. Padhi et al. (I967)reviewed the I5 published reports of repairfor acquired ventricular septal defect, and inthese there was a coexisting ventricular aneu-rysm in 6 of the IS hearts. Only in the twocases cited above was the repair recorded ofboth lesions with approach from the left ven-tricle. In the other I3 cases approach wasfrom the right ventricle and only the septaldefect was repaired.

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F I G . 3 b Phonocardiogram recorded iomonths after operation showing normal split-ting of the second heart sound and the absenceof a systolic murmur, suggesting completeclosure of the defect. EXP, expiration.

Acquired ventricular septal defects are as arule situated in the lowest part of the septum.The normal surgical approach is from theright ventricle. This access is, however, notideal, since the defect is often buried in thelattice of trabeculae on the right side of theseptum.Where a ventricular aneurysm coexists with

a ventricular septal defect, there is an obviousroute for access to the septum since the leftventricular myocardium is already damaged.The approach from the left which is thusafforded is ideal, first in that the septum onthis side is smoother and the defect thusmore easily defined, and secondly the leftventricular pressure keeps the patch in con-tact with the septum, whereas a patch appliedfrom the right side may be forced away fromthe septum.The present patient has remained well for

two years after operation, experiencing dys-pnoea only on severe exertion and being atfull-time work. Colris's patient survived 5years and 8 months, having enjoyed a fulllife (J. L. Collis, I969, personal communica-tion). A necropsy showed the ventricular sep-tum to be intact, and there was evidence ofthe old anterior infarct. The patient of F. H.Taylor (I969, personal communication) re-mains at work and is symptom free 5 yearsafter operation.

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866 Heath, Harris, and Wright

The timing of operation to repair an ac-quired ventricular septal defect is of import-ance. It is significant that the patients underreview waited between 26 and 9I days fromthe development of the ventricular septaldefect to its repair, and all survived. Resultsafter earlier intervention were uniformly bad(Padhi et al., I967). A period of several weeksallows time for the edges of the septal defectto become fibrous and thus enable safe sutur-ing of the myocardium. In the initial post-infarct state the myocardium is so friable thatsuture is impossible.These experiences show that surgical cor-

rection of ventricular septal defect caused bymyocardial infarction is feasible and should beattempted in those patients who survive thecritical period.

We wish to thank Dr. Aubrey Leatham andMr. Charles Drew for permission to publish thiscase report and for their helpful advice in prepar-ing the report.

ReferencesBeck, C. S. (I944). Operation for aneurysm of the

heart. Annals of Surgery, 120, 34.Collis, J. L., Mackinnon, J., Raison, J. C. A., and

Whittaker, S. R. F. (I962). Repair of acquiredinterventricular septal defect following myocardialinfarction. Lancet, 2, I72.

Cooley, D. A., Belmonte, B. A., Zeis, L. B., andSchnur, S. (1957). Surgical repair ofruptured inter-ventricular septum following acute myocardial in-farction. Surgery, 41, 930.

Lee, W. Y., Cardon, L., and Slodki, S. J. (I962).Perforation of infarcted interventricular septum.Archives of Internal Medicine, 109, 731.

Padhi, R. K., Fletcher, A. G., Dias, F., Servid, L. P.,Mutalik, G. S., and Mody, S. M. S. (I967). Closureof ventricular septal defect following myocardialinfarction. Archives of Surgery, 94, I68.

ThlichterTJ., Hellerstein, H. K., and Katz, L. N.(1954). Aneurysm of the heart: A correlative studyof I02 proved cases. Medicine, 33, 43.

Taylor, F. H., Citron, D. S., Robicsek, F., and Sanger,P. W. (I965). Simultaneous repair of ventricularseptal defect and left ventricular aneurysm follow-ing myocardial infarction. Annals of Thoracic Sur-gery, I, 72.



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