Postinfarction ventricular septal defect is a rare mechanical complication of myocardial infarction, with difficult management, debated closure timing and high mortality rates.
Standard repair techniques – infarcectomy and infarct exclusion through a left ventriculotomy – are surgically challenging and have high risk of operative mortality and frequently suboptimal results.
We report the case of a 66-year-old patient with a 1.4 cm septal rupture developed after a sub-acute STEMI.
At the admission, he had chest pain and moderate dyspnoea, EKG showed inferior STEMI with increased myocardial necrosis markers. Echocardiography showed a preserved ejection fraction, akinesia of the inferior, posterolateral walls and of the posterobasal septum, with septal rupture at this level and 1.5 Qp/Qs ratio. A total occlusion of proximal right main coronary artery was found at coronary angiography.
After the heart team meeting, we performed a new modified closure, in urgent setting, using two hand-made composite patches (Fig. 1) parachuted through a transversal aortotomy and a right atriotomy, without left ventriculotomy (Fig. 2). In the 7th postoperative day a second septal rupture was detected at the echocardiographic control. After two weeks follow-up in optimized medical therapy, we decided to complete the closure of the later developed septal rupture percutaneously using an Amplatzer device.
Six months after the event, the patient is still asymptomatic and echocardiography documents a 50% ejection fraction, with trivial residual left-to-right shunt and normal valve function. Computed tomography scans confirmed optimal surgical result. Timing, management and surgical strategy are still on debate. Our technique is effective, simple, reproducible and provides good result (Fig. 3) and can be perfectly integrated in a hybrid approach.