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Postinfarct VSD

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  • • Infarction of interventricular septum with subsequent VSD formation

    • Interval between myocardial infarction (MI) and septal rupture: 1-12 days

    Histologic findings: Cardiac muscle degeneration and weakening

    • Classically, sudden shock or congestive heart failure develops in a patient after MI

    • Defect in anterior apical septum if left anterior descending coronary artery occlusion, posterior basilar septum if right coronary occlusion

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LV Aneurysm

+

  • • Large MI progresses to thinned-out transmural scar, bulges paradoxically during systole

    • 90% of aneurysms involve anteroseptal LV, 10% posterior

    • 50% contain mural thrombus

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Epidemiology

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Postinfarct VSD

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  • • < 1% of patients with acute MI

    • Poor prognosis

    • -24% die on first day

      -65% by 2 weeks

      -81% by 2 mos

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LV Aneurysm

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  • • 2-4% of MI, incidence is decreasing with more aggressive management of MI

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Symptoms and Signs

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Postinfarct VSD

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  • • Harsh holosystolic murmur along left sternal border

    • 67% have palpable thrill

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LV Aneurysm

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  • • Congestive heart failure, angina, embolization, ventricular dysrhythmias

    • Prominent apical pulse

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Laboratory Findings

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  • • ECG: Q wave MI with persistent ST segment elevation

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Imaging Findings

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Postinfarct VSD

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  • • Echocardiography: Definitive diagnosis

    • Catheterization: Also definitive

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LV Aneurysm

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  • Chest film: Localized LV bulge

    • Echocardiography and catheterization are definitive

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  • • Echocardiography and catheterization

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Rule Out

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  • • Papillary muscle dysfunction

    • Rupture of papillary muscle with acute mitral insufficiency

    • Pericardial friction rub after MI (Dressler syndrome)

+

  • • Echocardiography: for definitive diagnosis

    • Catheterization allows assessment of coronary anatomy

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Postinfarct VSD

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  • • Preoperative intra-aortic balloon pump

    • Operation: Patch closure of VSD (using double patch) + coronary artery bypass performed early

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LV Aneurysm

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  • • Resect aneurysm (Dor procedure) + coronary revascularization

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Surgery

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Indications

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Postinfarct VSD

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  • • Indicated in nearly all cases

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LV Aneurysm

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  • • Good to moderate operative risk

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Contraindications

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  • Postinfarct VSD: Advanced age with multiorgan failure

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Complications

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Postinfarct VSD

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  • • 50-80% survive operation depending on degree of multiorgan failure

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Prognosis

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LV Aneurysm

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  • • Improvement in congestive heart failure, angina in 70-85% of survivors

    • 70-80% of patients alive 5 years postoperatively, significantly more than those who received medical therapy

    • Operative mortality: 5% elective, 20% for emergency procedures

    • Subendocardial resection for ventricular tachycardia: 11% mortality

++

References

Chaux AC et ...

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