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Rupture of the ventricular chamber (septum or free wall) after myocardial infarction is a relatively infrequent condition with high mortality. An acute postinfarction VSD is a perforation of the muscular ventricular septum occurring in an area of acutely infarcted myocardium. A ventricular septal rupture may be termed chronic when it has been present for more than 4 to 6 weeks. A postinfarction ventricular rupture is a perforation of the ventricular free wall occurring in an area of acutely infarcted myocardium. These conditions, resulting from transmural infarction, may cause rapid hemodynamic compromise and early death precluding surgical repair. Free wall rupture can result in tamponade and sudden cardiovascular collapse. In ventricular septal rupture, there is a variable amount of left-to-right shunting, but such defects typically lead to symptoms of heart failure. The clinical presentation ranges from an asymptomatic murmur to cardiogenic shock and sudden death.
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The early evolution of successful surgical repair of an acute postinfarction ventricular septal rupture involved differentiating the surgical treatment of these acquired lesions from surgical approaches used to repair congenital ventricular septal defects (VSDs), which are for the most part not applicable. Initial success was achieved with methods involving infarctectomy and patching. Specific methods were developed for differing anatomical locations of postinfarction VSDs, including location of the cardiotomy and patch methodology. With experience, there was gradual appreciation of different clinical courses pursued by patients after postinfarction ventricular septal rupture, both in terms of location of the defect and the degree of right ventricular functional impairment, led to an increased urgency relative to the timing of surgical repair. An important paradigm shift had resulted from improved results utsing a technique of endocardial patching with infarct exclusion. Surgical management requires an understanding of the various approaches. The incorporation of specific anatomic concepts of surgical repair and a better understanding of the physiologic basis of the disease has led to an integrated approach to the patient that has improved salvage of patients suffering this catastrophic complication of acute myocardial infarction (AMI).
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In 1845 Latham1 described a postinfarction ventricular septal rupture at autopsy, but it was not until 1923 that Brunn2 first made the diagnosis antemortem. Sager3 in 1934 added the 18th case to the world literature and established specific clinical criteria for diagnosis, stressing the association of postinfarction septal rupture with coronary artery disease (CAD).
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The treatment of this entity was medical and strictly palliative until 1956, when Cooley and associates4 performed the first successful surgical repair in a patient 9 weeks after the diagnosis of septal rupture. These first patients who underwent similar repairs in the early 1960s usually presented with congestive heart failure (CHF), having survived for more than a month after acute septal perforation.5,6 The success of operation in these patients and the precipitous, acute course of other patients with this complication gave rise to the belief that operative repair should be ...