Ventricular Septal Defect (VSD)

Postinfarct VSD

• • 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

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

Epidemiology

Postinfarct VSD

• • < 1% of patients with acute MI

  • Poor prognosis

  • -24% die on first day

    -65% by 2 weeks

    -81% by 2 mos

LV Aneurysm

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

Symptoms and Signs

Postinfarct VSD

• • Harsh holosystolic murmur along left sternal border

  • 67% have palpable thrill

LV Aneurysm

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

  • Prominent apical pulse

Laboratory Findings

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

Imaging Findings

Postinfarct VSD

• • Echocardiography: Definitive diagnosis

  • Catheterization: Also definitive

LV Aneurysm

• • Chest film: Localized LV bulge

  • Echocardiography and catheterization are definitive

• • Echocardiography and catheterization

Rule Out

• • 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

Postinfarct VSD

• • Preoperative intra-aortic balloon pump

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

LV Aneurysm

• • Resect aneurysm (Dor procedure) + coronary revascularization

Surgery

Indications

Postinfarct VSD

• • Indicated in nearly all cases

LV Aneurysm

• • Good to moderate operative risk

Contraindications

• • Postinfarct VSD: Advanced age with multiorgan failure

Complications

Postinfarct VSD

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

Prognosis

LV Aneurysm

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

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