Evolving a strategy for management

of post myocardial infarction

Ventricular septal rupture
Departments of Cardiac Surgery,
Cardiac Anaesthesia and Cardiology
Presented by Dr Suraj Pai
 The Heart Team
• Dr Ramsankar P, Dr Sreevatsa K Prasad, Dr
Hemachandran M,Dr Durgaprasad Rath ,Dr B V
Saichandran
• Dr Satyen Parida,Dr Ajay kumar Jha, Dr Sakthirajan,Dr
Chitra,Dr Ashok Sankar Badhe Dr Sandheep Misra
• Dr Ajith A,Dr Avinash,Dr Santhosh Satheesh,Dr Raja
Selvaraj
• Dr Kulkarni,Dr Abhishek Dr Basu
• The Perfusion team ,Nursing team, and the department
of Transfusion medicine
• Senior Residents of CTVS, Cardiology,Anaestheisa and
Bloodbank
 Surgical repair of Post AMI VSR
• Outline of the problem
• History of Surgical repair
• Our Statistics 2013 to 2018
• Patient characteristics
• What we did differently in 2018
• Optimal preoperative preparation
• Essential steps in surgical repair
• Conclusion and message
 Outline of the Problem
• Universal scenario (rare,rarer after early
intervention for ACS, 1 surgeon operates 1
case per year Mortality varies (mean
50%,range 12-84%)
• Indian scenario
• 2003 aggressive management suggested
• 2018 delayed surgery by 7 days to 21 days
yields as low as 10% mortality
 Indian Scenario

In unoperated cases, early death is common;

50% die in
<7 days, 70% within 2 weeks, and 80%-90% die
within 4 weeks[
History of Surgical repair
 Our Statistics
• 2013-2018 (N=15)
– 8 Patients, 4 male ,4 Female operated 2 Survived
but lost on followup after 6 months
– 7 patients either refused surgery or went
elsewhere
• 2018 (N=8)
– 4 were operated 2 male 2 female followup from 3
weeks to 10 months
– 4 did not come to surgery(2 mortality, 2 refused)
Patient characteristics at presentation
• Sex
• Age
• Presentation(Shock,Pul edema,Acs,)
• Duration between MI and VSR
• Intervention (Primary
PTCA/Thrombectomy/Thrombolysis)
• Euroscore 2(at presentation/ at surgery)
 Cardiology data(Table
• ECG-(Type of MI, )
• ECHO LVEF,RWMA,MR,TR, Pericardial effusion
• Site and size of VSR, Shunt L to right >2:1
• Coronary angiogram findings
 Patient characteristics 2013-18
Ag S Typ An Typ MI VSR to Eurosc Thro Natu Status of
e e e of gio e of to surger ore 2 mbol re of patient on
x MI VSR VSR y DAYS mortali ysis/ Surg table
days ty risk PCI/ ery

62 M AW 3 A 12 13 47.5 PCI S Inotropes

CPR
60 M AW 1 A 7 78 2.83 No EL Stable
65 M IW 2 B 2 1 28.9 STK S Inotropes
Intubated
50 F IW 2 B 11 1 19 No U Stable,
crashed
66 F AW 1 A 7 1 13.6 No U stable
60 F AW 1 A 4 5 5.63 No E Stable
70 F AW 2 A NA 2 29.8 No S CPR
52 M AW 1 A 2 2 12.43 no E Intubated
 Patient characteristics 2013-18
Ag Se mort Nature Characte
e x ality of ristic of
risk Surgery VSR
62 M 47.5 Sa Apical,
friable
60 M 2.83 EL Apical,
good rim
65 M 28.9 Sa Mid
basal,
friable
50 F 19 U Posterior
basal
multiple
66 F 13.6 U Apical,
friable
60 F 5.63 EM Apical,
friable
70 F 29.8 Sa Apical,
friable
 Patient characteristics 2018
Patients who did not have Patients who went for surgery
surgery
Age Sex MI- TYPE STAT EUR Age Sex MI- TYP STA EU
VSR OF US OSC VSR E TUS RO
TIME VSR ORE TIM OF SC
2 E VSR OR
E2
 The Change
Timing Critical Type of Type of CPB Cross Post Outco Follow
of status VSR Repair time clamp operati me up
surgery time ve
status