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British Heart,Journal, I970, 32, 863-866.
Clinical features and repair of ventricularseptal defect and
left ventricular aneurysmcomplicating myocardial infarction
A. D. Heath, A. M. Harris, and M. P. WrightFrom Departments of
Cardiology and Thoracic Surgery, St. George's Hospital, London
S.W.i
A 52-year-old man developed a ventricular septal defect and
ventricular aneurysm after myo-cardial infarction. The two defects
were repaired through the left ventricular aneurysm
usinghypothermic techniques. Only two similar cases have been
previously reported.
Myocardial infarction is frequently compli-cated by the
development of ventricularlesions, the commonest being a
ventricularaneurysm followed by ventricular septal defectand
ruptured papillary muscles. These ac-quired lesions are all
amenable to surgicalrepair, and this has become more common
inrecent years.The first successful repair of an acquired
ventricular aneurysm was made by Beck inI944 using a fascia lata
graft to plicate theaneurysm. Acquired ventricular septal defectwas
first surgically repaired by Cooley et al.(1957) using
cardio-pulmonary bypass andhypothermia. Subsequently similar
acquiredlesions were corrected surgically on manyoccasions, but not
until I962 were both de-fects repaired at the same operation. This
casereport describes the successful repair of anacquired
ventricular septal defect and leftventricular aneurysm through the
left ven-tricular aneurysm.
Case reportAn exhibition erector, a man of 52, was admittedto
St. George's Hospital, London, on 4 Novem-ber I967. Thirty-six
hours previously he had suf-fered a sudden attack of vomiting,
followed bydyspnoea and central chest pain which radiatedthrough to
the back. For several months he hadexperienced angina of effort.On
examination he was breathless at rest, with
central cyanosis. Pulse I28/minute regular, jugulo-venous
pressure + 6 cm. water, blood pressure120/85 mm. Hg.The heart
sounds were normal, but there was
a loud pansystolic murmur at the left sternal edge.There were
bilateral basal crepitations, the liverwas firm and palpable, but
there was no peripheraloedema.
The electrocardiogram (Fig. I) showed aninferior infarct, and
the chest x-ray (Fig. 2a)showed some cardiac enlargement and
bilateralpulmonary oedema.On the evening of admission he became
shocked
and there was wide splitting of the second soundin the pulmonary
area, the systolic murmur waslouder, and there was a pericardial
rub. The diag-nosis was thought to be either mitral
incompetencefrom a ruptured chorda or ventricular septal de-fect as
a result of an acute myocardial infarct.
Bed-rest and conservative management withdigoxin and diuretics
produced a good responseand over the next three weeks there was
steadyimprovement though the pansystolic murmurpersisted and the
second heart sound was widelysplit in expiration (Fig. 3a).By 5
December plans had been made for his
discharge to await cardiac catheterization in oneto two months,
but that morning he developedacute left ventricular failure which
respondedrapidly to intravenous frusemide and morphine.It was now
felt that he should undergo immediatecardiac catheterization with a
view to surgicalcorrection of his myocardial lesion.
Cardiac catheterization and angiocardiographywere performed on 8
December. A torrential left-to-right shunt was demonstrated by
serial bloodsamples at ventricular level and the pulmonaryartery
pressure was 50/25 mm. Hg, pulmonarycapillary mean pressure was I6
mm. Hg, andthe left ventricular end-diastolic pressure was 5mm. Hg.
Biplane Elema angiogram, with injec-tion of contrast medium into
the left ventricle,showed the mitral valve to be competent,
andconfirmed the left-to-right shunt at ventricularlevel (Fig. 2b).
The diaphragmatic surface of theleft ventricle was seen to move
paradoxically onx-ray screening, indicating a ventricular
aneurysm.Median sternotomy was started shortly after thecardiac
investigation was completed. Athin fibrousaneurysm was seen over
the diaphragmatic sur-face of the left ventricle and there was a
coarse
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864 Heath, Harris, and Wright
17-1l-2 3
VI V2 V3_
14-9s-2 3
r .1
.LV2 V3
v,,, .JEr.i4 .. - T
-
FIG. i Above. Pre-opegram showing Q waves i?V5-V6. Below.
Electroc(IO months after operatior,change from the pre-oper
F I G. 2 a Pre-operative ocardiac enlargement andcongestion.FI
G. 2b Elema angiogrAngioconray into the leftshowing simultaneous
filliright ventricles through tidefect and an inferior leftF I G.
2c Chest x-ray obafter operation showing asize and normal lung
field
b67 thrill palpable anteriorly over the septum whichaVR aVL aVF
could be abolished by local pressure.Right and left heart bypass
circuits were estab-
\~ %lished without an oxygenator, and the blood wascooled to 140
C. by heat exchanger in the linereturned to the femoral artery.
V4 V5vS The pumps were stopped and the still heart wasdislocated
forwards to expose the aneurysm. The
~ _ fibrous area was incised towards the apex of theheart, and
on examining the interior of the leftventricle a low septal defect
was found communi-cating by multiple holes with the trabeculae
ofthe right ventricle. Repair was effected with Tery-lene sutures
tied over Teflon felt buttresses. After
aVR aVL aV F excision of the thinned ventricular aneurysm,
theventricle was similarly repaired with sutures tiedover Teflon
felt buttresses.
Cardiac bypass was re-established, after 5 Iminutes of
circulatory arrest. Rewarming wascontinued for 72 minutes. The
heart was defibril-
V4 Vs. Vb lated by a single shock.After operation intermittent
positive pressure
NN- \, L \ via endotracheal tube was continued for I2 hours.The
heart sounds were normal and there were nomurmurs.
There was patchy basal pneumonia in the early,rative
electrocardio- post-operative period, and tracheostomy was per-i
leads II, III, aVF, formed on the sth day to facilitate
bronchialardiogram recorded aspiration. Good progress was made and
then showing very little tracheostomy tube was removed on the Iith
day.ative recording. Four weeks after operation he was ambulant.
His
chest was clear and there were no signs of failure.Maintenance
therapy with digoxin, frusemide andpotassium, and warfarin was
continued for 6
chest x-rays showing months and then tailed off. He took his own
dis-chestox-rays showong charge against medical advice on i
Januarypulmonary venous I968.He has been seen at intervals in
out-patients,
'am with injection of though a rather erratic attender, and 22
monthsventricular cavity, later he is well and working with only
occasional
ing of the left and chest pain after exertion.The
electrocardiogram recorded IO monthshze ventricular septal after
operation shows very little change from thetventricular aneurysm.
pre-operative recording (Fig. i). The chest x-rayxtained io months
(Fig. 2c) and phonocardiogram (Fig. 3b) werereduction in heart
normal.
ds.
ba c
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Repair of acquired ventricular septal defect and left
ventricular aneurysm 865
1 2 1 2 I: 2
PA
TA
CAK
POST-INFARC I VSD.
F IG . 3 a Pre-operative external phonocardio-gram showing the
pansystolic murmur and widesplitting of the second heart sound. The
timeintervals are 0O2o and o0o4 sec. PA, pulmon-ary area; TA,
tricuspid area; HF, high fre-quency; i, first heart sound; 2,
second heartsound; A2, aortic component; P2, pulmonarycomponent;
CAR, external carotid pulse;INSP, inspiration; L2, lead II of
electrocardio-gram.
DiscussionCollis et al. (I962) described the repair of a
ventricular septal defect and left ventricularaneurysm in a man
of 59. A similar procedurewas performed in I965 by Taylor et al.,
whocorrected the two defects in a 47-year-oldman. Both these
operations were performedusing profound hypothermia and access
tothe ventricular septal defect via the left ven-tricle, which thus
permitted coincident ex-cision of the ventricular aneurysm.
After myocardial infarction, the incidenceof ventricular septal
defect is about I per cent(Lee, Cardon, and Slodki, I962) and of
ven-tricular aneurysm about I5 per cent (Schlich-ter, Hellerstein,
and Katz, 1954). Figures forthe occurrence of both defects in the
sameheart can be derived from Schlichter et al.(I954): of I02
patients with ventricularaneurysm, 3 per cent had a coexisting
ven-tricular septal defect. Padhi et al. (I967)reviewed the I5
published reports of repairfor acquired ventricular septal defect,
and inthese there was a coexisting ventricular aneu-rysm in 6 of
the IS hearts. Only in the twocases cited above was the repair
recorded ofboth lesions with approach from the left ven-tricle. In
the other I3 cases approach wasfrom the right ventricle and only
the septaldefect was repaired.
-_2%
I2j .
F I G . 3 b Phonocardiogram recorded iomonths after operation
showing normal split-ting of the second heart sound and the
absenceof a systolic murmur, suggesting completeclosure of the
defect. EXP, expiration.
Acquired ventricular septal defects are as arule situated in the
lowest part of the septum.The normal surgical approach is from
theright ventricle. This access is, however, notideal, since the
defect is often buried in thelattice of trabeculae on the right
side of theseptum.Where a ventricular aneurysm coexists with
a ventricular septal defect, there is an obviousroute for access
to the septum since the leftventricular myocardium is already
damaged.The approach from the left which is thusafforded is ideal,
first in that the septum onthis side is smoother and the defect
thusmore easily defined, and secondly the leftventricular pressure
keeps the patch in con-tact with the septum, whereas a patch
appliedfrom the right side may be forced away fromthe septum.The
present patient has remained well for
two years after operation, experiencing dys-pnoea only on severe
exertion and being atfull-time work. Colris's patient survived
5years and 8 months, having enjoyed a fulllife (J. L. Collis, I969,
personal communica-tion). A necropsy showed the ventricular sep-tum
to be intact, and there was evidence ofthe old anterior infarct.
The patient of F. H.Taylor (I969, personal communication) re-mains
at work and is symptom free 5 yearsafter operation.
2
PA
1 2
A P2 2
1 2HF -i 1.
'F :..---- - - --,"q ..-t .1-1M.
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866 Heath, Harris, and Wright
The timing of operation to repair an ac-quired ventricular
septal defect is of import-ance. It is significant that the
patients underreview waited between 26 and 9I days fromthe
development of the ventricular septaldefect to its repair, and all
survived. Resultsafter earlier intervention were uniformly
bad(Padhi et al., I967). A period of several weeksallows time for
the edges of the septal defectto become fibrous and thus enable
safe sutur-ing of the myocardium. In the initial post-infarct state
the myocardium is so friable thatsuture is impossible.These
experiences show that surgical cor-
rection of ventricular septal defect caused bymyocardial
infarction is feasible and should beattempted in those patients who
survive thecritical period.
We wish to thank Dr. Aubrey Leatham andMr. Charles Drew for
permission to publish thiscase report and for their helpful advice
in prepar-ing the report.
ReferencesBeck, C. S. (I944). Operation for aneurysm of the
heart. Annals of Surgery, 120, 34.Collis, J. L., Mackinnon, J.,
Raison, J. C. A., and
Whittaker, S. R. F. (I962). Repair of acquiredinterventricular
septal defect following myocardialinfarction. Lancet, 2, I72.
Cooley, D. A., Belmonte, B. A., Zeis, L. B., andSchnur, S.
(1957). Surgical repair ofruptured inter-ventricular septum
following acute myocardial in-farction. Surgery, 41, 930.
Lee, W. Y., Cardon, L., and Slodki, S. J. (I962).Perforation of
infarcted interventricular septum.Archives of Internal Medicine,
109, 731.
Padhi, R. K., Fletcher, A. G., Dias, F., Servid, L. P.,Mutalik,
G. S., and Mody, S. M. S. (I967). Closureof ventricular septal
defect following myocardialinfarction. Archives of Surgery, 94,
I68.
ThlichterTJ., Hellerstein, H. K., and Katz, L. N.(1954).
Aneurysm of the heart: A correlative studyof I02 proved cases.
Medicine, 33, 43.
Taylor, F. H., Citron, D. S., Robicsek, F., and Sanger,P. W.
(I965). Simultaneous repair of ventricularseptal defect and left
ventricular aneurysm follow-ing myocardial infarction. Annals of
Thoracic Sur-gery, I, 72.
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