Case Report
A 71-year-old male was referred to the emergency department of our hospital for out-of-hospital cardiopulmonary arrest. He was transferred to our hospital under cardiopulmonary resuscitation. By the time he arrived at the emergency room, spontaneous circulation had returned. The electrocardiogram revealed ST-segment–elevation myocardial infarction. Emergent coronary angiography was performed, and 99% stenosis of the left anterior descending coronary artery (#8) was detected. Transthoracic echocardiography (TTE) revealed VSR with left-to-right shunting. An intra-aortic balloon pump (IABP) and a Swan-Ganz catheter were inserted, and the patient was admitted to the intensive care unit. Fortunately, his hemodynamics were almost stable under IABP support without high-dose catecholamine administration. Our heart team decided that the best timing for the surgical intervention would be not immediately but within a week. Before the surgery, we assessed the TTE daily to confirm that the VSR was not growing and the extent of left-to-right shunting was not increasing. After day 3, the TTE revealed the VSR with interventricular septum dissection (Fig. 1), but the hemodynamics were stable, and the extent of shunting was also constant. The VSR was about 15 mm in diameter and the pulmonary artery pressure was 34/18 mmHg (mean, 23 mmHg). We conducted electrocardiogram-synchronized contrast computed tomography (CT) to determine the extent of the dissection of the interventricular septum (Fig. 2). Based on these factors, our heart team decided that the surgical intervention should be performed one week after admission.
The operation was performed under a full median sternotomy. A cardiopulmonary bypass (CPB) was established using the ascending aorta for arterial cannulation and the superior and inferior vena cava for vein cannulation. We used epicardial echocardiography to detect the dissecting intraventricular false lumen and incised the false lumen cavity directly to approach the VSR site of the ventricular septum. After antegrade cold blood cardioplegia was infused to arrest the heart, a longitudinal incision was made along the intraventricular false lumen. The fragile myocardium surrounding the VSR was excised. We decided to repair the VSR and interventricular septum dissection using a modification of the extended double patch technique. A bovine pericardium patch was trimmed to make a circle with a diameter of 3 cm, to be used as the first patch for inside of the left ventricle (LV) cavity. The first patch was sutured with eight 3-0 polypropylene sutures; each suture was placed transmurally from the LV cavity via the false cavity to the right ventricle (RV) side or the outside of the LV. The second patch was trimmed in the same way as the first patch and fixed to the false cavity using transseptal sutures brought into the false cavity and to the RV. Sutures brought outside of the heart were secured with Teflon felt. Glue was inserted into the VSR before final knotting. The false cavity was closed with two Teflon felt strips with 3-0 polypropylene sutures (Fig. 3). The CPB time and aortic cross-clamp time were 163 min and 115 min, respectively.
The patient’s postoperative course was almost completely stable. His hemodynamics were almost stable without IABP support on postoperative day 2. The postoperative TTE and CT revealed no residual shunt and no false lumen. However, a massive melena was detected on postoperative day 5. The CT revealed bowel ischemia, based on a thrombus from the shaggy aorta, and unfortunately the extent of the bowel ischemia was too massive to resect. The patient died on postoperative day 6.