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.