CASE REPORT
A previously healthy 59 years old male presented to an outside facility
with an 8-day history of acute chest pain with subsequent dyspnea on
exertion. Electrocardiogram showed inferior Q waves with ST segment
elevation. Coronary angiogram revealed occlusion of the right coronary
artery. Three drug eluting stents were placed in the right coronary
artery. Subsequent echocardiogram demonstrated a large posterior
ventricular septal defect (VSD) involving the papillary muscle of the
tricuspid valve, severe tricuspid regurgitation, inferior wall akinesia,
decreased left ventricular ejection fraction (LVEF) and mild to moderate
right ventricular dysfunction (Figure 1).
Subsequently, the patient was transferred to our hospital for further
management. Upon arrival, the patient was bradycardic and hypotensive.
An intra-aortic balloon pump was placed, and inotropic support was
started. Nevertheless, signs of multi-organ failure developed.
Peripheral veno-arterial extracorporeal membrane oxygenator (VA ECMO)
was placed to stabilize the patient as a bridge to operation. Since the
patient’s femoral arteries were severely calcified, a peripheral VA ECMO
was established through the right axillary artery and the right femoral
vein. Over the following 72 hours, the patient showed significant
clinical and biochemical improvement. Definite surgical correction was
performed.
Considering the location of the VSD, a right atrial approach was
utilized. A ruptured papillary muscle to the posterior leaflet of
tricuspid valve was demonstrated intraoperatively. The edge of septal
defect was located approximately 2 cm below the tricuspid valve annulus.
The defect was approximately 3 cm in diameter (Figure 2A). The obvious
necrotic tissue was debrided. Pledget buttressed polypropylene 2-0
sutures were placed around the circumference of the ventricular septal
defect with the pledgets on the left ventricular side (3). Sutures in
the area near the free wall of the right ventricle were fixed from the
outer wall of the right ventricle directly. A bovine pericardial patch
was tailored and placed using the prefixed stiches. A running 3-0
polypropylene suture was used to secure edge of the patch (Figure 2B). A
tricuspid valve replacement was also performed.
The patient was easily weaned off cardiopulmonary bypass with minimal
inotropic support. Intra-operative transesophageal echocardiogram showed
an intact ventricular septum and normally functioning biological
prosthetic valve without significant gradient. The patient was weaned
from the ventilator within 48 hours. The remainder of the post-operative
course was uneventful. The patient was discharged on post-operative day
9.