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.