Discussion
Patient’s myocardium with post-infarction VSD is characterized by severe
dysfunction. The “additive ischemia” caused by aortic cross clamp,
ischemia and reperfusion injury, has a significant aggravation to the
myocardium and overall negative impact to patient’s outcome(6) . So, the operations are very high risk, and try to do the
best during myocardial preservation.
Post infarction VSR constitutes a severe mechanical complication of CAD
with very high surgical morbidity and mortality up to 50%. Many factors
contribute to an unfavorable surgical outcome such as the emergency,
presence of 3-MVD, posterior VSR, incomplete revascularization,
intractable shock and MOF. The adequate myocardial protection during the
operation is considered to be the cornerstone for a better outcome
postoperatively (6) . In our case, the risk factors were
emergency, cardiogenic shock, and posterior VSR.
Preoperative cardiogenic shock and early post infarction VSR carry a
grave prognosis. Achieving hemodynamic stability prior to surgery may be
beneficial but prolonged attempts to improve patients’ cardiovascular
state are hazardous (2) . Preoperative maximized inotropics
support and placement of IABP was essential to decrease left to right
shunt, and MOF.
Repair of post infarction VSD is still a challenging procedure with a
high risk of residual shunt and high mortality. CABG can be done safely
to control the added risk of an associated CAD, especially MVD should be
routinely revascularised (3-4). The role of primary PCI or
concomitant CABG in the setting of VSR closure is debatable as
myocardial damage is already transmural and residual viability therefore
questionable. However, PCI was done previous to RCA.