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\begin{document}

\title{Intraoperative Ventricular Septal Rupture: A Case Report}



\author[1]{Hannah Rando}%
\author[2]{Ahmet Kilic}%
\affil[1]{Johns Hopkins Medicine School of Medicine}%
\affil[2]{The Johns Hopkins Hospital}%


\vspace{-1em}



  
  \date{May 23, 2024}


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\selectlanguage{english}
\begin{abstract}
Ventricular septal rupture (VSR) is a rare complication of myocardial
infarction that requires surgical repair. Herein we describe a case of
intraoperative VSR requiring a second bypass run and patch repair. This
case highlights the importance of early reperfusion and poses concern
for delayed patient presentation during the COVID-19 pandemic.%
\end{abstract}%



\sloppy


\textbf{Abstract}

Ventricular septal rupture (VSR) is a rare complication of myocardial
infarction that requires surgical repair. Herein we describe a case of
intraoperative VSR requiring a second bypass run and patch repair. This
case highlights the importance of early reperfusion and poses concern
for delayed patient presentation during the COVID-19 pandemic.

\textbf{Introduction}

Ventricular septal rupture (VSR) is a rare complication of myocardial
infarction that classically presents within one week of
infarction\textsuperscript{1} as coagulation necrosis occurs within the
infarcted tissue. Prior to the widespread use of reperfusion therapy,
VSR was estimated to complicate between 1-3\% of acute myocardial
infarctions,\textsuperscript{2-4} whereas more recent estimates quote an
incidence of 0.17\%-0.34\%.\textsuperscript{5,6} While uncommon, VSR
carries a high risk of mortality when it occurs, estimated between
19-54\% even with optimal treatment.\textsuperscript{2, 7-10}

Although some controversy exists regarding the optimal timing of repair,
surgical treatment remains the mainstay of therapy. Without surgical
consultation and repair, blood flow is shunted from the high-pressure
left ventricle (LV) into the low-pressure right ventricle (RV),
resulting in RV overload, pulmonary congestion, and eventual
biventricular failure. Herein we present a rare case in which VSR
occurred during a cardiopulmonary bypass (CPB) run for urgent coronary
artery bypass grafting (CABG).

\textbf{Case History}

A 65-year-old male presented to our institution with sudden onset chest
pain, nausea, and diaphoresis and was found to have ST elevation in
leads I and aVL and ST depression in leads II, III, and aVF
(\textbf{Figure 1} ). He was diagnosed with an inferolateral wall
myocardial infarction and was taken for emergent cardiac
catheterization. Coronary angiography demonstrated 100\% thrombotic
mid-RCA occlusion with 80\% mid-LAD and 80-90\% mid-circumflex/proximal
OM2 stenoses (\textbf{Figure 2} ). He underwent balloon angioplasty and
drug eluting stent placement to the RCA, and cardiac surgery was
consulted for CABG given the presence of multi-vessel disease.

\textbf{Treatment}

Five days following initial presentation, the patient was taken to the
operating room for CABG, with planned anastomoses of the left internal
mammary artery (LIMA) to the left anterior descending artery (LAD), and
vein graft to the obtuse marginal artery. Transesophageal
echocardiography (TEE) after induction of anesthesia demonstrated normal
LV function and mild inferior wall hypokinesis, with no evidence of
left-to-right shunting (\textbf{Figure 3a} ).

Of note, while cannulating the right atrial appendage for venous
drainage, the right atrium (RA) and RV immediately gave way and there
was an abrupt change of hemodynamics. Out of concern for an RCA infarct
or an abrupt obstruction of the RCA, an additional piece of vein was
harvested, and the operative procedure was adjusted to include a vein
graft to the right side.

Upon initiation of CPB, the patient was noted to have visibly infarcted
myocardium in the inferior diaphragmatic aspect of the RV with
significant hypokinesis. For this reason, the PDA was bypassed first
before proceeding with the previously planned bypasses of the left
circumflex with vein graft and LIMA to the LAD.

On attempted weaning of the CPB circuit, the aortic valve did not open,
the LV did not distend, and any weaning maneuvers resulted in an
overloaded RV. At this time, echocardiography demonstrated a new finding
of a post-myocardial infarction VSR (\textbf{Figure 3b} ). The location
of the defect was in the basilar portion emanating from the
mid-papillary muscle, consistent with a basal infarction in the
distribution of the PDA.

A left ventriculotomy was made parallel to the LAD. This allowed
visualization of a large, linear VSR with necrotic septum emanating
between the papillary muscles and near the LVOT. The defect was repaired
with a large piece of bovine pericardium secured with interrupted 2-0
Tycron pledgeted sutures. The ventriculotomy was closed and the
cross-clamp removed.

After completion of the repair, the patient was able to be slowly weaned
from bypass, but there was significant RV and LV strain despite
placement of an intra-aortic balloon pump (IABP). Given the residual
hemodynamic instability, the CPB circuit was converted to an ECMO
circuit, with biatrial venous cannulae placed to minimize left to right
shunting. The chest was left open and the patient was taken to the ICU
for further management.

The patient's hemodynamics improved with resuscitation, but he
demonstrated persistent RV dysfunction due to RV infarction as well as
some residual left to right shunting suggesting an ongoing defect. Seven
days after the index operation, he was returned to the operating room
for sternal washout and attempted VSR repair. On direct visualization he
was noted to have progression of myocardial necrosis. Although the patch
was largely intact, there were small holes near the papillary muscles,
necessitating reinforcement of the entirety of the patch with 2-0 Tycron
pledgeted interrupted sutures.

\textbf{Outcome and follow-up}

The patient was continued on ECMO and returned to the ICU.
Unfortunately, despite definitive surgical management of the VSR, he
continued to demonstrate RV failure over the upcoming weeks and was
unable to be weaned from ECMO. The decision was ultimately made to
withdraw care.

\textbf{Discussion}

In this report, we describe a patient who presented with an
inferolateral wall myocardial infarction and subsequently developed the
mechanical complication of VSR during a planned CABG procedure. In this
case, we elected to perform immediate surgical repair and utilized ECMO
as a perioperative support strategy to alleviate biventricular
dysfunction and allow for revision of the repair after the patient's
condition had stabilized. Despite the ultimate patient outcome, we
believe this case highlights several important points regarding
perioperative management of VSR.

First and foremost, we acknowledge that the widespread use of early
reperfusion therapy has made the incidence of VSR relatively
minimal,\textsuperscript{5,6} and for that reason it may not be high on
the clinician's differential diagnosis when a patient decompensates.
Particularly for the surgeon, who does not often encounter such a
problem intraoperatively, it is important to be aware of this potential
complication. We believe this to be of particular importance during the
COVID-19 pandemic, as patients are more likely to delay seeking care in
an effort to avoid exposure to the virus in the healthcare
setting.\textsuperscript{11} Indeed, multiple studies have demonstrated
a longer time from symptom onset to first medical contact in the setting
of MI during the COVID-19 pandemic.\textsuperscript{12-14}

Exemplifying this fact, we were surprised to encounter a similar case
report by Kok et al. published in 2021.\textsuperscript{15} The authors
similarly describe a case of VSR during a CABG operation, in which the
patient was managed with ECMO cannulation and delayed surgical repair.
Despite the differences in management, this phenomenon of intraoperative
VSR had not been described in the literature prior to 2021, and may
reflect a rising rate of mechanical complications of MI due to delayed
patient presentation. To date, there have been several case series and
single institutional reviews that have demonstrated an increased
incidence of mechanical complications during the COVID-19
pandemic,\textsuperscript{16-18} but this has not yet been explored with
a large database or multi-institutional review.

It is also worth noting the differences in patient management between
the case report presented here and that of Kok et al, and more
specifically, the differences in timing of surgical repair. The
literature is divided in terms of optimal timing of VSR repair. While
several studies have reported lower operative mortality in patients with
delayed surgical repair,\textsuperscript{19-22} these studies may have a
significant component of selection bias, given that patients with
smaller defects and preserved LV function have more favorable overall
prognosis and are able to be medically temporized until definitive
surgical repair. The advocates for delayed surgical repair argue that
the delay allows for fibrosis of the septum and a more durable
repair,\textsuperscript{19,21} however without prompt repair many
patients will develop progressive heart failure and will not survive the
delay. Ultimately, we would argue that patient selection is critical,
and the timing of surgical repair does not fall into a
``one-size-fits-all'' approach.

Finally, this case highlights the utility of ECMO as an adjunctive
therapy in management of patients with VSR. Although no large
prospective or retrospective studies have evaluated the efficacy of ECMO
in the setting of VSR, several case reports and case series have
reported good results when using ECMO in the perioperative
period.\textsuperscript{23-27} By affording complete cardiopulmonary
support in the setting of cardiogenic shock, ECMO serves as a salvage
therapy to allow time for myocardial rest and recovery. In this case,
ECMO cannulation and delayed sternal closure provided the opportunity
for myocardial recovery and hemodynamic stabilization with subsequent
re-evaluation and revision of the ventricular septal repair.

In summary, VSR is a rare and often fatal mechanical complication of MI
that merits clinical awareness and discussion. Although uncommon, given
the additional myocardial manipulation that occurs in the operating
room, the surgeon should be aware of the potential for intraoperative
development of this complication. In these cases, the decision between
immediate and delayed repair should be based on the size of the defect
and the patient's overall clinical picture. In cases such as this, where
immediate repair was needed to alleviate biventricular dysfunction, ECMO
is a viable option both for temporary mechanical support and as a
bridging modality to allow for re-evaluation and revision of the VSR
repair at a later date.

\textbf{References}

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\end{enumerate}

\textbf{Figure Legends}

Figure 1: EKG on initial presentation with ST elevation in leads I and
aVL and ST depression in leads II, III, and aVF.

Figure 2: Coronary angiography with A) complete thrombotic mid-RCA
occlusion, B) partial occlusion of the mid-LAD (80\%) and
mid-circumflex/proximal OM2 (80-90\%).

Figure 3: Intraoperative echocardiography demonstrating A) no left to
right shunting on initiation of bypass and B) a large VSR with left to
right shunting on attempted weaning of cardiopulmonary bypass.\selectlanguage{english}
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