[HSF] Posterior Post-Infarction VSD, SAM, and other Misery

[Tea Acuff]

I recently did a two patch repair of a posterior VSD,  but not on the septum per se as described by Dr. Roberts. The patient eventually died but not of bleeding, recurrent VSD or likely even primary LV failure, but sequelae of pre and periop shock. (EF was 40-45% proir to death). 
I opened posteriorly a little more laterally than "usual" toward the mid infarct and did manage to stay off the papillary muscle. I laid a very large patch across the septum and across onto the lateral (nonseptal side) of my ventriculotomy.  I tied off my endopatch suture as I was coming to the lateral side. Then I closed the ventriculotomy primarily with a large needle 3-0 prolene (CT needle?) including the patch in the primary suture line. I could see some tearing of the suture line so I just approximated and did not add tension to this suture. Then I took a large piece of Cor Matrix pericardial membrane and ran a 5-0 suture patching the incision with several cms overlap. I filled under this patch with bioglue. It was completely hemostatic! I was worried that I may have had a residual VSD, so I wished that I had closed the VSD primarily (and loosely) and added some bioglue to back side of the endopatch (which was facing me and the ventriculotomy. This turned out not to be
 the case, however. Hal's extra VSD patch might give one better control as to how much bioglue might escape endoventricularly into the unseen RV if any (which could be done if one is too enthusiastic with the glue.) I was impressed with the fusion of the graft to the myocardium especially in face of what would be likely bleeding of the primary closure of an infarct. (Or in Hal's case the VSD.) It may be that bringing the endo patch across the ventriculotomy provided some extra mechanical support to the "glued patch".

 I think that Hal is right as to the utility of glue for patch adherence.
 
tea 


----- Original Message ----
From: "Hgrmd at aol.com" <Hgrmd at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Saturday, July 7, 2007 9:06:22 PM
Subject: Re: [HSF] Posterior Post-Infarction VSD, SAM, and other Misery


John,
  Coming from a very experienced surgeon, your words are much  appreciated.  
I'm glad that you realize I share the details of this case in  the spirit of 
teaching, and not bragging.  Quite frankly, I attribute my  much improved 
results with acquired VSD's to Bioglue sandwiched between 2 septal  patches.  Has 
anyone ever seen this technique described in the  literature?  If so, I can 
attest to its efficacy. If not, maybe I'll  write it up.

Hal



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