Printer Friendly

TRIPLE VESSEL CORONARY ARTERY DISEASE WITH VENTRICULAR SEPTAL RUPTURE.

Byline: Khalida Habib, Vaqar Elahi Paracha, Rehana Javaid and Najma Naureen Haider

INTRODUCTION

Ventricular septal rupture (VSR) is a rare but devastating complication after acute myocardial infarction that generally produces progressive circulatory failure and rapid deterioration. The differential diagnosis of postinfarction cardiogenic shock should exclude free ventricular wall rupture and rupture of the papillary muscles. Prompt diagnosis followed by surgical repair with perioperative circulatory support is often life-saving.

CASE REPORT

A 58 year old man was admitted on 17th Nov 2016 with 5 days history of chest pain. He was smoker, diabetic, hypertensive. ECG was suggestive of left anterior wall myocardial infarction which was late for streptokinase. He was admitted in critical care unit. His 2D Echo showed EF 30%, apical LV akinesia and VSR of 10 mm size with left to right shunt. Angiography showed critical disease of proximal to mid LAD and RCA with moderate disease in left circumflex system. He was optimized on vasodilators, diuretics and anti coagulated with heparin infusion for a weak before surgical intervention. On 30th Nov, patient underwent coronary artery bypass grafting and closure of VSR. Before anaesthesia induction intra aortic balloon pump was inserted for myocardial protection (fig-).

MATERIAL AND METHODS

After sternotomy and pericardectomy hemopericardium found suggestive of leakage of blood subacute free wall rupture near apex which was sealed by it and apical clot was still present in cavity. Left long saphenous vein harvested for grafting. After aortic and bicaval cannulation cardiopulmonary bypass was established. Myocardial protection by cold antegrade cardioplegia for Grafting (SVG to LAD and PDA of RCA). Left ventricle (infarctectomy) opened lateral to LAD (aneurysm). Multiple VSR from mid to distal septum found (1 moderate sized and 2 small sized) repaired with Gortex patch and Left ventricle closed with 4/0 20 mm prolene plegeted interrupted sutures with bilateral gortex patch. Raw surfaces from the lysis of adhesions were profusely bleeding, pericardial cavity washed with warm saline and cell saver machine was on standby for use in case of uncontrolled bleeding. Haemostasis secured. Drains and pacing wires placed.

Chest closed and patient shifted to ICU with circulatory support of nor adrenaline and Adrenaline at 0.2 mcg/kg/min. Gradually the supports were tapered off patient was weaned off from IABP and ventilator. Patient had smooth recovery and was discharged after 1 weak of his surgery.

DISCUSSION

The septal blood supply comes from branches of the left anterior descending coronary artery, the posterior descending branch of the right coronary artery1. After successful repair, survival and quality of life are excellent, even in patients older than 70 years. Operative mortality is directly related to the interval between myocardial infarction (MI) and surgical repair2. With the use of an early operative approach, most studies show an overall mortality of less than 25%. Sudden death is rare, and intractable heart failure can also occur3. Other causes of death include cerebral embolism. Most patients who survive the hospital period have good functional status.

To avoid the high morbidity and mortality associated with this disorder, patients should undergo emergency surgical treatment. Post infarction VSR is recognized as a surgical emergency4. The addition of CABG has helped improve long-term survival5. Developments in myocardial protection, improved surgical techniques, better perioperative mechanical and pharmacologic support helped lower mortality.

CONFLICT OF INTEREST

This study has no conflict of interest to declare by any author.

REFERENCES

1. Koh AS, Loh YJ, Lim YP, Le Tan J. Ventricular septal rupture following acute myocardial infarction. Acta Cardiol 2011; 66(2): 225-30.

2. Arnaoutakis GJ, Zhao Y, George TJ . Surgical repair of ventricular septal defect after myocardial infarction: outcomes from the Society of Thoracic Surgeons National Database. Ann Thorac Surg. 2012; 94(2): 436-43.

3. http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=178%7C179%7C180%7C181%7C182%7C183%7C184%7C

4. http://work.chron.com/roles-scrub-nurse-3069.html.

5. Bhimji S, Sheridan BC. Postinfarction Ventricular Septal Rupture 2015.
COPYRIGHT 2017 Asianet-Pakistan
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2017 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Publication:Pakistan Armed Forces Medical Journal
Date:Apr 30, 2017
Words:713
Previous Article:A CASE OF UNUSUAL SYSTEMIC AND PULMONARY VENOUS DRAINAGE.
Next Article:TRANSCATHETER STENTING OF SEVERE COARCTATION OF AORTA -TECHNIQUE TO PRESERVE FLOW TO LEFT SUBCLAVIAN ARTERY.
Topics:

Terms of use | Privacy policy | Copyright © 2018 Farlex, Inc. | Feedback | For webmasters