A Sandwich Technique Employing Right Ventricular Incision to Repair Posterior Ventricular Septal Rupture with Right Ventricular Wall Dissection: A Case Report
Background:Ventricular septal rupture (VSR) leading to right
ventricular (RV) wall dissection is an extremely rare and life-threatening
complication of inferior myocardial infarction (MI) with posterior VSR. Its
rare incidence and complex pathology make it difficult to select the
appropriate surgical procedures to prevent fatalities. Case Presentation:A 68-year-old woman was transferred to our hospital
because of a post-infarction VSR 12 days after symptom onset. Short-axis image
obtained using transthoracic echocardiography demonstrated a large posterior
VSR. Moreover, the VSR was continuous, with a large echo-free space in the
posterior wall of the right ventricle. Color echocardiography showed blood
flowing into the echo-free space through the septal defect and blood flowing
out into the RV lumen. Coronary angiography revealed complete occlusion of the
second segment of the right coronary artery. Thus, dissection of the posterior
wall of the right ventricle that continued into the RV lumen was considered to
have been caused by the posterior VSR caused by an inferior MI. The patient
underwent urgent surgery to repair the VSR using the sandwich double-patch
technique by making a posterior RV incision that was repaired using a third
patch. No additional procedure was required to block the flow from the cavity
of the RV wall dissection into the RV lumen. Postoperative echocardiography and
contrast-enhanced computed tomography demonstrated that the VSR was closed
securely and the RV wall dissection was almost completely thrombosed. Conclusion:In this case, a patient with a posterior VSR and RV
wall dissection was successfully treated using the sandwich double-patch
technique with a posterior RV incision. No additional procedure may be needed
for RV wall dissection when a secure VSR repair is complete; however, close
follow-up is essential to improve the long-term prognosis.
References
[1]
Ronco, D., Matteucci, M., Kowalewski, M., et al. (2021) Surgical Treatment of Postinfarction Ventricular Septal Rupture. JAMA Network Open, 4, e2128309. https://doi.org/10.1001/jamanetworkopen.2021.28309
[2]
Birnbaum, Y., Fishbein, M.C., Blanche, C., et al. (2002) Ventricular Septal Rupture after Acute Myocardial Infarction. The New England Journal of Medicine, 347, 1426-1432. https://doi.org/10.1056/NEJMra020228
[3]
Schram, G., Essadiqi, B., Doucet, M., et al. (2010) Ventricular Septal Rupture and Right Ventricular Free Wall Dissection after Inferior Myocardial Infarction: A Case Report and Review of the Literature. Journal of the American Society of Echocardiography, 23, 791.e1-791.e3. https://doi.org/10.1016/j.echo.2009.11.020
[4]
Li, T., Kong, F.X., Wang, J.L., et al. (2019) Ventricular Septal Rupture with Right Ventricular Wall Dissection after Inferior Ventricular Infarction: A Case Report and Literature Review. Journal of Clinical Ultrasound, 47, 247-252. https://doi.org/10.1002/jcu.22684
[5]
Soriano, C.J., Pérez-Boscá, J.L., Canovas, S., et al. (2005) Septal Rupture with Right Ventricular Wall Dissection after Myocardial Infarction. Cardiovascular Ultrasound, 3, Article No. 33. https://doi.org/10.1186/1476-7120-3-33
[6]
Tighe, D.A., Paul, J.J., Maniet, A.R., et al. (1997) Survival in Infarct Related Intramyocardial Dissection. Importance of Early Echocardiography and Prompt Surgery. Echocardiography, 14, 403-408. https://doi.org/10.1111/j.1540-8175.1997.tb00742.x
[7]
Takada, A., Saito, K., Murai, T., et al. (2015) Right Ventricular Free Wall Dissection as a Rupture Tract in Left Ventricular Rupture during Acute Myocardial Infarction. Legal Medicine (Tokyo, Japan), 17, 525-531. https://doi.org/10.1016/j.legalmed.2015.10.005
[8]
Daggett, W.M., Guyton, R.A., Mundth, E.D., et al. (1977) Surgery for Post-Myocardial Infarct Ventricular Septal Defect. Annals of Surgery, 186, 260-271. https://doi.org/10.1097/00000658-197709000-00004
[9]
Komeda, M., David, T.E. and Fremes, S.E. (1990) Surgical Repair of Postinfarction Ventricular Septal Defect. Circulation, 82, IV243-247.
[10]
Balkanay, M., Eren, E., Keles, C., et al. (2005) Double-Patch Repair of Postinfarction Ventricular Septal Defect. The Texas Heart Institute Journal, 32, 43-46.
[11]
Asai, T. (2016) Postinfarction Ventricular Septal Rupture: Can We Improve Clinical Outcome of Surgical Repair? General Thoracic and Cardiovascular Surgery, 64, 121-130. https://doi.org/10.1007/s11748-015-0620-1
[12]
Isoda, S., Osako, M., Kimura, T., et al. (2012) Midterm Results of the “Sandwich Technique” via a Right Ventricle Incision to Repair Post-Infarction Ventricular Septal Defect. Annals of Thoracic and Cardiovascular Surgery, 18, 318-321. https://doi.org/10.5761/atcs.oa.11.01703
[13]
Yamasaki, T., Matsuzaki, Y., Hohri, Y., et al. (2018) Modified Double Patch Repair for Septal Rupture with Ventricular Wall Dissection. The Annals of Thoracic Surgery, 106, e289-e291. https://doi.org/10.1016/j.athoracsur.2018.05.008
[14]
Okamura, H., Arakawa, M., Takeuchi, T., et al. (2019) Postinfarction Right Ventricular Wall Dissection with Left-to-Right Shunting. Interactive CardioVascular and Thoracic Surgery, 28, 499-501. https://doi.org/10.1093/icvts/ivy283
[15]
Morimura, H. and Tabata, M. (2020) Delayed Surgery after Mechanical Circulatory Support for Ventricular Septal Rupture with Cardiogenic Shock. Interactive CardioVascular and Thoracic Surgery, 31, 868-873. https://doi.org/10.1093/icvts/ivaa185
[16]
Asai, T., Kinoshita, T., Oishi, A., et al. (2022) Extended Sandwich Patch Technique to Repair Ventricular Septal Rupture. Annals of Cardiothoracular Surgery, 11, 337-339. https://doi.org/10.21037/acs-2021-ami-164
