Case report
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A 49 year male with complaint of sudden onset chest pain was referred to cardiac center. The patient was found to have acute inferior ST- segment elevation (STEMI). He denied a history of angina or myocardial infarction. The patient was a heavy smoker, diabetes mellitus (type I) with a family history of coronary heart disease (CAD). Coronary angiography was showed total occluded paraosteal right coronary artery (RCA), and subsequently underwent percutaneous coronary intervention (PCI). Bedside Trans Thoracic Echography (TTE) demonstrated a VSR 15mm located basal inferoseptal at level of mitral valve, moderate to severe mitral regurgitation (MR), severe tricuspid regurgitation (TR), and biventricular dysfunction (EF <30%) [Fig.1] . Patient was in cardiogenic shock and pulmonary edema, an intra-aortic balloon pump (IABP) was inserted for pressure support. On physical examination, the patient was restless and in overt distress, and a pansystolic murmur was auscultated from the left sternal border. The blood pressure was 80/50 mm Hg, pulse 125 bpm, respiratory rate 24 bpm. His skin was cool and poorly perfused with shallow respiration, and weak peripheral pulses. Laboratory investigations were showing troponin 0.170 ng/mL, serum creatinine level of 1.3 mg/dL, and MB-CK level of 229 U/L. Chest X-ray showed increased cardiothoracic ratio with remarkable lung congestion [Fig.2], and ECG showed sinus rhythm and STEMI in leads II, III, and aVF. Post-infarction posterior VSR was diagnosed, and emergency surgery was decided. Medical management is aimed to improve cardiac output and reduce the left to right shunt by reducing systemic vascular resistance and LV pressure. Inotropes, diuretics, and placement of IABP are often used.
Emergency transferred to operative room (OR) for VSD repair, because cardiogenic shock in the setting of post infarction VSD is a surgical emergency. Median sternotomy, then cardiopulmonary bypass (CPB) with moderate hypothermia (32°C) was established between both caval veins with caval tapes and ascending aorta. An aortic cross-clamp was placed, and antegrade blood cardioplegic arrest was induced. Deep left pericardial traction sutures were placed to facilitate exposure of the posterior wall of the heart. We made longitudinal incision lateral and parallel to posterior descending artery (PDA) and identified a VSR in the middle level of the posterior wall. Stay sutures were placed to expose the edges of the defect and to help visualize the interior of the ventricle. Exposure The necrotic myocardium around the VSR was resected, revealing a defect measuring 2 cm in diameter. Closure of VSR without tension employed using a bovine pericardial patch placed on the LV side of the septum, and Teflon felt pledgets placed on the RV and RV free wall. The edges of the ventriculotomy are re-approximated with a double layer buttressed closure with Teflon felt. Biological glue is often used to ensure complete hemostasis. [Fig.3-4] Postoperative TTE revealed no residual shunt, EF 35%, mild MR, and moderate TR. Patient was discharged from hospital on 15th POD.