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.