Selena S. Li, MD, Jordan P. Bloom, MD, and Thoralf M. Sundt III, MD
Massachusetts General Hospital, Boston, MA, USA
This chapter is a revision and update of that included in the previous edition of the TSRA Operative Dictations in
Cardiothoracic Surgery written by Amit Pawale, MD, FRCS, and Anelechi Anyanwu, MD, MSc, FRCS.
Essential Operative Steps (See Video)
Introduction
Ischemic ventricular septal defects are a rare but deadly complication after myocardial infarction.
Conservative management carries up to 90-95% mortality rates, and even with timely surgical
intervention, the 30-day mortality rate can be up to 40-50%. Surgery remains the only viable
treatment option and should be performed as early as possible after hemodynamic stability is
established. The location of the VSD, either anterior or inferoposterior, defines the surgical approach. In this chapter, we
describe the key steps to repair, tips to avoid potential complications, and two distinct operative examples of anterior and
inferoposterior VSD repairs.
Essential Operative Steps
- Lines and monitoring (radial arterial line, ± pulmonary artery catheter, TEE, Foley catheter with temperature probe)*
- General endotracheal anesthesia
- Median sternotomy
- Open pericardium, create pericardial well, and assess aorta for plaque burden (palpation ± epiaortic ultrasound)
- Systemic heparinization
- Aortic cannulation
- Right atrial cannulation
- Confirm ACT (>480 seconds)
- Initiation of CPB
- Placement of aortic root vent and antegrade cardioplegia cannula
- Aortic crossclamp and arrest the heart
- Systemic hypothermia (30-34oC)
- Transinfarct ventriculotomy**
- VSD closure (exclusion technique)
- Ventriculotomy closure
- Rewarm, deair, and place temporary epicardial pacer wires
- Wean from CPB
- Venous decannulation
- Protamine administration
- Aortic decannulation
- Assess hemostasis
- Place pleural/mediastinal tubes
- Sternotomy closure
*Patients may be on mechanical circulatory support (intra-aortic balloon pump, ECMO, or percutaneous ventricular assist) as
a bridge to surgery
**Key operative factors will differ based on the location of septal infarct (anterior vs inferoposterior), including exposure and
choice of ventriculotomy. We provide an example of each operation in this chapter
Potential Complications and Pitfalls
- Operative repair should be as immediate as possible with the proviso that a brief interval (hours to days) of mechanical
support to arrest or reverse end-organ dysfunction may be appropriate to reduce perioperative risk. Ideally patients should
be hemodynamically stabilized with pharmacologic and mechanical circulatory support, if indicated, including placement
of IABP, ECMO, or percutaneous ventricular assist devices - Choice of ventriculotomy site is based on VSD location (anterior or posterior). Regarding the former, the ventriculotomy
is made 1.5–2cm lateral to the LAD to permit closure of the ventriculotomy without obstruction of the LAD. For the
latter, the PDA is routinely sacrificed in the closure - The patch exclusion technique obviates the necessity to do any muscular debridement, and thereby preserves the
maximum amount of functional myocardium. The patch exclusion technique, whether in repair of an anterior or posterior
VSD, aims to use a generous patch such that there is no tension on any of the suture lines and such that intraventricular
pressure itself seals the patch against the ventricular wall. There is no penalty for an excessively large patch since the
geometry of the ventricle will be determined by the remaining viable wall and the only purpose of the patch is to plug the hole. The suture line securing the patch should be distant from the infarcted muscle itself such that the sutures are in
healthy tissue
Template Dictation
Anterior VSD Repair
Preoperative Diagnosis: Anterior post-myocardial infarction ventricular septal defect, cardiogenic shock, and multi-organ
failure
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Repair of anterior post-infarct ventricular septal defect; bypass of LAD
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with [COMPLAINT: e.g. syncope] was transferred from an outside
hospital in cardiogenic shock, intubated, and mechanically ventilated. They were taken to the cardiac catheterization lab where
proximal LAD occlusion was identified without other significant epicardial coronary disease. Stents were placed in the left
anterior descending coronary artery and the patient was taken to the ICU for recovery. The following day, an echocardiogram
demonstrated a large anterior VSD with dilatation of the right ventricle and severely depressed right ventricular function. The
patient was cannulated for extracorporeal membrane oxygenator support to immediately reverse cardiogenic shock and arrest
any end organ dysfunction associated. A plan was made to proceed to definitive repair as soon as the patient began to
demonstrate recovery from the acute insult. At this point, the patient had recovered sufficiently to permit definitive repair.
They were brought to the operating room for the same.
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure was verified, and the patient was placed on the operating room table in the supine position. Preoperative TEE was
performed, confirming a large anterior VSD with right ventricular dilatation and moderate dysfunction.
A median sternotomy was performed. The pericardium was opened, and a pericardial cradle was created. The right ventricle
was distended. Palpation and epiaortic ultrasound of the ascending aorta was performed. 400 u/kg of heparin were administered
intravenously. The ascending aorta and right atrium were cannulated. CPB was initiated when ACT was >480 seconds. An
aortic root vent was placed. Systemic cooling was started for a goal temperature of 34oC. The aorta was crossclamped and cold
cardioplegia delivered antegrade with a prompt diastolic arrest of the heart. Subsequent doses of cardioplegia were delivered
approximately every 20 minutes.
With laparotomy pads behind the heart to elevate the left anterior descending coronary artery into view, we opened the left
ventricle 1.5 to 2cm to the left of the left anterior descending coronary artery through the infarct itself, leaving enough room
for ventriculotomy closure without obstruction of the left anterior descending coronary artery. The ventricular cavities were
explored for thrombi which were removed meticulously. The septal infarct and VSD were readily apparent. A large piece of
bovine pericardium was fashioned in a shield shape and sutured to the left ventricular wall as one would for a Dor patch left
ventricular aneurysm repair. With the completion of the suture line, the wall of the left ventricle was accordingly reconstituted.
We then took two strips of Teflon felt and closed the left ventriculotomy in two layers with the suture line just lateral to the
left anterior descending coronary artery. We then proceeded to place a bypass graft to the LAD before weaning from CPB.
The crossclamp was removed and the heart was reperfused. Pacing wires were placed on the right ventricle and right atrium.
Following a period of deairing and reperfusion, cardiopulmonary bypass was weaned with the aid of high dose inotropes.
Echocardiography demonstrated no residual VSD.
Venous decannulation was performed, heparin was reversed, and the aortic cannula was removed. The right common femoral
artery was repaired primary via cutdown at the site of ECMO cannulation. Hemostasis was achieved throughout the operative
field and the wounds closed in layers in the usual manner. Drains were placed within the mediastinum and both pleural cavities.
The sternum was reapproximated with stainless steel wires and the soft tissues were closed with absorbable sutures.
All instrument, sponge, and needle counts were confirmed to be correct, twice, at the end of the operation. The patient was
subsequently transferred to the postoperative cardiac surgical intensive care unit in stable but critical condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Inferoposterior VSD Repair
Preoperative Diagnosis: Posterior post-myocardial infarction ventricular septal defect, cardiogenic shock, and multi-organ
failure
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Repair of posterior post-infarct ventricular septal defect
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with [COMPLAINT: e.g. syncope] was transferred from an outside
hospital in cardiogenic shock, intubated, and mechanically ventilated. They were taken to the cardiac catheterization lab where
a mid RCA occlusion was identified without other significant epicardial coronary disease. Stents were placed in the right
coronary artery and the patient was taken to the ICU for recovery. The following day, an echocardiogram demonstrated a large
inferior VSD with dilatation of the right ventricle and severely depressed right ventricular function. The patient was cannulated
for extracorporeal membrane oxygenator support to immediately reverse cardiogenic shock and arrest any end organ
dysfunction associated. A plan was made to proceed to definitive repair as soon as the patient began to demonstrate recovery
from the acute insult. At this point, the patient had recovered sufficiently to permit definitive repair. They were brought to the
operating room for the same.
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure was verified, and the patient was placed on the operating room table in the supine position. Preoperative TEE was
performed, confirming a large inferior VSD with severe right ventricular dysfunction.
A median sternotomy was performed. The pericardium was opened, and a pericardial cradle was created. The right ventricle
was distended with poor contractility. Palpation and epiaortic ultrasound of the ascending aorta was performed. 400 u/kg of
heparin were administered intravenously. The ascending aorta and right atrium were cannulated. Cardiopulmonary bypass was
initiated when ACT was >480 seconds. An aortic root vent was placed. Systemic cooling was started for a goal temperature of
34oC. The aorta was crossclamped and cold cardioplegia delivered antegrade with a prompt diastolic arrest of the
heart. Subsequent doses of cardioplegia were delivered approximately every 20 minutes.
Reflecting the apex of the heart cephalad with a pledgeted traction suture clipped to the drapes, we opened the inferior left
ventricle 1cm to the left of the posterior descending coronary artery through the infarct. The aim was to split the difference
between the septum itself and the posterior medial papillary muscle. The ventricular cavities were explored for thrombi which
were removed meticulously. The septal infarct and VSD were readily apparent. A large piece of bovine pericardium was
fashioned in a shield shape and anchored to the base of the heart with a pledgeted suture through-and-through the ventricular
wall just apical to the coronary sinus and at the base of the mitral annulus. The sutures were then passed back into the ventricle
and used to complete the septal suture line keeping the patch well beyond the area of the actual infarct and in good healthy
muscle. We identified the aortic valve through the ventriculotomy and took care to extend our patch repair up the septum
stopping short of the valve before coming across to the lateral wall at the apex of our patch. The other end of the suture was
used to secure the patch to the left ventricular free wall immediately medial to the papillary muscles and out to the apex. With
the completion of the suture line, the wall of the left ventricle was accordingly reconstituted. We then took two strips of Teflon
felt and closed the left ventriculotomy in two layers with the suture line encompassing the posterior descending coronary artery.
This placed our ventriculotomy on the right side of our patch, subjecting it to right ventricular and not left ventricular pressures.
The crossclamp was removed and the heart was reperfused. Pacing wires were placed on the right ventricle and right atrium.
Following a period of deairing and reperfusion, cardiopulmonary bypass was weaned with the aid of high dose inotropes.
ECMO was not reinitiated because the right ventricular function was gratifyingly good. [Had right ventricular function been
poor, as is often the case when the right coronary obstruction is more proximal, ECMO would have been continued
postoperatively awaiting right ventricular recovery.] TEE confirmed adequate repair with no residual shunt.
Venous decannulation was performed, heparin was reversed, and the aortic cannula was removed. The right common femoral
artery was repaired primarily via cutdown at the site of ECMO cannulation. Hemostasis was achieved throughout the operative
field and the wounds closed in layers in the usual manner. Drains were placed within the mediastinum and both pleural cavities.
The sternum was reapproximated with stainless steel wires and the soft tissues were closed with absorbable sutures.
All instrument, sponge, and needle counts were confirmed to be correct, twice, at the end of the operation. The patient was
subsequently transferred to the postoperative cardiac surgical intensive care unit in stable but critical condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure
Video 1. Transesophageal echocardiogram demonstrating inferior ventricular septal defect.
Figure 1. Intraoperative photos of inferior VSD and repair. (a) View of the inferior VSD through left transinfarct
ventriculotomy. (b) Exclusion technique using bovine pericardial patch and buttressed repair of free wall. (c) Final closure of
left ventriculotomy.
Figure 2. David technique for repair of inferoposterior VSD. Reproduced with permission from Society of Thoracic Surgeons
E-book. Schubert et al.
Multiple Choice Question(s)
During preoperative TEE, you visualize a 2cm inferior ventricular septal defect. What is the optimal approach for exposure
during the operation?
A. An anterior left ventriculotomy, 1cm to the left of the left anterior descending artery
B. An anterior right ventriculotomy, 1cm to the right of the left anterior descending artery
C. A posterior right ventriculotomy, 1cm to the right of the posterior descending artery
D. A posterior left ventriculotomy, 1cm to the left of the posterior descending artery
Answer: D. Defects located in the inferior portion of the septum are best exposed via a left ventriculotomy just lateral to the
posterior descending artery. This allows access to the defect while preserving left ventricular function.
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Malhotra A, Patel K, Sharma P et al. Techniques, timing & prognosis of post infarct ventricular septal repair: A re-look at old
dogmas. Braz J Cardiovasc Surg 2017;32(3):147-155.
Pojar M, Harrer J, Omran N, Turek Z, Striteska J, Vojacek J. Surgical treatment of postinfarction ventricular septal defect:
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