how i would do my anterior vsd closure john v. conte, md professor of surgery johns hopkins...
TRANSCRIPT
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How I would do my anterior VSD Closure
John V. Conte, MD
Professor Of Surgery
Johns Hopkins University School Of MedicineBaltimore, Maryland
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Disclosures• No relevant financial relationships related to
this presentation
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It Depends!!
Anterior Infarct = LAD InfarctIncidence 1-2% after acute MI
Present 2-7 days post-infarction
Treatment Surgical Closure
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What does it depend on ?• Size of Infarct• Definition of Infarct Borders
– Smaller, well defined VSD’s do exist– More distal the better
• Coronary artery anatomy– LAD size– Right coronary dominance
• Comfort level with different techniques• Pre-op condition
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Preop Optimization• Hemodynamic stability
– Inotropes?– IABP?– Diuresis?– Intubation?
• ECMO?– Primary reason to establish hemodynamic stability– Allowing tissue to “stabilize”/”firm up” questionable
• Myocardial edema the rule for weeks• To be truly beneficial in stable pts ECMO durations
would be long
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Catheter Based Repair
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Cardiofix® Starway Medical
Starflex® NMT Medical
Amplatzer®AGA Medical
Gore
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When would I want Catheter based repair ?
• Cardiogenic Shock• Not a candidate for surgery• Very few individuals have
significant experience• Technically challenging catheter
based procedure
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Two Basic Surgical Approaches
Patch Technique
Exclusion technique
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Operative Approach & Considerations
• Bicaval cannulation– Percutaneous femoral venous
• Antegrade & retrograde cardioplegia• Construct Grafts first• Open through infarct• Minimal debridement• Repair VSD
– Unclamped in many cases– If it moves its alive and will hold sutures
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Anterior Infarction
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Anterior Ventriculotomy
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Anterior Ventriculotomy
• Ventriculotomy thru infarct
• Assess full extent of infarct– Important for closure
• Note papillary muscle location
• Visualize how a patch or exclusion would be situated.
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Anterior Ventriculotomy
• Minimal debridement or maniipulation of infarcted tissue
• Assess suture placement
• Decide which technique
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Exclusion Technique
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Exclusion Technique
• Large, ill defined VSD• Two Major advantages
– Sutures in healthy / non-infarcted tissue– Patch / Infarcted septum / anterior wall
not exposed to systemic pressures
• Key Concept:– You are creating new septum / medial
wall for Left Ventricle
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Patch placement
• Deep bites thru good tissue • Continuous or Interrupted• Interrupted more flexible
– Sutures can be placed External to Internal
– Large needle– Bulky pledgets
• Do not undersize patch– Imperative to oversize
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Patch placement
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Patch placement
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Patch placement
• Area close to valves can be tricky
• Additional reinforcing sutures helpful
• Trim patch as you go and at end
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Patch Completion
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Patch Completion
• Clamp off• LV vent off to deair• Additional pledgeted
sutures• Bioglue is your friend
– Out of systemic circulation
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Ventriculotomy Closure
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Anterior Wall Closure
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Two Patch Technique
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Patch Technique
• Limit to small, well defined infarcts• Avoids conduction system• Avoids large patch with associated
thromboembolic risks
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Patch Technique – Septal patch
• Deep bites• Oversize patch • LV pressure helps
keep patch in place
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Patch Technique – Septal patch
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Septal Patch• Suture Considerations
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Anterior Patch Closure
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Post Op Care
• Biventricular pacing– Dys-synchrony and heart block common
• Inotropes• Inhaled pulmonary vasodilators• IABP “mandatory”• ECMO can be helpful
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SummaryPatch Technique
• Smaller, well defined infarcts
• Hemodynamically stable
Exclusion Technique
• Large, ill defined infarcts• Hemodynamically
unstable or CHF