İnfarktüs sonrası gelişen ventriküler septal defektte erken cerrahi girişim

Amaç: Akut miyokard infarktüsü sonrası gelişebilen komplikasyonlardan Ventriküler septal defektin (post-MI VSD), anatomik yerinin tayin edilmesi, uygulanacak cerrahi girişimin şeklini belirler. Gelişen cerrahi teknikler ve yeni protez yamalar, anestezi ve reanimasyon deneyimi, cerrahi başarıyı artırmıştır. Çalışmamızda post-MI VSD gelişip ameliyat edilen hastalarda hastane mortalitesine etkili faktörleri araştırmayı amaçladık. Materyal ve Metod: Nisan 1990 - Ekim 2002 tarihleri arasında tanısı konularak ameliyat edilen 21 post-MI VSD olgusu çalışma grubunu oluşturdu. Grup l (12 hasta), operasyon sonrası postoperatif dönemde yaşayan; Grup 2 (9 hasta) ise postoperatif dönemde mortal seyreden olgulardan oluştu. Bütün hastalara preoperatif ekokardiyografi ve genel durumu izin veren 18 hastaya kardiyak kateterizasyon ve anjiyografi uygulandı. Olgular preoperatif, peroperatif ve postoperatif klinik özellikleri açısından retrospektif olarak değerlendirildi. Mortaliteye etki eden faktörler saptanmaya çalışıldı.Bulgular: Hastane mortalitesi %42.85 olarak gerçekleşmiştir. Mortaliteye etki eden faktörler ileri yaş, post-MI VSD'nin anatomik lokalizasyonu, preoperatif kardiyojenik şok, düşük ejeksiyon fraksiyonu, geç operasyon (72 saat sonrası), uzamış kros klemp ve bypass süresi, gecikmiş olarak intraaortik balon pompası uygulanması olarak belirlenmiştir. Sonuç: Post-MI VSD'nin anatomik lokalizasyonu ne olursa olsun acil cerrahi müdahele gerekir. Multiorgan disfonksiyonu gelişmeden erken cerrahi girişim postoperatif mortaliteyi olumlu yönde etkilemektedir.

Early surgical treatment in postinfarct ventricular septal defect

Background: The anatomical localization of ventricular septal defect (VSD) occured after acute myocardial infarction (MI) strictly affects the type of surgery. New prosthetic patches and rapid progression in surgical techniques, increased experiences in anesthesiology and reanimation augment our surgical success. In our study we searched for the factors affecting the rate of hospital mortality. Methods: Between April 1990 and October 2002, 21 consecutive patients underwent surgical repair of post-MI VSD. Group 1 consists 12 patients who were alive postoperatively, and Group 2 consists 9 patients who died. All patients were evaluated by echocardiography, and cardiac angiography and catheterization were performed on 18 patients. We studied preoperative, peroperative and postoperative clinical findings retrospectively. Results: The hospital mortality was 42.85%. The risk factors for early mortality were older age, the anatomical localization of post-MI VSD, the presence of cardiogenic shock preoperatively, low ejection fraction, late surgical treatment (72 hrs later), prolonged cross clamp time and total bypass period, and late application of intraaortic ballon pump. Conclusions: Whereever the anatomical localization of post-MI VSD is, early surgical treatment is necessary. That decreases the rate of postoperative mortality if it is performed before the occurance of multiorgan failure.

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1. Di Summa M, Actis Dato GM, Centofanti P, et al. Ventricular septal rupture after a myocardial infarction: Clinical features and long term survival. J Cardiovasc Surg 1997;38:589-93.
2. Von Segesser LK, Siebenmann R, Schneider K, Jenni R, Gallino A, Turina M. Postinfarction ventricular septaldefect-surgical strategy and results. Thorac Cardiovasc Surg 1989;37:72-5.
3. Litton TC, Sutton JP, Smith CW, Allen WB,Yarbrough JW, Leppard EM. Surgical treatment of ventricular septal rupture complicating myocardial infarction. Am J Surg 1988;155:587-9.
4. Özbaran M, Posacıoğlu H, Nalbantgil S ve ark.İnfarktüs sonrası gelişen ventriküler septal rüptür tamiri sonuçlarımız: Morbidite ve mortalite üzerine etkili değişkenlerin değerlendirilmesi. Türk Kardiyol Dern Arþ 2002;30:627-33.
5. Berger TJ, Blackstone EH, Kirklin JW. Postinfarction ventricular septal defect. In: Kirklin Barratt-Boyes BG eds. Cardiac Surgery. New York: Churchill Livingstone, 1993:147.
6. Dalrymple-Hay, Langley SM, Ramesh P, et al. Surgical treatment of acquired ventricular septal defects in the elderly. Eur J Cardiothorac Surg 1997;12:298-303.
7. Davies RH, Dawkins KD, Skillington PD, et al. Late functional results after surgical closure of acquired ventricular septal defect. J Thorac Cardiovasc Surg 1993;106:592-8.
8. Cooley DA, Belmonte BA, Zeis LB, Schnur S. Surgical repair of ruptured interventricular septum following acute myocardial infarction. Surgery 1957;41:930.
9. Heimbecker RO, Lemire G, Chen C. Surgery for massive myocardial infarction. Circulation 1968;11:37.
10. Takahashi T, Kadoba K, Taniguchi K, et al. Repair of postinfarction ventricular septal defect on a beating heart. Ann Thorac Surg 1996;61:1816-7.
11. Reber D, Tosson R, Khargi K, Laczkovics A. Repair of a postinfarct ventricular septal defect on the beating heart. Surgical considerations. J Cardiovasc Surg 2002;43:465-6.
12. Szkutnik M, Bialkowski J, Kusa J, et al. Postinfarction ventricular septal defect closure with Amplatzer occluders Eur J Cardiothorac Surg 2003;23:323-7.
13. Pienvichit P, Piemonte TC. Percutaneus closure of postmyocardial infarction ventricular septal defect with the CardiSEAL septal occluder implant. Catheter Cardiovasc Interv 2001;54:495-6.
14. Hachida M, Nakano H, Hirai M, Shi CY. Percutaneous transaortic closure of postinfarction ventricular septal rupture. Ann Thorac Surg 1991:51:65-7.
15. Losiance DY, Lordez JM, Deleuze PH, et al. Acute postinfarction septal rupture: Long term results. Ann Thorac Surg 1991;52:474-8.
16. Blanche C, Khan SS, Matloff JM, et al. Results of early repair of ventricular septal defect after an acute myocardial infarction. J Thorac Cardiovasc Surg 1992;104:961-5.
17. Daggett WM, Guyton RA, Mundt ED, et al. Surgery for post myocardial infarct ventricular septal defect. Ann Surg 1977;186:260-70.
18. Muehrcke DD, Dagget WM Jr, Buckley MJ, Akins CW, Hilgenberg AD, Austen WG. Postinfarct ventricular septal defect repair: Effect of coronary artery bypass grafting. Ann Thorac Surg 1992;54:882-3.
19. Pretre R, Turina MI. Post infarction septal rupture: Surgical management and evolution. Arch Mal Coeur Vaiss, 1999;92:309-13.
20. Skillington PD, Davies RH, Luff AJ, et al. Surgical treatment for infarct related ventricular septal defects. Improved early results combined with analysis of late functinal status. J Thorac Cardiovasc Surg 1990;99:98-108.
21. Jones MT, Schofield PM, Dark Jf, et al. Surgical repairof acquired repair ventricular septal defect. Determinants of early and late outcome. J Thorac Cardiovasc Surg 1987;93:680-6.
22. Demirtaþ M, Yapýcý F, Akar H ve ark. Early surgical treatment of ventricular septal rupture in acute myocardial infarction. Türk Kardiyol Dern Arþ 1996;24:234-7.
23. Killen DA, Piehler JM, Borkon AM, Gorton ME, Reed WA. Early repair of postinfarction ventricular septal rupture. Ann Thorac Surg 1997;63:137-42.
24. Labrousse L, Choukroun E, Chevalier JM, et al. Surgery for post infarction ventricular septal defect (VSD): Risk factors for hospital death and long term results. Eur J Cardiothorac Surg 2002;21:725-32.