Concomitant Transventricular Mitral Valve Replacement in Posterior Postinfarction Ventricular Septal Defect

Background: Postinfarction ventricular septal defect is a life-threatening complication of myocardial infarction. In some cases, the septal defect reaches the posterior base of the left ventricle close to the papillary muscles and does not allow for sufficient anchoring of a pericardial patch. This poses a challenge as to the management strategy. We present a treatment concept consisting of a standard transapical closure of the ventricular septal defect and a simultaneous replacement of the mitral valve through the same access. This technique allows the anchoring of a pericardial patch in healthy myocardial tissue following the excision of the papillary muscles and the mitral valve. To our knowledge, there have been no other attempts at such a procedure.

Method: We performed this procedure in four patients from December 2020 to December 2021. All patients had sustained a recent myocardial infarction and had developed a hemodynamically relevant ventricular septal defect requiring surgical intervention.

Following conventional full sternotomy, cannulation of the aorta and the right atrium, aortic cross-clamping and administration of the cardioplegic solution, access to the ventricular septum is gained via a left apical ventriculotomy. The mitral valve is excised and replaced with a prosthesis. Closure of the septal defect is achieved with a pericardial patch and left ventricular closure is performed with a mattress suture. Subsequently, standard weaning off cardiopulmonary bypass and wound closure is performed. We recommend liberal use of mechanical circulatory support in these patients.

Results: We performed this procedure on four patients (age: 68 ± 9 years, 100% male, EuroSCORE II: 19.9 ± 7.3%). The time from symptom onset until the procedure was 9.8 ± 8.0 days. Two cases were urgent and the other emergent. Operation time was 202 ± 65 minute, cross-clamp time of 84 ± 19 minutes. Satisfactory closure of the septal defect and valve function could be confirmed by echocardiography. However, the prognosis remains limited due to the initial conditions. In-hospital mortality was 50%. The remaining two patients were alive at follow-up (382 ± 123 days).

Conclusion: We consider this approach to be advantageous due to the opportunity to anchor a large patch in viable tissue for the closure of the septal defect without having to compromise to retain the subvalvular mitral apparatus. Further standardization and research into the outcomes of this procedure are needed.

Publication History

Article published online:
28 January 2023