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Post-infarct VSD And MR

Post-infarct VSD

1. Morphological Features

A. Location: 60% anterior, 40% posterior
B. Associated with total occlusion coronary artery, few collaterals
1) Large loss of myocardium
C. My be multiple; staged appearance
D. Posterior VSD- can have MR
E. Late complication- aneurysm

2. Clinical Features & Diagnosis

A. Murmur, pansystolic, LLSB
1) (Also consider acute MR murmur)
B. Chest X-Ray- pulmonary venous hypertension, large pulmonary blood flow
C. ECHO- site, size, ?MR
D. Swan-Ganz- Qp:Qs >/= 2, hemodynamics
E. Cardiac catheterization (optional??)
1) Coronary angiography
2) Left ventriculography (only if condition permits)

3. Natural History

A. Occurence- 1-2% of MI
1) (Decreased since thrombolytics)
B. Timing- 2-3 days post MI up to 2 weeks
C. Early death is common

4. Indications for Operation

A. Indication = presence of VSD
B. Timing
1) Urgent- for hemodynamic or end-organ decline
2) Delayed (2-3 weeks) - if stable

5. Operative Considerations

A. Urgency, IABP
B. Approached through LV
C. Patch technique
1) 2 patches unless apical
D. Concomittant procedures
1) CABG
2) MV replacement
3) Aneurysm resection
4) Free wall perforation (especially posterior)

6. Results or Repair

A. Survival: 35% early mortality
B. Functional status: good
C. Modes of death
1) 50% CHF, acute
2) 10% sudden death
3) 5% CHF, chronic, intractable
4) CVA
D. Risk factors
1) Hemodynamic status & RV function preoperatively
2) Extent of myocardial necrosis
3) Posterior VSD >> anterior VSD