Repair of acute inferior wall myocardial infarction-related basal ventricular septal defect: Transatrial versus transventricular approach

Background We describe our contemporary experience for the management of patients with an acute postinfarction basal ventricle septal defect (VSD) using the transatrial (TA) and transventricular (TV) approaches. Methods Retrospective review of all patients diagnosed with an ischemic basal VSD since January 2000. There were 20 patients with a median age of 68 years (39 to 85); 13 (65%) were males. Median time from diagnosis of the ischemic basal VSD to operation was 22 hours (6 to 144). Results All patients received standard patch closure of the septal defect with exposure of the VSD through the TA approach in eight patients (40%) and the TV approach in 12 (60%). All TA group patients received tricuspid valve replacement, while in the TV group, two had tricuspid valve replacement and two repair. Five patients (25%) had clinically insignificant (<0.5 mm) residual septal defects; three additional patients (15%) experienced patch dehiscence and two (10%) underwent re-exploration. There were five mortalities (25%): one in the TA group (right ventricular heart failure) and four in the TV group (one right ventricular heart failure, three ventriculotomy site hemorrhage or patch dehiscence). Preoperative right atrial pressure (p = 0.0003) and right ventricular dysfunction (p = 0.04) were predictors of hospital mortality. Follow-up of the hospital survivors was 4.3 years (40 days to 11.5 years) with one death at seven years. Conclusion Operative mortality associated with repair of postinfarction basal ventricular septal defect is high and is related to right ventricular failure and bleeding from the ventriculotomy. The TA approach avoids ventriculotomy-associated bleeding and provides excellent exposure but is associated with an increased incidence of tricuspid valve replacement. doi: 10.1111/jocs.12156 (J Card Surg 2013;28:475-480)