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Epidural/Echo/Coagulation

Perioperative transoesophageal echocardiography and post-infarct ventricular septal defect: 018

Ragheb, J. W.; Griffin, M.

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European Journal of Anaesthesiology: June 2004 - Volume 21 - Issue - p 30

We report on 2 patients who presented with ventricular septal defects complicating acute myocardial infarction, in whom transoesophageal echocardiography (TOE) impacted significantly on their management.

Case Reports: An 82 year old female patient with no past medical history presented with acute anterior myocardial infarction. Twenty-four hours later a new onset holosystolic murmur was noted and the diagnosis of a new onset ventricular septal defect was confirmed using TOE and ventriculogram. Emergency surgical repair was carried out.

The second patient was a 79 year old male patient who presented with acute inferior myocardial infarction and post-infarction ischaemia. Emergency revascularization was carried out and postero-septal ventricular septal defect was diagnosed intra-operatively using TOE. Both patients made an uneventful postoperative recovery.

Preoperative management and optimization of both patients for emergency surgery required the use of both inotropic support to increase cardiac output and the judicious use of vasodilators to reduce ventricular afterload and to decrease left to right shunt.

An intra-aortic balloon pump was inserted perioperatively to optimize coronary blood flow. Intraoperatively, cardiopulmonary bypass was rapidly established, the defects were surgically repaired adequately as confirmed by TOE post bypass. In the second case revascularization was also carried out.

Postoperatively both patients required inotropic support. Milrinone was our inotrope of choice as it also provided vasodilatation and a decrease of ventricular afterload.

Discussion: Ventricular septal defect complicates 2% of all acute myocardial infarctions. The incidence is higher in patients with single vessel disease namely the left anterior descending artery. Anterior myocardial infarction is complicated by antero-apical ventricular septal defect while inferior myocardial infarction is complicated by postero-septal ventricular septal defect. The mortality rate is high and early surgical intervention has been shown to decrease the mortality rate from 85% to 25% if treated within the first 24 hours post onset. The anaesthetic management of patients with ventricular septal defects complicating acute myocardial infarction is complex and challenging. The anaesthetist is involved in every stage of management. In the first case we used TOE to confirm the location and the size of the defect and to guide surgical intervention. In the second case we used TOE to make the unexpected diagnosis intraoperatively and subsequently to guide surgical management.

Reference:

1 Bouchart F, Besson JP, Tabley A, et al. Urgent surgical repair of postinfarction ventricular septal rupture: early and late outcome. J Card Surg 1998; 13: 104-112.
© 2004 European Society of Anaesthesiology