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Surgical Repair Of Post Infarction Ventricular Septal Defect And Acute Tricuspid Regurgitation With Cardiogenic Shock Through Right Atrial Approach
Sanjay Kumar, MCh,FRCS1, Lavanya Bellumkonda, MD2, Abeel A. Mangi, MD3.
1Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT, USA, 2Section of Cardiology,Yale University School of Medicine, New Haven, CT, USA, 3Section of Cardiac Surgery,Yale University School of Medicine, New Haven, CT, USA.
OBJECTIVE:
A complex case of inferior wall infarction with VSD and severe TR due to acute papillary muscle rupture is described. Such lesions & novel surgical approach is not described earlier
METHODS and RESULTS:
65-year-old male with dyspnea, chest pain, and peripheral edema,showed Q waves in inferior leads in ECG. Angiogram showed occluded proximal RCA and 90% lesion in distal LAD [Figure 1A,B].The preoperative TEE showed a large VSD with left-to-right flow (Qp:Qs=2.5:1). [Figure 2 A]& severe TR with flail anterior leaflet [Figure 2C].Through median sternotomy, CPB was established after aorto-bicaval cannulation. RA was opened transversely showing TR due to ruptured papillary muscle & 2 cm VSD in the high inferior septum.The anterior and posterior leaflets were resected & septal leaflet preserved. CABGX2 was done( SVG to PDA & LIMA to LAD). VSD was closed with bovine pericardial patch through the tricuspid valve.TV was replaced with 29-mm Biocor bioprosthesis . He was weaned off CPB on milrinone & epinephrine . There was no evidence of a residual VSD. [Figure 2B] & no paravalvular leak[Figure 2D]. Postoperatively he was stable and discharged from service on day 5.
CONCLUSIONS:
The urgent TVR was warranted in our case due to severe TR. VSD closure through unique RA approach avoiding ventriculotomy alongwith complete surgical revascularization led to excellent outcome. 
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