although several surgical interventions have been developed , mortality and complications related to surgical management remains high , especially with respect to trans - ventricular approach .
ventricular incision also has several disadvantages : increased postoperative bleeding , ventricular malfunction , and ventricular arrhythmia . in the present work , we report a successful case of repair of posterior ventricular septal rupture ( vsr ) via transatrial approach .
a 73-year - old woman presented to a local hospital with shortness of breath and anterior chest pain . the electrocardiogram ( ecg ) demonstrated st - segment elevations in the inferior leads , but regional wall motion abnormality was not noted on the transthoracic echocardiogram .
the coronary angiogram showed severe stenosis at the middle of the right coronary artery ( fig .
1 ) . the left coronary catheterization revealed mild stenosis in the middle left anterior descending coronary artery .
percutaneous coronary intervention ( pci ) was performed at the right coronary artery by stent insertion .
after pci , sinus tachycardia changed to ectopic junctional rhythm on the ecg , and severe hypotension was noted .
the additional transthoracic echocardiogram revealed vsr at the basal inferoseptal wall and severe tricuspid regurgitation with right ventricular dilation ( fig .
a median sternotomy was performed , and cardiopulmonary bypass ( cpb ) was established via ascending aortic and bicaval cannulation .
vsr was noted at the basal inferior septum measuring approximately 1.5 cm in diameter ( fig .
the septal and posterior leaflet and a few chordae were resected for more consistent access to the vsr .
eleven stitches of pledget buttressed by 2 - 0 prolen were sutured by the method of interrupted horizontal mattress along the ventricular septal defect ( vsd ) margin .
the stitches near the septal leaflet were sutured through the annulus of the septal leaflet , and the stitches for the inferior margin were sutured through the inferior free wall of the right ventricle .
these stitches were passed through the trimmed teflon felt and tied into place without difficulty .
tricuspid valve replacement was performed with a carpentier edward valve ( edwards lifesciences , irvine , ca , usa ) by using a supra - annular technique ( fig .
although pci for right coronary artery lesion was done successfully , we decided to perform a right coronary artery bypass to be prepared for the possibility of acute thrombosis .
the distal right coronary artery was bypassed with a saphenous venous graft in an end - to - side fashion .
the immediate postoperative transthoracic echocardiogram ( tte ) revealed right ventricular dysfunction , and the iabp was removed from the patient on postoperative day 4 .
there was no evidence of residual vsr , and right ventricular function was in the normal range on the tte .
several risk factors are associated with post - infarct vsr : first infarction , inferior location , transmural infarction , complete and sudden occlusion of a coronary artery , poor collateral blood flow , and left ventricular hypertrophy.1)2 ) with the development of percutaneous coronary intervention , the incidence of postinfarct vsr has been reduced ; however , mortality remains high.3 ) post - infarct vsr is associated with an 87% mortality within 2 months if managed medically.4 ) previously , many surgeons delay surgical intervention while waiting for myocardial fibrosis to occur because this facilitates surgical repair .
more recently , the majority of surgeons have advocated more aggressive management , with immediate start of iabp and urgent repair of vsr . in general
, most surgeons conduct the operation via left ventriculotomy or via the infarcted free wall .
however , in the case of posterior vsr , access is difficult through left ventriculotomy or infarcted free wall.5 ) ventricular incision also has several disadvantages : increased postoperative bleeding , ventricular malfunction , and ventricular arrhythmia . in 1986 , filgueira et al.6 ) described the transatrial approach to repair the vsr in order to avoid some of the problems of ventricular incision .
it is difficult to expose the vsr and to accurately identify the vsd due to the trabeculation of the right ventricle .
in addition , the placement of the stitch through the tricuspid valve may interfere with the subvalvular apparatus , and tricuspid regurgitation can occur .
however , the tricuspid valvectomy method requires tricuspid valve repair after vsr repair . in the present case , we performed a tricuspid valve replacement instead of a repair to avoid the risk of tricuspid regurgitation that might occur if the valvular mechanism is compromised during exposure and patch closure of the vsr . moreover
, inferior myocardial infarctions may result in right ventricular dysfunction and low cardiac output syndrome postoperatively , which can worsen due to residual tricuspid regurgitation .
accurate identification of vsr is crucial to avoid residual shunt flow and can be achieved by injecting blood - tinged saline solution through a left ventricular vent catheter placed via the right superior pulmonary vein .
massetti et al.7 ) found that posterior vsr could be successfully repaired via the transatrial approach . by avoiding additional damage to the ventricle
lee et al.8 ) reported a successful right atrial approach operation for post - infarction rupture of the posterior ventricular septum .
however , unlike in our case , the operation was conducted 12 days after infarction . in conclusion , many surgeons advocate the use of ventriculostomy or infarcted tissue for the treatment of postinfarct vsr ; however , posterior septal rupture can be repaired successfully through an alternative transatrial approach , thus avoiding the complications that can occur due to ventriculotomy .
 ventricular septal rupture ( vsr ) is a disastrous mechanical complication of myocardial infarction . 
 although several surgical interventions have been developed , mortality due to surgical management remains high , especially in the case of posterior vsr . 
 we report a successful case of repair of posterior vsr using an alternative transatrial approach to avoid the complications related to ventricular incision . 
Introduction
Case
Discussion