Total Transmural Sutures (TTS) Method, Modified Infarction Exclusion Technique for Ventricular Septal Rupture after Extensive Myocardial Infarction

The infarction exclusion technique using endoventricular continuous sutures for ventricular septal rupture after acute myocardial infarction may be a difficult surgical technique and create residual shunt due to fragile myocardium. We present a patient of ventricular septal rupture (VSR) after extensive anteroseptal myocardial infarction who underwent successful repair using a modified infarction exclusion technique. In our procedure interrupted mattress sutures were placed through the ventricular wall in a way as to exclude the VSR and infarcted muscle of the left ventricle. A heterogeneous pericardial patch is sutured to healthy endocardium in the free and septal wall all around the infarcted area. We describe a procedure for repairing postinfarction VSR, by the infarction exclusion technique with total transmural sutures (TTS) method.


Introduction
Operation for postinfarction ventricular septal rupture (VSR) is associated with high operative mortality in the acute phase of the myocardial infarction. The conventional procedure established by Daggett et al. [1] has been reported to prolong postoperative heart failure and result in high mortality especially in extensive myocardial infarction [2]. The infarction exclusion technique proposed surgical technique and create residual shunt due to fragile myocardium from using endoventricular continuous sutures [5] [6]. Gerola et al. [7] reported a method using transmural sutures and a patch for reinforcement of septal wall.
Although this method could prevent residual shunt, it is basically considered to be a similar method to the Daggett's original. Therefore, it seems unsuitable for some cases with a large VSR and/or a widespread infarction. Our method is presented here as a procedure to prevent residual shunt by transmural sutures and exclude an infarcted area with a large patch to suppress the adverse effects on the remaining functional myocardium. We describe a procedure performed with a modification of the infarction exclusion technique to dispel some concerns.

Case Report
A 53-year-old male patient was referred to our institution with acute myocardial infarction. He complained of anterior chest pain. His blood pressure was 80/57 mmHg and heart rate was 120 beats/min. A twelve-lead electrocardiogram showed abnormal Q wave and T wave elevation in V2 -V5. A chest radiograph demon-

Discussion
Despite the evolution in surgical treatment of patients with heart failure, mortality and morbidity rates of postinfarction VSR remain high. The prognosis of the VSR is related to the residual shunt and the postoperative cardiac function. Repair of postinfarction VSR using infarction exclusion technique [3] [4] has been reported to be excellent in restoring postoperative ventricular function as compared with traditional operative technique, infarctectomy and reconstruction of the left and right ventricular walls [1]. However, the infarction exclusion technique is technically difficult due to the need for repair with a continuous suture requiring a large patch placed for uneven ventricular cavityin a three-dimensional manner. Some reports described residual shunt after the infarction exclusion operation [5]. In the acute phase of myocardial infarction the margin between infarcted and healthy myocardium was often unclear. The technique may be insufficient for suturing fragile myocardium in the acute phase of myocardial infarction. In our method a pericardial patch is anchored tightly to endocardium with transmural sutures, therefore our technique may reduce the risk of residual shunt. The method allows fairly easy suture of pericardial patch to exclude the infarcted area. Gerola et al. [7] reported a method using transmural sutures and a patch for reinforcement of septal wall with an emphasis on preventing residual shunt, however it is basically considered to be a similar method to the Daggett's original. Therefore, it seems unsuitable for cases with a large VSR and/or a widespread infarction. Our method is presented here as a procedure to prevent residual shunt by transmural sutures and exclude an infarcted area with a large patch to suppress adverse effects on the remaining functional myocardium. And we added a tongue-shaped large Teflon felt patch to the septum wall side, furtherapplieda biological glue to the space between the Teflon felt patch on the interventricular septum and the pericardial patch. We believe these additional reinforced measures could result in less residual leakage and bleeding. Musumeci et al. [8] reported the application of gelatin-resorcin-formol (GRF) biological glue in the space between the pericardial patch and infarcted septum. Theoretically the method may contain the risk of contamination of the systemic circulation with formaldehyde because GRF glue is directly applied on the interventricular septum with a ventricular septal defect. Our method prevents the risk by the Teflon felt patch being on the interventricular septum.
Once we reported a transmural suture technique for postinfarction VSR [9]. In the procedure the interrupted mattress sutures to exclusion the midportion of ventricular septum were placed on the septal wall of non-infarcted LV to anchor the pericardial patch through the RV. We considered to minimize adverse effects on right ventricular functionin this current patient with an extensive myocardial infarction, and placed the interrupted mattress sutures along the inferior interventricular groove on postero-inferior wall of the LVto exclusion the midportion of the ventricular septum.
The concern about our operative technique is the effect on right ventricular function because the interrupted mattress sutures on the septal wall in upper part World Journal of Cardiovascular Surgery of the LV are anchored to the RV and reduce a part of right ventricular space.
The other concern is the myocardial damage of the transfixed suture line. The postoperative cardiac catheter study demonstrated normal pressure, cardiac output and contraction of the left ventricular wall except for the infarcted anteroseptal wall. These drawbacks could be minimized. The patient has had a good postoperative course without formation of left ventricular aneurysm and heart failure in the midterm follow-up.

Conclusion
We report a case of VSR after extensive anteroseptal myocardial infarction that underwent successful surgical treatment using a modified infarction exclusion technique, specifically total transmural sutures (TTS) method. This procedure is technically easy and can be effective for the surgical treatment of postinfarction VSR.