Tratamento cirúrgico da rotura do septo interventricular pós infarto agudo do miocárdio

Tanajura, Luiz Fernando Leite; Piegas, Leopoldo S; Mattos, Luiz Alberto; Pinto, Ibraim Francisco; Magalhães, Hélio M. de; Bembom, Jaime da Cunha; Arnoni, Antoninho S; Oliveira, João Bosco de; Abdulmassih Neto, Camilo; Dinkhuysen, Jarbas J; Souza, Luiz Carlos Bento de; Paulista, Paulo P; Jatene, Adib D; Sousa, José Eduardo M. R

doi:10.1590/S0102-76381987000200001

Resumos

A rotura do septo interventricular (RSI) reduz a perspectiva de sobrevida do paciente com infarto agudo do miocárdio (IAM). Entre 1968 e 1987, atendemos 48 pacientes (p) com este diagnóstico, sendo 16 (33%) mantidos clinicamente e 32 (67%) submetidos a cirurgia. Todos os p clínicos faleceram durante a internação. Dentre os p operados, o IAM se localizava na parede anterior em 18 (56%) e na inferior em 14 (44%), com mortalidades respectivas de 6 (33%) e 4 (29%). Disfunção ventricular esquerda severa (Killip III e IV) foi encontrada em 26 (81%). Em 18 (56%) p foi introduzido o cateter de Swan-Ganz. Dos 31 (97%) p que se submeteram a cinecoronariografia, 22 (71%) apresentavam lesão uniarterial e 9 (29%), doença multiarterial. Entre os p com lesões isoladas, a descendente anterior foi acometida em 15 (68%), a coronária direita em 6 (27%) e a circunflexa em 1 (5%). A cirurgia foi realizada nas 2 primeiras semanas de evolução em 8 (25%) e, após este período, em 24 (75%), com mortalidades de 6 (75%) e 4 (17%), respectivamente. O balão intra-aórtico foi usado em 7 (22%). Os procedimentos cirúrgicos associados ao fechamento da RSI foram revascularização miocárdica em 10 (31%), aneurismectomia de VE em 17 (53%) e infartectomia e 6 (19%). Na evolução tardia, dos 22 sobreviventes, 14 (64%) encontram-se assintomáticos, 1 (5%) sintomático, ocorreram 4 (18%) óbitos e perdeu-se a evolução de 3 (13%). Concluímos que, apesar do risco cirúrgico, a cirurgia precoce ainda é a melhor opção terapêutica desta complicação.

septo interventricular, rotura; infarto do miocárdio

The ventricular septal rupture (VSR) following acute myocardial infarction (AMI) is a rare and catasthrophic complication with a high mortality rate. Surgery is the only effective procedure to try to control this complication. However the surgical mortality is elevated and is closely related to the post-infarct period thus making the indication for the precise time for surgery one the fundamental aspects for its success. In a population of 48 patients with diagnosis of VSD following AMI, according to the criteria of the Myocardial Infarction Research United, we treated 32 (67%) with surgery. The diagnosis was confirmed by hemodynamic in all patients. The AMI was anterior in 18 cases (56%) and inferior in 14 (44%); the mortality rate is 6 (33%) and 4 (29%) cases respectively. Severe heart failure (Killip III and IV) was present in 26 cases (81%) and life threatening arrhythmias in 13 (41%). A Swan-Ganz catheter was introduced at bedside in 18 (56%) patients to confirm the diagnosis and provide a better therapeutic management. Angiographic studies were performed in 31 (97%). Cineangiography showed a critical lesion (obstruction equal or greater than 70% of the lumen) in one vessel in 22 patients (71%): left anterior descending coronary artery in 15 (68%), right coronary artery in 6 (27%) and left circunflex in 1 (5%). Nine cases (29%) had critical lesions in two vessels. The pulmonary artery pressure was always elevated in those patients in whom the pressure was measured. Clinical treatment was used in 16 (33%) cases and all died during hospitalization. Eight patients (25%) underwent the surgery within the first two weeks and 24 (75%) after this period; mortality rate was 6 (75%) and 4 (17%) cases respectively. Nine patients were re-catheterized in the post operative period and only one presented signs of significant shunt in the ventricular level. This patient who was the oldest of the group was reoperated later. Of the 22 patients discharged from the hospital 15 are long-term survivors. In 3 the follow-up was lost and 4 died. The accumulated data allows us to conclude that: 1) the attempt to postpone surgery by keeping the patients under medical treatment waiting for a more favorable time for surgery did not produce satisfactory results; 2) surgery should be performed in the acute phase (first two weeks) in spite of a still elevated mortality in this group; 3) after the first two weeks the results are good with low mortality rate for this kind of surgery; 4) VSD reappearence was infrequent.

ventricular septal defect; myocardial infarct

Tratamento cirúrgico da rotura do septo interventricular pós infarto agudo do miocárdio

Surgical treatment of ventricular septal defect post acute myocardial infart

Luiz Fernando Leite Tanajura^I; Leopoldo S. Piegas^I; Luiz Alberto Mattos^I; Ibraim Francisco Pinto^I; Hélio M. de Magalhães^I; Jaime da Cunha Bembom^II; Antoninho S. Arnoni^I; João Bosco de Oliveira^II; Camilo Abdulmassih Neto^I; Jarbas J. Dinkhuysen^I; Luiz Carlos Bento de Souza^I; Paulo P. Paulista^I; Adib D. Jatene^III; José Eduardo M. R. Sousa^I

^IDo Instituto Dante Pazzanese de Cardiologia

^IIDo Serviço de Clínica e Cirurgia Cardiovascular Prof. Dr. Adib Jatene. Hospital da Beneficência Portuguesa

^IIIDo Hospital do Coração da Associação do Sanatório Sírio

^{Endereço para separatas} Endereço para separatas: Luiz Fernando Tanajura Caixa Postal 215 01000, São Paulo, SP, Brasil

RESUMO

A rotura do septo interventricular (RSI) reduz a perspectiva de sobrevida do paciente com infarto agudo do miocárdio (IAM). Entre 1968 e 1987, atendemos 48 pacientes (p) com este diagnóstico, sendo 16 (33%) mantidos clinicamente e 32 (67%) submetidos a cirurgia. Todos os p clínicos faleceram durante a internação. Dentre os p operados, o IAM se localizava na parede anterior em 18 (56%) e na inferior em 14 (44%), com mortalidades respectivas de 6 (33%) e 4 (29%). Disfunção ventricular esquerda severa (Killip III e IV) foi encontrada em 26 (81%). Em 18 (56%) p foi introduzido o cateter de Swan-Ganz. Dos 31 (97%) p que se submeteram a cinecoronariografia, 22 (71%) apresentavam lesão uniarterial e 9 (29%), doença multiarterial. Entre os p com lesões isoladas, a descendente anterior foi acometida em 15 (68%), a coronária direita em 6 (27%) e a circunflexa em 1 (5%). A cirurgia foi realizada nas 2 primeiras semanas de evolução em 8 (25%) e, após este período, em 24 (75%), com mortalidades de 6 (75%) e 4 (17%), respectivamente. O balão intra-aórtico foi usado em 7 (22%). Os procedimentos cirúrgicos associados ao fechamento da RSI foram revascularização miocárdica em 10 (31%), aneurismectomia de VE em 17 (53%) e infartectomia e 6 (19%). Na evolução tardia, dos 22 sobreviventes, 14 (64%) encontram-se assintomáticos, 1 (5%) sintomático, ocorreram 4 (18%) óbitos e perdeu-se a evolução de 3 (13%). Concluímos que, apesar do risco cirúrgico, a cirurgia precoce ainda é a melhor opção terapêutica desta complicação.

Descritores: septo interventricular, rotura, cirurgia; infarto do miocárdio, cirurgia.

ABSTRCT

The ventricular septal rupture (VSR) following acute myocardial infarction (AMI) is a rare and catasthrophic complication with a high mortality rate. Surgery is the only effective procedure to try to control this complication. However the surgical mortality is elevated and is closely related to the post-infarct period thus making the indication for the precise time for surgery one the fundamental aspects for its success. In a population of 48 patients with diagnosis of VSD following AMI, according to the criteria of the Myocardial Infarction Research United, we treated 32 (67%) with surgery. The diagnosis was confirmed by hemodynamic in all patients. The AMI was anterior in 18 cases (56%) and inferior in 14 (44%); the mortality rate is 6 (33%) and 4 (29%) cases respectively. Severe heart failure (Killip III and IV) was present in 26 cases (81%) and life threatening arrhythmias in 13 (41%). A Swan-Ganz catheter was introduced at bedside in 18 (56%) patients to confirm the diagnosis and provide a better therapeutic management. Angiographic studies were performed in 31 (97%). Cineangiography showed a critical lesion (obstruction equal or greater than 70% of the lumen) in one vessel in 22 patients (71%): left anterior descending coronary artery in 15 (68%), right coronary artery in 6 (27%) and left circunflex in 1 (5%). Nine cases (29%) had critical lesions in two vessels. The pulmonary artery pressure was always elevated in those patients in whom the pressure was measured. Clinical treatment was used in 16 (33%) cases and all died during hospitalization. Eight patients (25%) underwent the surgery within the first two weeks and 24 (75%) after this period; mortality rate was 6 (75%) and 4 (17%) cases respectively. Nine patients were re-catheterized in the post operative period and only one presented signs of significant shunt in the ventricular level. This patient who was the oldest of the group was reoperated later. Of the 22 patients discharged from the hospital 15 are long-term survivors. In 3 the follow-up was lost and 4 died. The accumulated data allows us to conclude that: 1) the attempt to postpone surgery by keeping the patients under medical treatment waiting for a more favorable time for surgery did not produce satisfactory results; 2) surgery should be performed in the acute phase (first two weeks) in spite of a still elevated mortality in this group; 3) after the first two weeks the results are good with low mortality rate for this kind of surgery; 4) VSD reappearence was infrequent.

Descriptors: ventricular septal defect, surgery; myocardial infarct, surgery.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Trabalho realizado no Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brasil.

Apresentado ao 14º Congresso Nacional de Cirurgia Cardíaca. Salvador, BA, 27 e 28 de março, 1987.

1 BRUNN, F. - Zur Diagnostic der erworbenen Ruptur der Kammersscheidewand des Herzens, Wien. Arch. Int. Med, 6: 533-544, 1923.
2 BURAKOVSKY, V. I. ; TSUKERMAN, G. I. ; KRAKOVSKY, A. A. - Basic courses of approach to the surgical treatment of postinfarct delects of the interventricular septum . Kardiologiia, 19 (1): 8-15,1979.
3 CAMPION, B. C.; HARRISON, C. E.; GUILlANI, E. R. - Ventricular septal defect after myocardial infarction. Ann. Int. Med, 70 (2) : 251-261, 1969.
4 COOLEY, D. A.; BELMONTE, B. A.; ZEIS, L. B.; SCHNUR, S. - Surgical repair of ruptured interventricular septum following acute myocardial infarction. Surgery, 41: 930-937, 1957.
5 DAGGETT; W. M.; GUYTON, R. A.; MUNDTH, E. D.; BUCKLEY, M. J.; McENANY, M. T.; GOLD, H. K.; LEINBACH, R. C.; AUSTEN, W. G. - Surgery for post-myocardial infarct ventricular septal defect. Ann. Surg, 186 (3): 268-271, 1977.
6 HILL, J. D.; LARY, D.; KERTH, W. J.; GERBODE, F. - Acquired ventricular septal defects. J. Thorac. Cardiovasc. Surg, 70 (3) : 440-450, 1975.
7 HUTCHINS, G. M. - Rupture of the interventricular septum complicating myocardial infarction: pathological analysis of 10 patients with clinically diagnosed perforations. Am. Heart J, 97 (2): 165-173, 1979.
8 IBEN, A. B.; PUPELLO, D. F.; STINSON, E. B.; SHUMWAY, N. E. - Surgical treatment of postinfarction ventricular septal defects. Ann. Thorac. Surg, 8 (3): 252-262, 1969.
9 KITAMURA, S.; MENDEZ, A.; KAY, J. H. - Ventricular septal defects following myocardial infarction. J. Thorac. Cardiovasc. Surg, 61 (2): 186-199, 1971.
10 LATHAM, P. M. - Lectures on subjects connected with clinical medicine compromising disease of the heart. London, Brown, Green and Longmans, 1945. p. 163-164.
11 LEE, W. Y.; CARDON, L.; SLODKI, S. J. - Perforation of infarcted interventricular septum. Arch. Int. Med, 109 (6): 731-741, 1962.
12 LEMERY, R.; SMITH, H. C.; GERSH, B. J.; GIULIANI, E. R.; SCHAFF, H. V. - Prognosis of ventricular septal defect following acute myocardial infarction. J. Am. Coll. Cardiol, 7(2): 33, 1986.
13 LOISANCE, D. Y.; CACHERA, J. P.; POULAIN, H.; AUBRY, P.; JUVIN, A. M.; GALEY, J. J. - Ventricular septal defect after acute myocardial infarction. J. Thorac. Cardiovasc. Surg, 80: (1): 61-67, 1980.
14 MONTOYA, A.; McKEEVER, L.; SCANLON, P.; SULLIVAN, H. J.; GUNNAR, R. M.; PIFARRE, R. - Early repair of ventricular septal rupture after infarction. Am. J. Cardiol, 45 (2): 345-348, 1980.
15 OLDHAM Jr. H. N.; SCOTT, S. M.; DART Jr., C. H. - Surgical correction of ventricular septal defect following acute myocardial infarction. Ann. Thorac. Surg, 7 (3): 193-201, 1969.
16 PETROV, K.; KARALAMBEV, N.: TONEVA, N.: VASSILEV, C. - Analyse de 153 cas de rupture du myocarde après l'infarctus aigu du myocarde. Arch. Mal. Coeur. 70 (7): 691-697, 1977.
17 PIEGAS, L. S.: CARVALHO, H. G.: SOUSA, J. E. M. R.: RESECK, P. A. R.: JATENE, A. D. - Use of the Swan-Ganz catheter in the diagnosis of ventricular septal defect after myocardial infarction: case report. Heart Lung, 2 (4): 539-541, 1973.
18 PIEGAS, L. S.; SANTOS, R. J.; MIRANDA, M. A. T.; BEMBOM, J. C.; TIMERMAN, A.; BARBOSA, M. A. O.; EGITO, E. T.; ABDULMASSIH NETO, C.; SOUZA, L. C. B.; PAULISTA, P. P.; JATENE, A. D. - Ruptura do septo interventricular pós infarto agudo do miocádio: o dilema da indicação cirúrgica. Arq. Bras. Cardiol. 37 (4): 241-246, 1981.
19 PIWNICA, A.; NOTTIN, R.; BERCOT, M.; DELOCHE, A.; D'ALLAINES, C.; CARPENTIER, A.; BLONDEAU, P.; DUBOST, C. - Resultats du traitement chirurgical de 31 cas de perforation septale operés au cours des 21 premier jours de l'infarctus myocardique. Ann. Chir. Thorac. Cardiovasc., 30 (9): 257-262, 1976.
20 SAGER, R. V. - Coronary thrombosis: perforation of the infarcted interventricular septum. Arch. Int. Med, 53 (1): 140-148, 1934.
21 SANDERS, R. J.; KERN, W. H.; BLOUNT Jr., S. G. - Perforation of the interventricular septum complicating myocardial infarction: a report of eight cases, one with cardiac catheterization. Am. Heart J, 51 (5): 736-748, 1956.
22 STINSON, E. B.; BECKER, R. J.; SHUMWAY, N. E. - Successful repair of post infarction ventricular septal defect by biventricular aneurysm. J. Thorac. Cardiovasc. Surg, 58 (1): 20-24, 1969.
23 VLODAVER, Z. & EDWARDS, J. E. - Rupture of ventricular septum or papillary muscle complicating myocardial infarction. Circulation, 55 (5): 815-822, 1977.

Endereço para separatas:

Luiz Fernando Tanajura

Caixa Postal 215

01000, São Paulo, SP, Brasil

Datas de Publicação

Publicação nesta coleção
16 Fev 2011
Data do Fascículo
Ago 1987

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1 BRUNN, F. - Zur Diagnostic der erworbenen Ruptur der Kammersscheidewand des Herzens, Wien. Arch. Int. Med, 6: 533-544, 1923.

[2] 2 BURAKOVSKY, V. I. ; TSUKERMAN, G. I. ; KRAKOVSKY, A. A. - Basic courses of approach to the surgical treatment of postinfarct delects of the interventricular septum . Kardiologiia, 19 (1): 8-15,1979.

[3] 3 CAMPION, B. C.; HARRISON, C. E.; GUILlANI, E. R. - Ventricular septal defect after myocardial infarction. Ann. Int. Med, 70 (2) : 251-261, 1969.

[4] 4 COOLEY, D. A.; BELMONTE, B. A.; ZEIS, L. B.; SCHNUR, S. - Surgical repair of ruptured interventricular septum following acute myocardial infarction. Surgery, 41: 930-937, 1957.

[5] 5 DAGGETT; W. M.; GUYTON, R. A.; MUNDTH, E. D.; BUCKLEY, M. J.; McENANY, M. T.; GOLD, H. K.; LEINBACH, R. C.; AUSTEN, W. G. - Surgery for post-myocardial infarct ventricular septal defect. Ann. Surg, 186 (3): 268-271, 1977.

[6] 6 HILL, J. D.; LARY, D.; KERTH, W. J.; GERBODE, F. - Acquired ventricular septal defects. J. Thorac. Cardiovasc. Surg, 70 (3) : 440-450, 1975.

[7] 7 HUTCHINS, G. M. - Rupture of the interventricular septum complicating myocardial infarction: pathological analysis of 10 patients with clinically diagnosed perforations. Am. Heart J, 97 (2): 165-173, 1979.

[8] 8 IBEN, A. B.; PUPELLO, D. F.; STINSON, E. B.; SHUMWAY, N. E. - Surgical treatment of postinfarction ventricular septal defects. Ann. Thorac. Surg, 8 (3): 252-262, 1969.

[9] 9 KITAMURA, S.; MENDEZ, A.; KAY, J. H. - Ventricular septal defects following myocardial infarction. J. Thorac. Cardiovasc. Surg, 61 (2): 186-199, 1971.

[10] 10 LATHAM, P. M. - Lectures on subjects connected with clinical medicine compromising disease of the heart. London, Brown, Green and Longmans, 1945. p. 163-164.

[11] 11 LEE, W. Y.; CARDON, L.; SLODKI, S. J. - Perforation of infarcted interventricular septum. Arch. Int. Med, 109 (6): 731-741, 1962.

[12] 12 LEMERY, R.; SMITH, H. C.; GERSH, B. J.; GIULIANI, E. R.; SCHAFF, H. V. - Prognosis of ventricular septal defect following acute myocardial infarction. J. Am. Coll. Cardiol, 7(2): 33, 1986.

[13] 13 LOISANCE, D. Y.; CACHERA, J. P.; POULAIN, H.; AUBRY, P.; JUVIN, A. M.; GALEY, J. J. - Ventricular septal defect after acute myocardial infarction. J. Thorac. Cardiovasc. Surg, 80: (1): 61-67, 1980.

[14] 14 MONTOYA, A.; McKEEVER, L.; SCANLON, P.; SULLIVAN, H. J.; GUNNAR, R. M.; PIFARRE, R. - Early repair of ventricular septal rupture after infarction. Am. J. Cardiol, 45 (2): 345-348, 1980.

[15] 15 OLDHAM Jr. H. N.; SCOTT, S. M.; DART Jr., C. H. - Surgical correction of ventricular septal defect following acute myocardial infarction. Ann. Thorac. Surg, 7 (3): 193-201, 1969.

[16] 16 PETROV, K.; KARALAMBEV, N.: TONEVA, N.: VASSILEV, C. - Analyse de 153 cas de rupture du myocarde après l'infarctus aigu du myocarde. Arch. Mal. Coeur. 70 (7): 691-697, 1977.

[17] 17 PIEGAS, L. S.: CARVALHO, H. G.: SOUSA, J. E. M. R.: RESECK, P. A. R.: JATENE, A. D. - Use of the Swan-Ganz catheter in the diagnosis of ventricular septal defect after myocardial infarction: case report. Heart Lung, 2 (4): 539-541, 1973.

[18] 18 PIEGAS, L. S.; SANTOS, R. J.; MIRANDA, M. A. T.; BEMBOM, J. C.; TIMERMAN, A.; BARBOSA, M. A. O.; EGITO, E. T.; ABDULMASSIH NETO, C.; SOUZA, L. C. B.; PAULISTA, P. P.; JATENE, A. D. - Ruptura do septo interventricular pós infarto agudo do miocádio: o dilema da indicação cirúrgica. Arq. Bras. Cardiol. 37 (4): 241-246, 1981.

[19] 19 PIWNICA, A.; NOTTIN, R.; BERCOT, M.; DELOCHE, A.; D'ALLAINES, C.; CARPENTIER, A.; BLONDEAU, P.; DUBOST, C. - Resultats du traitement chirurgical de 31 cas de perforation septale operés au cours des 21 premier jours de l'infarctus myocardique. Ann. Chir. Thorac. Cardiovasc., 30 (9): 257-262, 1976.

[20] 20 SAGER, R. V. - Coronary thrombosis: perforation of the infarcted interventricular septum. Arch. Int. Med, 53 (1): 140-148, 1934.

[21] 21 SANDERS, R. J.; KERN, W. H.; BLOUNT Jr., S. G. - Perforation of the interventricular septum complicating myocardial infarction: a report of eight cases, one with cardiac catheterization. Am. Heart J, 51 (5): 736-748, 1956.

[22] 22 STINSON, E. B.; BECKER, R. J.; SHUMWAY, N. E. - Successful repair of post infarction ventricular septal defect by biventricular aneurysm. J. Thorac. Cardiovasc. Surg, 58 (1): 20-24, 1969.

[23] 23 VLODAVER, Z. & EDWARDS, J. E. - Rupture of ventricular septum or papillary muscle complicating myocardial infarction. Circulation, 55 (5): 815-822, 1977.