THERAPY AND RESULTS OF SURGERY - REQUIRING INFARCTION COMPLICATIONS -AN 8-YEAR EXPERIENCE

Among myocardial infarction (MI) secondary complications requiring sur gical intervention, the primary sequel is the left ventricular aneurys m (LVA), as a matter of fact, the ventricle septum rupture (VSR) and t he moderate to severe ischemic mitral valve regurgitation (IMR) are co mmon as secondary or third follow ones. Between June 1985 and June 199 3 in our department, we performed 6418 operations with the support of the heart-lung-machine. This number includes 74 (1.15%) operations of MI complications; 38 interventions because of LVA,18 operations becaus e of IMR and 18 gical corrections of VSR. In the great majority of cas es a myocardial revascularization was performed simultaneously. Preope ratively the distribution of the whole patient population according to the functional NYHA classification was as follows: NYHA class I: 0, c lass II: 0, class III: 36 (48.6%), class Iv: 27 patients (36.5%) and c ardiogenic shock: 11 patients (14.9%). LVA surgery consists in aneurys mectomy and linear closure or endoventricular patch reconstruction, VS R was closed with synthetic patch material and the correction of IMR w as performed mainly through partial resection and replacement with a p rosthetic valve. Our early mortality was 13.1% for the LVA, 38.8% for the VSR and 11.1% for the IMR patient population, which was congruent with the rates quoted in current literature. The patient follow-up was done within a period of 6 to 90 months after discharge and the availa ble results are very good. Late mortality was 15%. The actuarial survi val rate after 7 years was 85% for the LVA, 82% for the VSR and 87% fo r the IMR patient population. Pursuant to the functional NYHA classifi cation, 16(31.4%) range in class I, 24 (47%) in class II, 10 patients (19.6%) in class III and 1 patient (2%) remain in class IV as preopera tively. Statistically significant for the early mortality was: for the VSR the cardiogenic shock but mainly an unstable hemodynamic after a prolonged failed attempt to stabilization, and an over 100 minute aort ic crossclamp time for the LYA patients. The complete myocardial revas cularization was also statistically significant for the postoperative distribution of the LVA and IMR patients in the NYHA class I and II, a nd had no influence upon the VSR patient population. A preoperative ej ection fraction > 40% as well as a left ventricular end-diastolic pres sure < 15 mmHg were pet centage significant for a better and late outc ome of the LVA and IMR patients. Reconstructive procedures for LVA and preserving interventions for IMR showed a better late postoperative s tatus. We conclude that the VSR patients with cardiogenic shock repres ents an extreme cardiosurgical emergency and must be operated on witho ut any delay. Long delay of operation for the hemodynamic instable pat ients after VSR represents a failed therapeutic strategy. A too great extent of simultaneous myocardial revascularization is to be avoided m ainly in case of severe myocardial impairment and emergency conditions because of the prolonged aortic crossclamp time. The revascularizatio n of coronary vessels with a good run-off should be performed especial ly for LVA and IMR patients. Both reconstructive operations for patien ts with LVA, and preservation of the posterior mitral valve cusp in ca se of valve replacement for IMR lead to very good postoperative late r esults and should be increasingly performed.