**10. References**


**2**

*USA* 

**Post Myocardial Infarction** 

Michael S. Firstenberg and Jason Rousseau

*Division of Cardiac Surgery, The Ohio State University Medical Center, Columbus,* 

With advances in the management of acute myocardial infarction (AMI) the incidence of mechanical complications continues to decline. Nevertheless, when they occur, unfortunately, despite similar advances and growing experiences in the surgical management of these problems, morbidity and mortality remain high. Post-myocardial infarction ventricular septal defects (PI-VSD) have fascinated and challenged clinicians for years. The timing of presentation can be quite variable, as they tend to occur in patients several days after their initial cardiovascular insult (acute PI-VSD) – and unfortunately, they can occur in patients who appear to have been making significance progress on the road to recovery. In addition, although more rare, some patients might not present until weeks, if not longer, after their infarction with symptoms that prompt the discovery of a chronic PI-VSD. Early PI-VSDs tend to be catastrophic and typically result in early death. The pathophysiology is also variable and complex, but common themes include: 1) worsening cardiac output, often with manifestations of shock and end-organ damage, from acute left ventricular (LV) dysfunction and from increased left-right shunting, 2) acute right ventricular (RV) dysfunction from a sudden increase in pressure, volume, and flow from left to right shunts, and 3) pulmonary hypertension also from the increase in RV flow. Definitive management remains surgical, however controversies continue to exist regarding the timing of surgery and the role of concomitant coronary revascularization. Unfortunately, despite early repair and standardization of techniques, both short and long-term outcomes remain

As with many cardiovascular conditions, post-myocardial infarction ventricular septal defects (PI-VSD) were described first at autopsy (Latham, 1845) and then pre-mortum in 1923, many years before the pathophysiology was understood (Brunn, 1923). It was not until 1934 that the association with coronary artery disease was described (Sager, 1934). The first report of a surgical repair came in 1956 when Denton Cooley described the surgical management in a patient 9 weeks after the initial diagnosis (Cooley, 1956). With advances in cardiovascular surgery and peri-operative management of the cardiac surgery patient there were increasing reports of survival in what was previously felt to be a lethal problem. Most of the successful cases occurred in patients who presented in congestive heart failure many

**1. Introduction** 

less than ideal.

**2. History** 

**Ventricular Septal Defect** 

JS. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J AmColl Cardiol 2008;52:e1–e142.

