**12. Conclusions**

Post-myocardial infarction ventricular septal defects complicate up to 0.02% of acute myocardial infarctions. Despite advances in the surgical care of these moribund patients, operative mortality still approaches 50% with major risks including cardiogenic shock, renal failure, right and/or left ventricular failure, size of VSD, posterior/inferior locations, and residual VSD. While some patient may present late or benefit from a delayed repair, typically surgical intervention is indicated prior to irreversible end-organ damage. Repair techniques emphasize closure of the defect and protecting the injured septum from left ventricular pressures. Post-operative management is typically challenging considering the inherent pre-operative biventricular dysfunction and associated end-organ damage. Those who survive there initial event and operation tend to have favorable 5 and 10-year survivals.

#### **13. Conflicts of interest**

The authors have no conflicts of interest or disclosures related to any of the topics or technologies discussed in this manuscript.

#### **14. References**


A total artificial heart precludes native cardiac recovery and obligates transplantation, nevertheless, it may be an option with appropriate resources and experience in highly

Residual shunts are found in up to 25% of patients after definitive repair (Skillington, 1990). The etiology of residual shunts is either a missed defect at the time of initial repair, dehiscence of a patch (sewn to necrotic or friable tissue), or further extension of the initial defect. Fortunately, most residual shunts tend to be physiologically tolerated and spontaneous closure has been reported. Operative re-intervention is associated with a >60% mortality (Jeppsson, 2005) and surgery is reserved for patients in heart failure failing medical management or those with large shunts (Qp:Qs>2.0) (Murashita, 2010). Because of the high operative mortality with repairing residual or recurrent shunts there has been interest, but limited success, with percutanous closure devices (Shah, 2005). Nevertheless, the role of percutaneous closure and the ideal devices are undefined (Pienvichit, 2001) and probably best reserved for use in those centers with extensive experience in the closure of

Post-myocardial infarction ventricular septal defects complicate up to 0.02% of acute myocardial infarctions. Despite advances in the surgical care of these moribund patients, operative mortality still approaches 50% with major risks including cardiogenic shock, renal failure, right and/or left ventricular failure, size of VSD, posterior/inferior locations, and residual VSD. While some patient may present late or benefit from a delayed repair, typically surgical intervention is indicated prior to irreversible end-organ damage. Repair techniques emphasize closure of the defect and protecting the injured septum from left ventricular pressures. Post-operative management is typically challenging considering the inherent pre-operative biventricular dysfunction and associated end-organ damage. Those who survive there initial event and operation tend to have favorable 5 and 10-year survivals.

The authors have no conflicts of interest or disclosures related to any of the topics or

Agnihotri AK, Madsen JC, Daggett WM. Surgical Treatment of Complications of Acute

Berger TJ, Blackstone EH, Kirklin JW. Postinfarction ventricular septal defect, in Kirklin JW,

Myocardial Infarction: Postinfarction Ventricular Septal Defect and Free Wall Rupture. Cohn L, ed. Cardiac Surgery in the Adult. New York: McGraw-Hill,

Barratt-Boyes BG (eds): Cardiac Surgery*.* New York, Churchill Livingstone, 1993; p

selected patient with few other comorbidities.

**11.3 Residual/recurrent defects** 

congenital VSDs.

**12. Conclusions** 

**13. Conflicts of interest** 

2008:753-784.

**14. References** 

403.

technologies discussed in this manuscript.


**3** 

*USA* 

Hitoshi Hirose

**Current Trend of Off-Pump** 

*Thomas Jefferson University, Philaelphia PA,* 

**Coronary Artery Bypass Grafting** 

*Division of Cardiothoracic Surgery, Department of Surgery* 

Coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) and cardioplegic arrest has been performed safely over several decades. Cardiac surgery under cardiac arrest provides a bloodless stable operative field, that can facilitate anastomosis. In last decade, CABG without CPB, off-pump CABG (OPCAB) has become more common with advances in surgical instruments and technique. This chapter summarizes the surgical

After standard sternotomy and appropriate graft harvesting, a pericardial well is created. A standard dose of heparin is administered by the anaesthesiologist. The anaesthesia team should be prepared to perform appropriate hemodynamic monitoring. We use transesophageal echocardiography and Swan-Gantz catheters to monitor cardiac function in all patients. Activated clotting time above 350 is sufficient to perform OPCAB; however, a full dose of heparin may be given in cases undergoing emergent conversion to CABG using CPB. The anaesthesiologist should inform the surgical team any abrupt decrease in blood pressure, ST changes on EKG and arrhythmia, because these are signs

The patient is placed in the Trendelenburg position and the sternal retractor is open widely. Right side stitches holding the pericardial well are released to minimize compression of the right heart. While the apex of the heart is gently elevated using one hand, retropericardial sutures are placed to support the heart (Figure 1). To minimize hemodynamic instability, we place the first retropericardial stitch into the mid-portion of the diaphragm. The stitch is pulled out to the right side of the lower edge of the skin incision and tightly secured so that the heart is somewhat elevated. The second deep pericardial stitch is applied to the midportion between the inferior vena cava and the left lower pulmonary vein, and the stitch is passed though a rubber catheter so that the heart

**1. Introduction** 

**2. Technical aspects** 

**2.1 Anesthesia** 

technique, risks and benefits of OPCAB.

for possible emergent conversion to CPB.

will not be injured by the retropericardial sutures.

**2.2 Retropericardial suture** 

septal defect and papillary muscle rupture: study of 62 patients. *Am Heart J*. 1993;126(3 Pt 1):667-75.

