Another complication of coronary artery disease that requires heart surgery is called post-myocardial infarction ventricular septal defect. This happens when the common wall between the right and the left ventricle (the ventricular septum) ruptures after a heart attack.
This is different and a much more serious problem than the congenital type of ventricular septal defect. The postmyocardial infarction ventricular septal defect needs to be repaired relatively soon after it occurs, and the risk of death for this surgery is higher than that for congenital surgery. These patients can be very unstable and sometimes are in cardiogenic shock. This surgery usually requires placement of the intra-aortic balloon pump to assist the heart before the patient is taken to the operating room.
When the surgeon opens the heart to repair the hole, he may find that the heart muscle tissue around the hole is also dying or dead, which makes the hole technically challenging to repair. Nonetheless, the majority of the patients who undergo the repair survive. In some cases, coronary bypass grafting or other heart surgery procedures are done at the same time. Depending on the circumstances, about 70 percent or 80 percent of the patients undergoing this operation survive the procedure and do well.
In many cases, it is a life-saving surgical procedure, and, without the surgery, death may occur within a few days.
Mitral Valve Replacement for Papillary Muscle Rupture
Another complication of a heart attack is that one of the papillary muscles, which is inside the left ventricle and helps control the mitral valve, may be involved in the heart attack. The entire muscle may become detached from the ventricular wall (Fig. 8.8). If this happens, the mitral valve will no longer function effectively, blood will flow backwards into the lungs, and they will fill with fluid. The person will suffer from congestion of the lungs and be very short of breath and may go into heart failure or cardiogenic shock.
This is often a surgical emergency that requires the intra-aortic balloon pump to help stabilize the patient's condition while being prepared for mitral valve replacement surgery. This is a high-risk surgical procedure, but it must be done and hopefully will be life saving.
Unfortunately, because this condition is associated with heart attacks, we may be doing several operations at once. We might be placing coronary artery bypass grafts and, in some cases, may even have to remove a left ventricular aneurysm.
The chance of surviving emergency mitral valve replacement for papillary muscle rupture is about 70 percent, and most of the survivors do well providing the left ventricle has not been too badly damaged by the heart attack.
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