Post-Myocardial Infarction Ventricular Septal Defect: A Comprehensive Review

Ventricular Septal Rupture After Myocardial Infarction: JACC Focus Seminar 3/5

Ventricular septal rupture remains a dreadful complication of acute myocardial infarction. Although less commonly observed than during the prethrombolytic era, the condition remains complex and is often associated with refractory cardiogenic shock and death. Corrective surgery, although superior to medical treatment, has been associated with high perioperative morbidity and mortality. Transcatheter closure techniques are less invasive to surgery and offer a valuable alternative, particularly in patients with cardiogenic shock. In these patients, percutaneous mechanical circulatory support represents a novel opportunity for immediate stabilization and preserved end-organ function. Multimodality imaging can identify favorable septal anatomy for the most appropriate type of repair. The heart team approach will define optimal timing for surgery vs percutaneous repair. Emerging concepts are proposed for a deferred treatment approach, including orthotropic heart transplantation in ideal candidates. Finally, for futile situations, palliative care experts and a medical ethics team will provide the best options for end-of-life clinical decision making.

Post-infarction ventricular septal rupture complicated with cardiogenic shock and multiple organ hemorrhage: An autopsy case report

Ventricular septal rupture (VSR) is a catastrophic mechanical complication of acute myocardial infarction (AMI) that can result in acute heart failure. Delaying operative intervention frequently leads to cardiogenic shock and multi-organ failure. Here we report a case of massive anterior MI complicated with VSR that was discovered through cardiac Doppler ultrasound and suspected multiple organ hemorrhage. The patient showed signs of rapid cardiogenic shock and eventually died. The morphological changes of VSR and MI were identified during necropsy, and microscopic examinations of the heart, brain, and kidney revealed multiple organ hemorrhage. This autopsy case suggested that the complication of VSR caused by AMI results in a reduction of oxygen and nutrient content of the circulating blood throughout the body and, eventually, functional failure of multiple organs. We provide clinical and pathological evidence elucidating changes in multiple organs under the severe condition of post-infarction VSR and demonstrate the consequences of a lack of immediate surgery and sufficient medical intervention for a patient suffering from AMI with VSR.

[Right ventricle free wall rupture during transcatheter occluder implantation in a patient with postinfarction rupture of the interventricular septum and COVID-19-associated myocarditis. Case report]

Intraventricular septum rupture is a rare mechanic complication of myocardial infarction associated with high mortality. This case describes STEMI in recovered patient after COVID 19 associated pneumonia, which was complicated by ventricular septum rupture followed by cardiogenic shock. It was managed by percutaneous occluder implantation. The procedure was complicated by right ventricular wall rupture. Postmortem examination of myocardium showed the signs of inflammation infiltrate and myocyte necrosis, according to histopathological Dallas criteria diagnosis of COVID-19 associated myocarditis was established. The COVID-19 pandemic has contributed to increasing cardiovascular mortality. This is typically attributed to diminishing resources for timely and appropriate medical care, and patients' late presentations for fear of contracting the infection. Cardiovascular complication of COVID-19 may be another contributing factor. Further research is needed to improve our understanding of the mechanisms and long-term sequelae of myocardium damage in COVID-19, to optimize treatment strategy and subsequent follow-up in such patients.

Post-infarction ventricular septal defect surgery in Portugal

INTRODUCTION AND OBJECTIVE

We performed a collective analysis of a dedicated national post-myocardial infarction ventricular septal defect (VSD) registry to further elucidate controversial areas of this clinical entity's surgical treatment.

METHODS

A descriptive statistical analysis was carried out and cumulative survival using the Kaplan-Meier method and multivariate logistic regression of risk factors for 30-day mortality are presented.

RESULTS

Median survival of the cohort (n=76) was 72 months (95% CI 4-144 months). Better cumulative survival was observed in patients who underwent VSD closure more than 10 days after myocardial infarction (log-rank p=0.036). Concomitant coronary artery bypass grafting (CABG), different closure techniques, location of the VSD, extracorporeal membrane oxygenation as bridge to closure, or intra-aortic balloon pump as bridge to closure showed no statistically significant differences at Kaplan-Meier analysis. Multivariate binary logistic regression for independent factors affecting status at 30 days showed a statistically significant effect of age (OR 1.08; 95% CI 1.01-1.15) and concomitant CABG (OR 0.23; 95% CI 0.06-0.90).

CONCLUSIONS

Our results are comparable with previous reports regarding mortality, risk factors and concomitant procedures. Timing of surgery remains a controversial issue. Later closure seems to be advantageous, however, there is significant observational bias.

Post-myocardial Infarction Ventricular Septal Defect in the Setting of No-Reflow and COVID

The occurrence of post-myocardial infarction (MI) ventricular septal defect (VSD) is a rare but life-threatening complication. This case report presents a unique case of a 49-year-old female patient with an anterolateral ST-segment elevation MI who underwent percutaneous coronary intervention (PCI) and drug-eluting stent (DES) placement, complicated by a no-reflow phenomenon in the distal left anterior descending artery (LAD) and subsequent development of a hemodynamically significant VSD. Notably, this case occurred during the COVID-19 pandemic, which added to the complexity of the patient's management. The patient's clinical course was further complicated by cardiogenic shock, acute respiratory failure, COVID-19 pneumonia, and gastrointestinal bleeding. Despite these challenges, the patient received prompt treatment and optimal medical management, including the use of vasopressor support, insulin therapy, and bicarbonate infusions. The patient also underwent surgical repair of the VSD at a quaternary center, resulting in a favorable outcome. This case report highlights the increased incidence of mechanical complications, such as VSD, during the COVID-19 pandemic due to delayed presentation and patient concerns about exposure to the virus. It also emphasizes the occurrence of a no-reflow phenomenon during PCI, which can lead to adverse outcomes, including larger infarct size and potential ventricular septal rupture. The case further underscores the importance of multidisciplinary collaboration and early subspecialist involvement in managing complex cases of post-MI VSD.

Mechanical Complications of Myocardial Infarction

Mechanical complications of myocardial infarction include rupture of a papillary muscle, ventricular septum, and free wall. Since the advent of acute coronary reperfusion, there has been a significant reduction in the incidence of these complications. One must have a high index of suspicion for a mechanical complication in any patient who develops cardiogenic shock in the days following a myocardial infarction. The most important diagnostic investigation in evaluation of these complications is echocardiography. Although there is a role for mechanical circulatory support, urgent surgical repair is required in most cases. We will review the predictors, clinical features, diagnostic, and management strategies in patients with these complications.

Post-Myocardial Infarction Ventricular Septal Defect Successfully Treated with Impella as Bridge to Cardiac Transplantation

A 63-year-old female presented late with anterior ST-elevation myocardial infarction and cardiogenic shock. This was complicated by acute ventricular septal defect with large left-to-right shunt. An Impella CP was inserted on day seven with rapid haemodynamic improvement. This facilitated bridge to cardiac transplant on day twelve post-MI.

Increased incidence of postmyocardial infarction ventricular septal defects during Covid-19 pandemic: A case series

Introduction

Ventricular septal defect (VSD) is one of the mechanical complications of acute myocardial infarction (MI), whose incidence has been decreasing throughout the years because of the emergence of different reperfusion therapy strategies.

Methods

We present a series of seven patients who underwent surgery for post‐MI VSD repair in our institution in the period between March 2020 and June 2021.

Discussion

During the recent SARS‐COV2 pandemic, time to hospital admission increased due to patients being overcautious out of fear of exposing themselves to COVID‐19. The increased time to hospital admission, with associated late reperfusion therapy and delayed PCI, is closely related to an augmented incidence of post‐myocardial infarction mechanical complications such as ventricular septal defects. For this reason, we witnessed an increase in the incidence of post‐MI VSD.

Conclusion

Fear of exposure to SARS‐COV2 in the medical environment was a major source of concern for all our patients. The target of hospital policy should be to reassure patients of freedom from COVID in the emergency department and cardiac wards in order to prevent such dreadful complications.

Percutaneous Closure of Post-infarction and Iatrogenic Ventricular Septal Ruptures Using Amplatzer Occluder®: A Systematic Review

Ventricular septal rupture (VSR) is a rare complication of myocardial infarction (MI), open heart surgery, and cardiac-based procedures, such as septal myectomy and valve replacement. VSR is associated with high mortality rates and the reported 30-day survival rate is less than 10% without any interventional therapy. Hence, prompt diagnosis and aggressive medical treatment with appropriate surgical intervention are necessary to improve survival. Immediate surgical intervention which is the standard treatment of VSR has a mortality rate of 19-60%. Due to persistent high mortality rate and challenging management of VSR, alternatives to surgical repair has been proposed; transcatheter approach as a new alternative method has been used for the closure of post-surgery residual defects or as a bridge to surgery and in some cases as a definitive therapy instead of surgical repair. Amplatzer Occluder® (AO), a type of transcatheter closure devices, is an approved method of repairing congenital atrial septal defects and it is being used as an alternative method of treatment in VSR. In this systemic review, we assessed the cases of VSR who underwent septal repair by using AO. The study shows that the total mortality rate of percutaneous VSR repair with AO is 20% which is comparable to 19-60% rate of death in patients who undergo surgery. While early intervention is necessary to prevent biventricular dysfunction, immediate surgical intervention on soft and friable tissue surrounding the infarction increases the risk of residual shunt and reoperation. However, this study reveals that the mortality rate of primary percutaneous VSR closure within 7 days of VSR detection was 37 % which is significantly lower than 60% in surgical repair in the same period. In conclusion, given that the prevalence of residual leak in both interventions are similar and close to 20%, percutaneous VSR closure with AO device could be superior to the surgical repair as a primary intervention in unstable or high-risk surgical patients.