Early Mortality and Long-term Survival after Repair of Post-infarction Ventricular Septal Rupture: An Institutional Report of Experience

Current Understanding of Timing of Surgical Repair for Ventricular Septal Rupture following Acute Myocardial Infarction

BACKGROUND

Ventricular septal rupture (VSR) is a mechanical issue that can occur following an acute myocardial infarction (AMI) and has a high mortality rate. It requires a comprehensive, team-based approach for prompt diagnosis and maintaining stable blood flow. While the occurrence of VSR has lessened over the past hundred years and advancements have been made in treatment techniques, the mortality rate within 30 days can still surpass 40 percent. Surgery is the primary treatment method. For patients with stable blood flow, it is generally considered safer to perform surgery 4-6 weeks after the AMI to repair the VSR. However, the timing of surgery for patients with early instability in their blood flow is still a topic of debate.

SUMMARY

There is a lack of set criteria and standards to determine the best time for surgery in patients with VSR following an infarction who have unstable blood flow, especially when considering the use of blood circulation support devices and other techniques for maintaining blood flow that are used in clinical settings.

KEY MESSAGES

This review outlines the features of different mechanical circulatory support devices utilized in treating VSR, along with the current scoring system designed to direct the treatment approach for VSR patients.

Surgical repair of post myocardial infarction ventricular septal defect: a retrospective analysis of a single institution experience

INTRODUCTION

Ventricular septal defect (VSD) is a mechanical complication of acute myocardial infarction (MI) with a very high mortality, despite advances in surgical and circulatory support. The tremendous hemodynamic disturbance and the severely fragile myocardium render surgical repair a great challenge. The optimal time of surgical repair with or without circulatory support is still controversial.

OBJECTIVE

The aim of this study is to review our experience with early surgical repair of post-MI VSD in a single major cardiac institution in China.

METHODS

From January 2013 to October 2020, 9consecutive patients presented to our emergency department with a diagnosis of post-MI VSD. Among them, 8 were male, and the mean age was 58 ± 7years. The mean VSD size was 22.5 ± 5.7 mm. In all patients, an intra-aortic balloon pump (IABP)was inserted immediately after admission to cardiac surgery service. All patients were operated at a mean of 3.3 ± 2.9 days, and 4 within 24 h of the rupture (range 1 to 9 days post-VSD). In 5 cases, the VSD was located superiorly, and 4 cases in the posterior septum.

RESULTS

The overall 30-day mortality was 11% (1/9). Coronary angiography was performed in all nine patients, four with single vessel disease had coronary stents implanted, and the other five received concomitant coronary artery bypass grafting during VSD repair surgery. There was no death in all 5 patients with anterior septal perforation. One patient with posterior septal perforation died in the operating room due to bleeding from the ventriculotomy site. Three survived patients were diagnosed with a small residual defect and mild left to right shunt post-repair. However, no further intervention was required, and patients remained asymptomatic (Killip II in 1 and III in 2).

CONCLUSION

In our experience, immediate insertion of IABP and hemodynamic stabilization with early surgical intervention of VSD repair and concomitant coronary revascularization provided an 89% survival rate.

Effects of concomitant coronary artery bypass grafting on early and late mortality in the treatment of post-infarction mechanical complications: a systematic review and meta-analysis

BACKGROUND

Mechanical complications of acute myocardial infarction represent life-threatening events, including ventricular septal rupture (VSR), left ventricular free-wall rupture (LVFWR) and papillary muscle rupture (PMR). In-hospital mortality is high, even when prompt surgery can be offered. The role of concomitant coronary artery bypass grafting (CABG) in the surgical treatment of these conditions is still debated.

METHODS

A systematic review of the literature, from 2000 onwards, about these complications was performed, analyzing data of subjects receiving versus not-receiving concomitant CABG. Primary outcome was early mortality. Secondary outcome was late mortality for hospital survivors. Subgroup analysis for VSR, LVFWR and PMR was also performed.

RESULTS

Thirty-six studies were identified, including 4,321 patients (mostly VSR-related). Preoperative coronarography was performed in 92.2% of the cases, showing single-vessel disease in 54.3% of patients. Concomitant CABG rate was 49.0%. Early mortality was 32.6% and late mortality was 40.0% with 5.2 years of mean follow-up. The analysis showed no difference in early (OR 0.96; P=0.60) or late mortality (RR 0.91; P=0.49) between CABG and non-CABG group. In subgroup analysis, concomitant CABG was associated with significantly lower mortality at long term for PMR (RR 0.42; P=0.001), although it showed a higher, but not significant, mortality in VSR (RR 1.24; P=0.20).

CONCLUSIONS

Concomitant CABG in the treatment for post-infarction mechanical complications showed no significant impact on both early and late mortality, although deserving some distinctions among different types of complication and single versus multiple vessel disease. However, larger, dedicated studies are required to provide more consistent data and evidence.

In-hospital outcome of patients with post-MI VSD: a single-center study

Introduction

Ventricular septal defect (VSD) is a rare but life-threatening complication of acute myocardial infarction (AMI). There is a paucity of data regarding the natural history of this devastating complication of myocardial infarction in the Middle East region with restricted financial resources and unsolved major health problems.

Aim

To evaluate the clinical presentation and in-hospital outcome of patients with post-infarction VSD over a 10-year period in a tertiary center in northwest Iran.

Material and methods

Data from 64 consecutive patients with VSD complicating AMI were retrospectively analyzed from March 2005 to May 2015.

Results

The mean age of the patients was 71.62 ±9.38 years with 57.8% of them being female. The VSDs were anterior in 52 (82%) patients. More than half of patients were in cardiogenic shock during the initial presentation. Multivessel coronary artery disease was found on coronary angiography in 70.3% of patients. In-hospital mortality was 82.8%. Multivariate analysis revealed cardiogenic shock (HR = 12.5, p = 0.001) as the only independent predictor of in-hospital mortality and surgical treatment as the only predictor of in-hospital survival (HR = 0.2, p = 0.02).

Conclusions

Our study demonstrated that VSD complicating myocardial infarction had an extremely high in-hospital mortality rate. Cardiogenic shock was the only independent predictor of in-hospital mortality and surgical treatment was the only predictor of in-hospital survival.

Fowl cholera and acute heart rupture in a backyard turkey

Pasteurella multocida is the causative agent of fowl cholera, an economically important disease of commercial and backyard poultry. Turkeys are particularly susceptible to fowl cholera; both backyard and commercial turkeys can succumb to disease. On April 10, 2018, a dead 9-mo-old male Bronze turkey was submitted to the California Animal Health and Food Safety Laboratory System (CAHFS)-Turlock branch for postmortem examination. History included previous housing and fighting with another male turkey, after which separation by a fence was instituted. Fighting continued, and depression and anorexia of 2 d duration was followed by acute collapse and death. At autopsy, blood clots markedly expanded the pericardium, and a tear was visible in the left ventricular free wall. Vegetative aortic valvular lesions were observed. Microscopically, infarcts were observed in kidney, liver, heart, spleen, and pancreas, with large numbers of gram-negative bacterial colonies present in most organs. P. multocida was isolated from multiple organs, and identified as serotype 2,5 and fingerprint 1604. Septic embolization from the vegetative valvular aortic lesions likely led to infarcts in multiple organs, including the left ventricular free wall, which ultimately caused weakening of the ventricular wall, ventricular rupture, and exsanguination into the pericardial space. Rupture of the left ventricular free wall has not been previously documented in turkeys with P. multocida infection, to our knowledge, and demonstrates an atypical presentation of fowl cholera in this backyard turkey.