Management and Outcome of Ventricular Septal Rupture Complicating Acute Myocardial Infarction: What Is New in the Era of Percutaneous Intervention?

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 Outcomes of Post-myocardial Infarction Ventricular Septal Defect/Rupture: A Systematic Review and Meta-Analysis

Ventricular septal defect (VSD) is a catastrophic acute myocardial infarction (MI) complication. Despite a significant reduction in the prevalence of post-MI VSD with the advancement of surgical techniques, it is still considered fatal with a high mortality rate. The trends in the clinical outcomes of patients with post-MI VSD show discretion due to the complexity of the disease. Therefore, the present analysis aimed to evaluate the surgical outcomes and associated risks in the patients of post-MI VSD. A thorough literature survey resulted in 40 studies of our interest. The pooled proportion of differential variables, including the incidence of cardiogenic shock, 30-day survival, and overall mortality, were estimated using Bayesian hierarchical models. The risk difference was estimated for the location of MI and VSD and mortality in patients with coronary artery bypass graft (CABG). In addition, the heterogeneity tests for inconsistency and publication biases using Egger's and Begg's tests were also estimated. The analysis revealed a significant risk difference of 0.23 and 0.27 for the anterior vs. posterior location of MI and VSD, respectively. Further, the pooled proportion of 30-day survival and mortality was found to be 54.43% (95% credible interval (CI): 52.88-55.98%) and 48.22% (95% CI: 4-12.3%), respectively. Moreover, the heterogeneity test revealed significant inconsistencies in all the datasets with an I2 index of >90% (p<0.0001). Lastly, the publication bias results suggested no evidence of asymmetry and small-study effects. Conclusively, the surgical management of post-MI VSD patients is considered beneficial; however, the outcomes signify its fatal behavior.

Clinical characteristics, prognostic factors, and outcomes of ventricular septal rupture in patients with acute myocardial infarction

Ventricular septal rupture (VSR) is a rare but devastating complication in patients with acute myocardial infarction (AMI). This was a retrospective single-center observational study which aimed to assess the characteristics and outcomes of VSR patients and identify risk factors for in-hospital mortality of VSR patients in the era of percutaneous intervention. Patients with VSR after AMI at the First Affiliated Hospital of Xi'an Jiaotong University from January 2016 to December 2020 were enrolled. Among 5395 consecutive patients with AMI, 42 patients (0.78%) were diagnosed with VSR. Left anterior descending coronary artery was the culprit vessel in most cases (84.4%, 27/32). In the multivariate analysis, female sex (odds ratio (OR): 14.043, 95% confidence interval (CI): 1.396-141.283, p = 0.025) and lower platelet count on admission (OR: 0.979; 95% CI: 0.963-0.995; p = 0.009) were significant risk factors of in-hospital death in VSR patients. In all, 11 patients (26.2%) underwent surgical repair, and the rest were treated medically. The 1-year mortality was lower in the surgical group (36.4%, 4/11) than that in the conservative group (74.2%, 23/31) (p = 0.034). During the follow-up, VSR patients treated surgically tended to have a higher long-term survival rate than those treated medically (log rank χ² = 5.005, p = 0.025). The prognosis of patients with VSR remained poor in this study. Female sex and lower platelet count were independent risk factors of in-hospital death in VSR patients. The long-term survival rate of patients treated with surgical repair was significantly better than that of patients treated conservatively.

Transcatheter closure of large postinfarct ventricular septal defect: Initial results of prototype Occlutech® device including the first-in-human

BACKGROUND

Postinfarct ventricular septal rupture is a serious complication in delayed or failed reperfusion with a grim prognosis. The optimal timing and treatment option remain debatable in the absence of randomized controlled trials. Percutaneous device closure is a well-reported and less invasive treatment option but recent imaging studies indicate that majority of defects are too large to be adequately covered by the currently Conformite Europeenne and Food and Drug Administration approved occluder devices.

METHODS

Six patients presented with large and complex postinfarct ventricular septal ruptures, considered unsuitable for the Amplatzer post-infarct ventricular septal defect Occluder, so were treated using the prototype Occlutech® 36 mm PI-VSD occluder, including the first-in-human use.

RESULTS

The prototype device was successfully deployed in all patients with satisfactory immediate results and shunt reduction. Three patients (50%) in cardiogenic shock did not survive beyond discharge, of which two were complicated by device dislodgement or embolization.

CONCLUSIONS

Percutaneous closure of large postinfarct ventricular septal ruptures is possible using newer device with a wider coverage. Further device refinement is necessary to improve treatment outcomes.

Systematic review and meta-analysis of the mechanical complications of ischemic heart disease: papillary muscle rupture, left ventricle rupture and post-infarct ventricular septal defect

BACKGROUND

Improvements in revascularisation, including pharmacological, catheter-based and surgical, have resulted in improved outcomes for patients with acute myocardial infarction (AMI), leading to decreased frequency of mechanical complications. Improvements in both techniques and technology have permitted select patients to be managed with a purely percutaneous, transcatheter strategy. Through systematic review, this study aims to synthesise the collective experience of percutaneous treatment of the mechanical complications of ischaemic heart disease.

METHODS

The search strategy queried the electronic databases PubMed, Embase and the Cochrane Central Register of Controlled Trials, from 1 January 2000 to 31 December 2020. Studies highlighting the outcomes of patients receiving percutaneous treatment of post-myocardial infarction papillary muscle rupture (PMR), ventricular septal defect (VSD), left ventricular free wall rupture (FWR) and pseudoaneurysm (PA) were included. A qualitative review of studies was conducted for PMR, FWR and PA. A quantitative analysis was conducted for VSD.

RESULTS

Fifteen studies were included in the qualitative synthesis of the percutaneous management of PMR, 4 were included in the qualitative analysis of the percutaneous management of left ventricular FWR, 7 studies defined the outcomes of the percutaneous management of PA and 25 were included in the quantitative meta-analysis of the primary percutaneous management of post-MI VSD. For VSD, there were 43 failed procedures in 314 patients. The proportion of failed procedures was 15.9% and there were 174 deaths in 428 patients. 37.5% of patients experienced early mortality.

CONCLUSIONS

Although surgical techniques remain the gold standard, we have shown that percutaneous management may be a viable option in certain cases.

An Undiagnosed Ventricular Septal Rupture Presenting as New Onset Heart Failure: A Rare Complication of an Anterior Myocardial Infarction

Ventricular septal ruptures (VSR) are a rare but fatal complication of acute myocardial infarctions. We present a patient complaining of new onset heart failure symptoms that were found to be secondary to a new ventricular septal rupture from a recently undiagnosed anterior myocardial infarction. The patient underwent successful VSR patch repair with eventual recovery. This case highlights the importance of early diagnosis of VSR and reviews management options and appropriate timing for intervention.

Indicators and predictors of in-hospital mortality and survival in patients with ventricular septal rupture

Background

Ventricular septal rupture (VSR), a mechanical complication of myocardial infarction (MI), usually presents with rapid clinical deterioration with acute heart failure or cardiogenic shock. VSR may occur within 24 h to several days after MI and can occur in both anterior and inferior wall MI. Although guidelines recommend emergent surgery, this is associated with a high mortality rate of up to 40%. Intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO) stabilize patients in preparation for angiography and surgery. Delayed surgery allows better septal repair in scarring tissue but also carries the risk of rupture extension and death while waiting. Percutaneous closure of the defect with appropriately designed devices results in better survival in the subacute phase.

Aims

To study the indicators and predictors of VSR in the current era of primary percutaneous coronary interventions and mechanical circulatory support.

Methods

Of total of 34,681 patients presenting with MI, the incidence of VSR was 0.45%. We sought to evaluate the predictors of survival and death in VSR. Coronary angiography (CAG) was performed, hemodynamic support provided to unstable patients, and consenting patients were referred to definitive therapy, either surgery or percutaneous device closure. The previously postulated hypotheses of triple vessel disease (TVD), diabetes mellitus (DM), and concentric left ventricular hypertrophy (LVH) due to Hypertension (HTN) being protective against VSR were explored.

Results

Of the 169 patients with VSR, we found that the group that survived was mostly men and the mean age was 61.5 years; this was in contrast to the non-survivors, who were mainly women, and the mean age was 65.2 years (p = 0.025); higher Killip Class was 111-1V (p = 0.001), lower LVEF (p = 0.010), apical VSR and LV aneurysm (p = 0.015 and p = 0.002, respectively) were predictors of death. 48 patients underwent CAG, with single vessel disease (SVD) with lower-grade Rentrop collateral flow being most common in the death group. 25 patients were subjected to definitive therapy with surgical patch closure or percutaneous device closure. The patients who died were older by approximately 7 years. The risk factors for coronary artery disease, such as HTN, diabetes, and smoking, were not statistically different between the two groups.

Conclusion

Prevention of myocardial infarction is more important than managing a VSR, which carries a high mortality despite advanced mechanical support and definitive interventional therapy such as emergent surgery and percutaneous device closure.

Transcatheter closure for postinfarction ventricular septal defect: A meta-analysis of the current evidence

OBJECTIVE

Postinfarction ventricular septal defect (PIVSD) is a severe complication of acute myocardial infarction (AMI). Transcatheter closure (TCC) is an alternative option to surgical repair. This study was undertaken to examine the published literature to provide objective evidence for TCC using a meta-analysis.

METHODS

We searched for significant medical and publisher databases. Two reviewers checked the quality of the studies and extracted data. Eligible studies included single-arm studies and comparative studies. Weighted means, pooled event rates, efficacy outcomes and odds ratios (ORs) for immediate shunt reduction (ISR), presence of cardiogenic shock (CS), New York Heart Association (NYHA) class IV, time from AMI to ventricular septal defect (VSD), and time to VSD closure was estimated.

RESULTS

A total of 27 single-arm articles (462 patients) were included. The pooled event rate was 89.7% (95% confidence interval [CI]: 0.772-1.021) for successful device implantation, 80.9% (95% CI: 0.645-0.972) for ISR, 31.5% (95% CI: 0.149-0.482) for 30-day mortality, and 25.3% (95% CI: 0.072-0.434) for 30-day mortality of primary closure at the acute phase. CS (OR = 3.607, 95% CI: 2.301-5.653), NYHA class IV (OR = 6.491, 95% CI: 1.444-29.188) and time to VSD closure were risk predictors for TCC. There was no correlation between defect size (OR = 2.592, 95% CI: 0.380-17.661) and mortality.

CONCLUSION

TCC should be a relatively safe and minimally invasive method for PIVSD, with an excellent successful device implantation rate and acceptable low 30-day mortality. The procedure appears promising, but its safety and efficacy could only be demonstrated by randomized controlled trials. Therefore, the mortality of data comparing surgery to TCC compels the need for future comparative trials.

Long-Term Survival and Risk Factors for Post-Infarction Ventricular Septal Rupture

BACKGROUND

This study was performed to assess long-term survival and identify risk factors for acute myocardial infarction in patients complicated with ventricular septal rupture (VSR).

METHOD

A retrospective analysis of 116 patients with post-infarction VSR (PI-VSR) hospitalised in Beijing Anzhen Hospital from January 2008 to February 2019 was performed. The independent risk factors for in-hospital mortality were assessed using multivariate analysis with a logistic regression model. The Kaplan-Meier method and log-rank test were carried out for long-term survival in the surgery group.

RESULTS

The overall in-hospital mortality rate was 47.4%. Logistic regression analysis revealed that age (p<0.05), female sex (p<0.05), no surgical repair (p<0.05), liver dysfunction (p<0.05), high heart rate (p<0.05), and low platelet count (PLT; p<0.05) were independent risk factors for in-hospital mortality. The 1-year mortality rate was lower in the surgery group than in the medical treatment group (18.3% vs 84.5%; p<0.005). During the mean follow-up of 5.2±5.1 years (median, 1.3 years), the actuarial survival rates of these patients at 5 and 10 years were 72.3% and 43.2%, respectively.

CONCLUSIONS

The overall in-hospital mortality rate remained high. The independent risk factors for in-hospital mortality associated with PI-VSR were age, female sex, no surgical repair, liver dysfunction, tachycardia, and low PLT level. The 1-year mortality and long-term outcomes of patients treated with surgery were significantly better than those of patients who were treated conservatively.

Retrograde transcatheter closure of ventricular septal perforation after acute myocardial infarction: a case report

The use of the Lunderquist exchange guide wire via the retrograde approach of the right femoral vein-inferior vena cava-right atrium-right ventricle-ventricular septal perforation-left ventricle-descending aorta can maintain guide wire tension and significantly reduce the operative time. The patient was admitted due to chest pain for 3 hours. The diagnosis was acute anterior septal myocardial infarction with ventricular septal perforation. One week after admission, a drug-eluting stent was implanted in the left anterior descending branch. Repeated echocardiography revealed that the diameter of the ventricular septal perforation had increased from 6 to 12 mm. During this period, the patient suffered from repeated episodes of shortness of breath that were progressively exacerbated. The patient was transferred to the intensive care unit (ICU) and underwent intra-aortic balloon pump (IABP) implantation. Twenty days after admission, the Lunderquist exchange guide wire was used via the retrograde approach of the right femoral vein-inferior vena cava-right atrium-right ventricle-ventricular septal perforation-left ventricle-descending aorta. A 26-mm occluder was released for transcatheter closure of the ventricular septal perforation. Shortness of breath was immediately relieved. The patient was discharged 3 days later. Retrograde transcatheter closure of ventricular septal perforation can effectively reduce operative time and is conducive to quick and stable improvement of the patient’s condition.

Successful occlusion of ventricular septal rupture in myocardial infarction under the guidance of echocardiography

Introduction

The traditional treatment of myocardial infarction with ventricular septal rupture is surgical treatment. For the elderly patients with cardiac insufficiency, surgical treatment is very risky. The successful treatment of this case by interventional occlusion is a new method. No relevant literature reports have been found.

Case

A 77-year-old man with a past medical history of old myocardial infarction presented to the physician with sudden onset of palpitation and shortness of breath. Echocardiography showed thinning of the interventricular septum near the apex and bulging toward the right ventricular side with “paradoxical motion”, on which a rupture of about 8 mm in diameter was seen. CDFI: left ventricular blood shunted to the right ventricle through the rupture.Echocardiographic diagnosis: old left ventricular anteroseptal myocardial infarction with ventricular septal rupture. Due to the older age of the patient and reduced left ventricular function, surgical repair of the ventricular septal rupture site was more difficult. After multidisciplinary discussion, it was agreed that the patient could not afford thoracotomy and was not suitable for thoracotomy, and echocardiography guided interventional occlusion of the ruptured interventricular septum could be performed.

Conclusion

Transesophageal echocardiography-guided interventional occlusion of myocardial infarction with ventricular septal rupture in elderly patients with cardiac insufficiency is a new attempt, the successful treatment of this case shows that this method is feasible, for some patients is an appropriate treatment.