Postinfarction Ventricular Septal Defect

Clinical manifestation of early phase left ventricular rupture complicating acute myocardial infarction in the primary PCI era

OBJECTIVE

Before reperfusion therapy was introduced, the incidence of ventricular septal and left ventricular free wall rupture complicating acute myocardial infarction (AMI) was 1-3%. Primary percutaneous coronary intervention (PCI) was expected to reduce the incidence of such mechanical complications.

METHODS

We retrospectively analysed 1290 AMI patients referred to our institute from January 2005 to January 2011. Primary PCI was done in 1002 cases of the study patients (77.7%).

RESULTS

Ventricular septal rupture (VSR) occurred in 19 cases (1.5%) and left ventricular free wall rupture (LVFR) in 17 cases (1.3%). Mean observation periods from onset to VSR and LVFR were 2.6 days. We demonstrated that risk factors for LV rupture were advanced age, female sex, absence of history of angina or myocardial infarction, lack of previous PCI, and absence of previous hypertension. Coronary angiography revealed that the culprit lesions of the left anterior descending artery or single vessel disease were the risk factors for LV rupture. Furthermore, in the present observation, 9 patients (47.4%) with VSR and 8 patients (47.1%) with LVFR developed LV rupture within 24h after symptoms onset (early rupture). The early rupture demonstrated extremely poor outcome compared with late rupture (in-hospital mortality was 88.2% in early rupture and 63.1% in late rupture).

CONCLUSION

Even in the patients' cohort with higher prevalence of primary PCI, LV rupture cases were not decreased in contrast to our expectations. More attention should be paid to early LV rupture cases within 24 h from symptom onset in those cases.

Temporary balloon closure of a postinfarction interventricular septal rupture

The technical aspects of temporary closure of a postinfarction interventricular septal rupture in a 76-year-old woman in critical circulatory status ruling out conservative therapy and making surgical management unfeasible, are described. The patient was in cardiogenic shock with hepatorenal failure in acute myocardial infarction of both the anterior and posterior walls. A balloon catheter developed in our unit was employed to close the rupture.

Inferior cardiac aneurysm involving the interventricular septum. A complication of an acquired ventricular septal defect

An acquired ventricular septal defect led to the formation of an unusual aneurysm within and overlying the posteroinferior part of the interventricular septum. This is a rare complication of a myocardial infarction and may not have been reported before. The aneurysm probably developed because of a combination of the anatomical localisation of the small ventricular septal defect and the long survival of the patient after its formation.

Urgent operation for acquired ventricular septal defect

Recent experience suggests that ventricular septal defect (VSD) secondary to myocardial infarction constitutes an indication for urgent operation. Acquired VSD at St. Thomas Hospital, Nashville, was reviewed to substantiate the obsolescence of protracted medical therapy designed to allow a late, technically less demanding, repair. Twenty-two acute VSDs (less than four weeks following onset of murmur) have been treated since 1970. Five patients died during medical therapy. Two patients survived for more than four weeks without operation. One never manifested significant cardiac decompensation. The other was operated on at 33 days, after progressive deterioration. No technical advantage from the delay was apparent, although survival was achieved. Ten of 15 patients (67%) operated on during the first four weeks survived. Fourteen had reached a level of marked instability prior to operation. Of the five deaths, four were technical and were the product of an initial lack of recognition of the necessity for patch replacement of the interventricular septum. The prosthetic patch is now considered essential to minimize suture-line stress in necrotic muscle. Potentially, only one of 15 patients operated on early using current methods would have expired. This experience supports an aggressive surgical approach to any unstable patient with postinfarction VSD. Early repair requires specific techniques. Results of early operation using these techniques are dramatically superior to past efforts designed to delay definitive repair.

Ventricular septal rupture: a review of clinical and physiologic features and an analysis of survival

Forty-one patients with postinfarction ventricular septal rupture were cared for in our hospital during 1971-1975. Cardiogenic shock developed after septal rupture in 55% of these patients. Shock was unrelated to site of infarction, extent of coronary artery disease, left ventricular ejection fraction, or pulmonary-to-systemic flow ratio, but mean pulmonary artery pressure was lower in shock than in nonshock patients. These observations suggest that shock was produced mainly by right ventricular impairment. Perioperative survival was much higher in patients who did not have shock preoperatively (14 of 17 [82+]) than in those who did (three of 11 [27%]). Magnitude of shunt, left ventricular ejection fraction, extent of coronary artery disease, and performance of aortocoronary bypass grafting were not distinctly correlated with perioperative survival. After a minimum 4-year follow-up, 76% of the perioperative survivors are alive, and none suffer more than New York Heart Association functional class II disability. All 13 unoperated patients (11 in shock) died within 3 months.

Intraventricular free wall dissection causing acute interventricular communication with intact septum in myocardial infarction

This report delineates a previously unrecognized complication of acute myocardial infarction, an intraventricular wall dissection producing interventricular communication without septal perforation. The clinical, hemodynamic, and pathologic features of this unique condition are documented, as well as the factors important in the mechanism of its production.

Superimposition of transmural infarction following acute subendocardial infarction; how frequent?

Thirty-five consecutive patients with acute subendocardial infarction admitted to the coronary care unit during a 15-month period were identified and analyzed for location of infarction, and for the in-hospital course in terms of recurrent chest pain, the occurrence of a second infarction, and the clinical status at the end of hospitalization. Thirteen patients developed a transmural infarction sometime between 3 and 21 days (average, ten days) after the initial subendocardial infarction. The transmural infarction was defined by a separate episode of severe and prolonged chest pain, late development of QRS alteration, and an appropriate elevation of the creatine phosphokinase concentration. Our experience with acute subendocardial infarction, hertofore regarded as a relatively benign event, indicates that the immediate prognosis of the patient who sustains his first episode of subendocardial infarction is not at all benign, and, indeed, subendocardial infarction frequently heralds transmural infarction within the acute phase of the disease.

Surgical considerations in the treatment of acute acquired ventricular septal defect

In the light of our experience and that of others (Oldham et al., 1969; Iben, Pupello, Stinson, and Shumway, 1969), early surgical closure of acquired ventricular septal defect is advocated. Two successful cases are presented, one after myocardial infarction and one after penetrating trauma to the heart. Description of the present method of repair is presented. Two prosthetic patches are interposed in the closure of the defect. The advantages of this technique are (a) the key sutures are placed through healthy tissue and are anchored by the two patches, and (b) an additional suture line along the free edge of the right ventricular patch ensures a complete closure.