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Schlotter F, Huber K, Hassager C, Halvorsen S, Vranckx P, Pöss J, Krychtiuk K, Lorusso R, Bonaros N, Calvert PA, Montorfano M, Thiele H. Ventricular septal defect complicating acute myocardial infarction: diagnosis and management. A Clinical Consensus Statement of the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the ESC Working Group on Cardiovascular Surgery. Eur Heart J 2024; 45:2478-2492. [PMID: 38888906 DOI: 10.1093/eurheartj/ehae363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/26/2024] [Accepted: 05/22/2024] [Indexed: 06/20/2024] Open
Abstract
Ventricular septal defects are a rare complication after acute myocardial infarction with a mortality close to 100% if left untreated. However, even surgical or interventional closure is associated with a very high mortality and currently no randomized controlled trials are available addressing the optimal treatment strategy of this disease. This state-of-the-art review and clinical consensus statement will outline the diagnosis, hemodynamic consequences and treatment strategies of ventricular septal defects complicating acute myocardial infarction with a focus on current available evidence and a focus on major research questions to fill the gap in evidence.
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Affiliation(s)
- Florian Schlotter
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Kurt Huber
- Departments of Cardiology and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University, Medical School, Vienna, Austria
| | | | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevål and University of Oslo, Oslo, Norway
| | - Pascal Vranckx
- Department of Cardiology and Intensive Care Medicine, Heart Center Hasselt, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, University of Hasselt, Hasselt, Belgium
| | - Janine Pöss
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Konstantin Krychtiuk
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- Duke Clinical Research Institute, Durham, NC, USA
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+) and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Matteo Montorfano
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
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Jhand A, Elgendy IY. Transcatheter Closure of Postinfarct Ventricular Septal Defect: Promises and Uncertainties. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:102071. [PMID: 39132599 PMCID: PMC11308426 DOI: 10.1016/j.jscai.2024.102071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 08/13/2024]
Affiliation(s)
- Aravdeep Jhand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Islam Y. Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
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Iyer V, Weiler C, Merhi W, Kar B, Fudge JC, Seshiah P, Mahadevan VS, Gutfinger D, Resar J. Transcatheter Closure of Postinfarct VSD With the Amplatzer PIVSD Occluder: Results of a US Study. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:102016. [PMID: 39132602 PMCID: PMC11307684 DOI: 10.1016/j.jscai.2024.102016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 08/13/2024]
Abstract
Background A postinfarct ventricular septal defect (PIVSD) is associated with high mortality and morbidity, particularly in patients with hemodynamic instability who are not suitable candidates for surgical repair. The Amplatzer PIVSD Occluder (Abbott) is indicated for transcatheter PIVSD closure in patients who are not satisfactory candidates for surgical repair. The objective of this study was to evaluate associated clinical outcomes. Methods A total of 131 patients underwent transcatheter PIVSD closure using the Amplatzer PIVSD Occluder between 2011 and 2021 as part of a postapproval, multicenter, retrospective, observational study. The patients were analyzed in 2 cohorts. Cohort 1 included 99 patients (age 68.6 ± 11.9 years) implanted from 2011 to 2016 and evaluated technical success, procedure survival, and 6-month survival. Cohort 2 included 32 patients (age 66.4 ± 10.9 years) implanted from 2012 to 2021 with postprocedure echocardiograms and evaluated 24-hour closure, 6-month closure, and 6-month survival. Results Technical success was achieved in 76.8% (76/99), procedure survival in 84.3% (75/89), and 6-month survival was observed in 37.2% of cohort 1 patients. Twenty-four-hour closure and 6-month closure were achieved in 53.1% (17/32) and 66.7% (4/6) of cohort 2 patients, respectively. Six-month survival was 46.4% of cohort 2 patients. Of the 16 deaths in cohort 2, 11 were cardiac-related, 4 were noncardiac-related, and 1 was of unknown etiology. Conclusions This study demonstrates high morbidity of patients undergoing PIVSD closure using the Amplatzer PIVSD Occluder and that the device continues to be a safe alternative to medical therapy in patients who are not satisfactory candidates for surgical repair of a PIVSD.
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Affiliation(s)
- Vijay Iyer
- Buffalo General Hospital, Buffalo, New York
| | | | | | | | - J. Curtis Fudge
- UF Health Shands Hospital, University of Florida, Gainesville, Florida
| | - Puvi Seshiah
- TriHealth Bethesda North Hospital, Cincinnati, Ohio
| | - Vaikom S. Mahadevan
- University of Massachusetts Chan School of Medicine, Worcester, Massachusetts
| | | | - Jon Resar
- The Johns Hopkins Hospital, Baltimore, Maryland
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Cubeddu RJ, Lorusso R, Ronco D, Matteucci M, Axline MS, Moreno PR. Ventricular Septal Rupture After Myocardial Infarction: JACC Focus Seminar 3/5. J Am Coll Cardiol 2024; 83:1886-1901. [PMID: 38719369 DOI: 10.1016/j.jacc.2024.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/07/2023] [Accepted: 01/03/2024] [Indexed: 06/05/2024]
Abstract
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.
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Affiliation(s)
- Roberto J Cubeddu
- Division of Cardiology, Section for Structural Heart Disease, Naples Comprehensive Health Rooney Heart Institute, Naples Comprehensive Health Healthcare System, Naples, Florida, USA; Igor Palacios Fellows Foundation, Boston, Massachusetts, USA
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Daniele Ronco
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands; Cardiac Surgery Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Matteo Matteucci
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands; Cardiac Surgery Unit, ASSTSette Laghi, Varese, Italy
| | - Michael S Axline
- Division of Cardiology, Section for Structural Heart Disease, Naples Comprehensive Health Rooney Heart Institute, Naples Comprehensive Health Healthcare System, Naples, Florida, USA
| | - Pedro R Moreno
- Igor Palacios Fellows Foundation, Boston, Massachusetts, USA; Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Zhang RS, Ro R, Bamira D, Vainrib A, Zhang L, Nayar AC, Saric M, Bernard S. Echocardiography in the Recognition and Management of Mechanical Complications of Acute Myocardial Infarction. Curr Cardiol Rep 2024; 26:393-404. [PMID: 38526749 DOI: 10.1007/s11886-024-02042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 03/27/2024]
Abstract
PURPOSE OF REVIEW Although rare, the development of mechanical complications following an acute myocardial infarction is associated with a high morbidity and mortality. Here, we review the clinical features, diagnostic strategy, and treatment options for each of the mechanical complications, with a focus on the role of echocardiography. RECENT FINDINGS The growth of percutaneous structural interventions worldwide has given rise to new non-surgical options for management of mechanical complications. As such, select patients may benefit from a novel use of these established treatment methods. A thorough understanding of the two-dimensional, three-dimensional, color Doppler, and spectral Doppler findings for each mechanical complication is essential in recognizing major causes of hemodynamic decompensation after an acute myocardial infarction. Thereafter, echocardiography can aid in the selection and maintenance of mechanical circulatory support and potentially facilitate the use of a percutaneous intervention.
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Affiliation(s)
- Robert S Zhang
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Richard Ro
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Daniel Bamira
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Alan Vainrib
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Lily Zhang
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Ambika C Nayar
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Muhamed Saric
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Samuel Bernard
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA.
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Fiszer R, Galeczka M, Smolka G, Sukiennik A, Chojnicki M, Tyc F, Bialkowski J, Szkutnik M. Multicentre short- and medium-term report on the device closure of a post-myocardial infarction ventricular septal rupture - In search of risk factors for early mortality. Int J Cardiol 2024; 401:131820. [PMID: 38307419 DOI: 10.1016/j.ijcard.2024.131820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/14/2024] [Accepted: 01/28/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Post-myocardial infarction ventricular septal rupture (VSR) is a rare and severe complication of myocardial infarction. To find early mortality (<30 days) risk factors of device VSR closure and to evaluate its medium-term outcome. METHODS Multicenter retrospective analysis on all 46 consecutive patients with percutaneous (n = 43) or hybrid (n = 3) VSR closure in 2000-2020 with various nitinol wire mesh occluders. Medical records, hemodynamic data, procedure results, short- and mid-term follow-up were analyzed (4.8 ± 3.7 years, range: 0.1-15, available in 61.7% of patients). Of the patients, 34.8% underwent VSR closure in acute phase (<21 days after VSR occurrence), 17.4% underwent device closure due to significant residual shunt after previous VSR surgery. RESULTS Success rate was 78.3%. More than moderate residual shunt, major complications, and early surgical reintervention affected 18.9%, 15.2% (including 2 intra-procedural deaths), and 21.7% of patients, respectively. Early mortality was 26.1% (13.9% in successful vs. 70% in unsuccessful closure; p < 0.001). Older age, need for intra-aortic balloon counterpulsation, severe complications, and procedural failure were identified as risk factors for early mortality. Among patients who survived the early period, the 5-year survival rate was 57.1%. NYHA class improved in 88.2% patients at the latest follow-up. CONCLUSIONS Procedure of VSR device closure demonstrates an acceptable technical success rate; however, the incidence of severe complications and early mortality is notably high. Older patients in poor hemodynamic condition and those with unsuccessful occluder deployment are particularly at a higher risk of a fatal outcome. The prognosis after early survival is promising.
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Affiliation(s)
- Roland Fiszer
- Department of Pediatric Cardiology and Congenital Heart Defects, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Michal Galeczka
- Department of Pediatric Cardiology and Congenital Heart Defects, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland.
| | - Grzegorz Smolka
- Department of Cardiology and Structural Heart Diseases, 3(rd) Division of Cardiology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Adam Sukiennik
- Department of Cardiology and Internal Diseases, University Hospital No. 1, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Torun, Poland
| | - Maciej Chojnicki
- Department of Cardiology and Internal Diseases, University Hospital No. 1, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Torun, Poland
| | - Filip Tyc
- Department of Pediatric Cardiology and Congenital Heart Defects, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Jacek Bialkowski
- Department of Pediatric Cardiology and Congenital Heart Defects, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Malgorzata Szkutnik
- Department of Pediatric Cardiology and Congenital Heart Defects, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
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Al-Bulushi A, Salmi IA, Ahmed AR, Rahbi FA. Post-Infarction Ventricular Septal Defect: A quarter century experience. Sultan Qaboos Univ Med J 2023; 23:22-30. [PMID: 38161766 PMCID: PMC10754311 DOI: 10.18295/squmj.12.2023.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/14/2023] [Accepted: 04/19/2023] [Indexed: 01/03/2024] Open
Abstract
Objectives Post-infarction ventricular septal defect (VSD) is one of the known complications after acute myocardial infarction. This study investigated the clinical results after surgical repair of VSD. Methods This retrospective study included all patients undergoing surgical repair of VSD from 1996 to 2020 in Oman. Results Out of a total of 75 patients, 62.5% were men, with a mean age of 59 years. The mean follow-up was 17.2 (7.5) years. Of the 75 patients, 34 (45.3%) patients died within 30 days. Total survival was 41.3% at 5 years, while the 10-year survival rate was 33.3%. Outcomes and predictors for 30 days mortality were the number of concomitant coronary involvement and anastomoses performed, residual postoperative shunt and postoperative dialysis. Conclusion Even with surgical repair, early mortality of post-infarction septal defect is still considerably high. Early repair and the anatomically posterior rupture are predictors of early mortality. In patients surviving the immediate postoperative period, long-term survival is limited by pre-existing coronary artery disease, postoperative renal failure and the presence of a residual postoperative shunt.
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Affiliation(s)
| | - Issa Al Salmi
- Medicine Department, The Royal Hospital, Muscat, Oman
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Sandoval Boburg R, Kondov S, Karamitev M, Schlensak C, Berger R, Haeberle H, Jost W, Fagu A, Beyersdorf F, Kreibich M, Czerny M, Siepe M. Role of ECLS in Managing Post-Myocardial Infarction Ventricular Septal Rupture. J Cardiovasc Dev Dis 2023; 10:446. [PMID: 37998504 PMCID: PMC10672658 DOI: 10.3390/jcdd10110446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/25/2023] [Accepted: 10/28/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVES The aim of this study was to analyze outcomes in patients undergoing surgery for ventricular septal rupture (VSR) after myocardial infarction (MI) and the preoperative use of extracorporeal life support (ECLS) as a bridge to surgery. METHODS We included patients undergoing surgery for VSR from January 2009 until June 2021 from two centers in Germany. Patients were separated into two groups, those with and without ECLS, before surgery. Pre- and intraoperative data, outcome, and survival during follow-up were evaluated. RESULTS A total of 47 consecutive patients were included. Twenty-five patients were in the ECLS group, and 22 were in the group without ECLS. All the ECLS-group patients were in cardiogenic shock preoperatively. Most patients in the ECLS group were transferred from another hospital [n = 21 (84%) vs. no-ECLS (n = 12 (57.1%), p = 0.05]. We observed a higher number of postoperative bleeding complications favoring the group without ECLS [n = 6 (28.6%) vs. n = 16 (64%), p < 0.05]. There was no significant difference in the persistence of residual ventricular septal defect (VSD) between groups [ECLS n = 4 (16.7%) and no-ECLS n = 3 (13.6%)], p = 1.0. Total in-hospital mortality was 38.3%. There was no significant difference in in-hospital mortality [n = 6 (27.3%) vs. n = 12 (48%), p = 0.11] and survival at last follow-up between the groups (p = 0.50). CONCLUSION We detected no statistical difference in the in-hospital and long-term mortality in patients who received ECLS as supportive therapy after MI-induced VSR compared to those without ECLS. ECLS could be an effective procedure applied as a bridge to surgery in patients with VSR and cardiogenic shock.
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Affiliation(s)
- Rodrigo Sandoval Boburg
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, 79106 Freiburg, Germany
- Medical Faculty, Albert-Ludwigs-University Freiburg, 79106 Freiburg, Germany
| | - Mladen Karamitev
- Medical Faculty, Albert-Ludwigs-University Freiburg, 79106 Freiburg, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Rafal Berger
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Helene Haeberle
- Department of Anesthesiology and Critical Care Medicine, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Walter Jost
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Albi Fagu
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, 79106 Freiburg, Germany
- Medical Faculty, Albert-Ludwigs-University Freiburg, 79106 Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, 79106 Freiburg, Germany
- Medical Faculty, Albert-Ludwigs-University Freiburg, 79106 Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, 79106 Freiburg, Germany
- Medical Faculty, Albert-Ludwigs-University Freiburg, 79106 Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, 79106 Freiburg, Germany
- Medical Faculty, Albert-Ludwigs-University Freiburg, 79106 Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, 79106 Freiburg, Germany
- Medical Faculty, Albert-Ludwigs-University Freiburg, 79106 Freiburg, Germany
- Department of Heart Surgery, Cardiovascular Center, Inselspital, 3010 Bern, Switzerland
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Magro P, Soeiro A, Guerra N, Coutinho G, Antunes P, Nobre Â, Neves J, Sousa-Uva M. Post-infarction ventricular septal defect surgery in Portugal. Rev Port Cardiol 2023; 42:775-783. [PMID: 36948458 DOI: 10.1016/j.repc.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/04/2022] [Accepted: 10/10/2022] [Indexed: 03/24/2023] Open
Abstract
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.
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Affiliation(s)
- Pedro Magro
- Department of Cardio-thoracic Surgery, Hospital de Santa Cruz, Carnaxide, Portugal.
| | - André Soeiro
- Department of Cardio-thoracic Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Nuno Guerra
- Department of Cardio-thoracic Surgery, Hospital Santa Maria, Lisboa, Portugal
| | - Gonçalo Coutinho
- Department of Cardio-thoracic Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Pedro Antunes
- Department of Cardio-thoracic Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Ângelo Nobre
- Department of Cardio-thoracic Surgery, Hospital Santa Maria, Lisboa, Portugal
| | - José Neves
- Department of Cardio-thoracic Surgery, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Miguel Sousa-Uva
- Department of Cardio-thoracic Surgery, Hospital de Santa Cruz, Carnaxide, Portugal
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Tanto IV, Dharma S, Juzar DA, Bono AA. Ventricular Septal Rupture Complicating an Acute ST-Segment Elevation Myocardial Infarction during the COVID-19 Pandemic. Int J Angiol 2023; 32:194-196. [PMID: 37576532 PMCID: PMC10421677 DOI: 10.1055/s-0040-1720971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/17/2020] [Indexed: 10/22/2022] Open
Abstract
Ventricular septal rupture (VSR) is rare but a lethal complication of acute myocardial infarction (MI). Definite treatment requires the surgical closure of the VSR and coronary artery bypass grafting (CABG). However, the optimal timing for surgery is still controversial, particularly during the novel coronavirus disease 2019 (COVID-19) pandemic where medical procedures should be performed within the safest environment. Before surgery, a proper management in the intensive cardiovascular care unit is essential to maintain the stability of the hemodynamic profile related with VSR and determines the prognosis of the patient. We described a case of VSR complicating an anterior wall MI in a patient who admitted to our hospital during the COVID-19 pandemic that was treated successfully by surgical closure of the VSR and CABG.
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Affiliation(s)
- Ines V. Tanto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Surya Dharma
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Dafsah A. Juzar
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Arinto A.H. Bono
- Division of Cardiothoracic and Vascular Surgery, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
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Tripathi A, Bisht H, Arya A, Konat A, Patel D, Patel J, Godhani D, Mozumder K, Parikh D, Jain P, Sharma K. Ventricular Septal Rupture Management in Patients With Acute Myocardial Infarction: A Review. Cureus 2023; 15:e40390. [PMID: 37456418 PMCID: PMC10345166 DOI: 10.7759/cureus.40390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Untreated myocardial infarction (MI) can potentially lead to many fatal complications which require immediate management. One of them is ventricular septal rupture (VSR) which necessitates the hemodynamic stabilization and closure of the septal rupture. Conventional treatment strategy involves surgical repair; however, percutaneous transcatheter repair using an occluder device is a promising upcoming approach. We conducted a detailed review of various published articles and examined the trends in incidence, risk factors, and pathophysiology of MI leading to VSR followed by an in-depth analysis of the various management strategies for the same. In the current clinical scenario, thrombolysis is an imperative management strategy that has been shown to decrease the occurrence of VSR by manifolds, more specifically in patients having ST-elevated MI. Delayed surgical closure remains the main treatment for post-infarction VSR. Other newer modalities, such as percutaneous closure devices and mechanical circulatory supports, are attractive alternative or complementary strategies to treat such patients, both postoperatively and perioperatively. However, earlier surgical repair in VSR increases the risk of mortality, and the optimal timing for VSR closure remains controversial. Despite surgical closure of VSR being the traditional treatment, it presents a considerably high operative risk. Although newer interventions such as percutaneous closure devices and mechanical circulatory supports provide impressive outcomes, their efficacy in high-risk patients remains inconclusive.
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Affiliation(s)
| | - Himanshi Bisht
- Medicine, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | - Akshat Arya
- Internal Medicine, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | - Ashwati Konat
- Department of Zoology, Biomedical Technology and Human Genetics, Gujarat University, Ahmedabad, IND
| | - Divya Patel
- Internal Medicine, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | - Jay Patel
- Internal Medicine, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | - Dhruvin Godhani
- Trauma and Orthopaedics, Gujarat Medical Education and Research Society Medical College, Gandhinagar, IND
| | - Kamalika Mozumder
- Internal Medicine, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | - Dhyey Parikh
- Internal Medicine, Gujarat Medical Education and Research Society Medical College, Gandhinagar, IND
| | - Pragya Jain
- Internal Medicine, Smt Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad, IND
| | - Kamal Sharma
- Cardiology, Dr. Kamal Sharma Cardiology Clinic, Ahmedabad, IND
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12
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Cadogan D, Daghem M, Snosi M, Williams LK, Weir-McCall J, Calvert PA, Giblett JP. Percutaneous Transcatheter Closure of Post-infarction Ventricular Septal Defect: An Alternative to Surgical Intervention. Interv Cardiol 2023; 18:e19. [PMID: 37435604 PMCID: PMC10331564 DOI: 10.15420/icr.2023.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/03/2023] [Indexed: 07/13/2023] Open
Abstract
Post-infarction ventricular septal defect is a mechanical complication of acute MI. The incidence of this complication is low in the primary percutaneous coronary intervention era. However, the associated mortality is very high at 94% with medical management alone. Open surgical repair or percutaneous transcatheter closure still has an in-hospital mortality >40%. Retrospective comparisons between both closure methods are limited by observation and selection bias. This review addresses the assessment and optimisation of patients prior to repair, the optimal timing of repair, and the limitations in current data. The review considers techniques for percutaneous closure, and finally considers the path that future research should take to improve outcomes for patients.
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Affiliation(s)
- Diarmaid Cadogan
- Department of Cardiology, Liverpool Heart and Chest HospitalLiverpool, UK
| | - Marwa Daghem
- Department of Cardiology, Liverpool Heart and Chest HospitalLiverpool, UK
| | - Mostafa Snosi
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest HospitalUK
| | | | - Jonathan Weir-McCall
- Department of Radiology, Royal Papworth HospitalCambridge, UK
- Division of Cardiovascular Medicine, University of CambridgeCambridge, UK
| | - Patrick A Calvert
- Department of Cardiology, Royal Papworth HospitalCambridge, UK
- Division of Cardiovascular Medicine, University of CambridgeCambridge, UK
| | - Joel P Giblett
- Department of Cardiology, Liverpool Heart and Chest HospitalLiverpool, UK
- Liverpool Centre for Cardiovascular Science, University of LiverpoolLiverpool, UK
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13
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Sánchez-Luna JP, Amat-Santos IJ. Interventional management of mechanical complications in acute myocardial infarction. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:362-369. [PMID: 36813110 DOI: 10.1016/j.rec.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/23/2022] [Indexed: 04/29/2023]
Abstract
Mechanical complications following a myocardial infarction are uncommon, but with dramatic consequences and high mortality. The left ventricle is the most often affected cardiac chamber and complications can be classified according to the timing in early (from days to first weeks) or late complications (from weeks to years). Despite the decrease in the incidence of these complications thank to primary percutaneous coronary intervention programs -wherever this option is available-, the mortality is still significant and these infrequent complications are an emergent scenario and one of the most important causes of mortality at short term in patients with myocardial infarction. Mechanical circulatory support devices, especially if minimally invasive implantation is used avoiding thoracotomy, have improved the prognosis of these patients by providing stability until definitive treatment can be applied. On the other hand, the growing experience in transcatheter interventions for the treatment of ventricular septal rupture or acute mitral regurgitation has been associated to an improvement in their results, even though prospective clinical evidence is still missing.
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Affiliation(s)
- Juan Pablo Sánchez-Luna
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Ignacio J Amat-Santos
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, España; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
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14
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Sarkar S, Agrawal G, Khadse S, Chaturvedi A. Persistent Winking Coronary Sign in a Case of Post-myocardial Infarction Ventricular Septal Rupture After Device Closure. Cureus 2023; 15:e39167. [PMID: 37332463 PMCID: PMC10276187 DOI: 10.7759/cureus.39167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/17/2023] [Indexed: 06/20/2023] Open
Abstract
A winking coronary sign refers to the partial collapse of an artery situated over the ventricular septal rupture during systole and refilling of the same during diastole, which is seen as phasic filling and disappearance of the arterial segment during coronary angiography. In this article, we discuss the case of a patient who reported to the emergency department of a tertiary care hospital in central India with myocardial infarction of the anterior wall. Two-dimensional echocardiography and coronary angiography revealed ventricular septal rupture. The patient was promptly managed by a percutaneous coronary angiography and interventricular septal device closure. Even after the defect closure, the winking coronary sign persisted on coronary angiography, and the patient was then discharged in stable condition.
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Affiliation(s)
- Souvik Sarkar
- Respiratory Medicine, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Gajendra Agrawal
- Cardiology, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Satish Khadse
- Cardiology, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Anuj Chaturvedi
- Cardiology, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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15
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Aggarwal P, Mahajan S, Halder V, Bansal V. Early surgical outcomes of a modified infarct exclusion technique in acute post-myocardial infarction ventricular septal rupture: a single-centre experience. Indian J Thorac Cardiovasc Surg 2023; 39:251-257. [PMID: 37124587 PMCID: PMC10140259 DOI: 10.1007/s12055-023-01479-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 02/12/2023] Open
Abstract
Introduction Operative mortality in an acute post-myocardial infarction (AMI) ventricular septal rupture (VSR) is high. In addition to ventricular dysfunction, friable myocardium adds to the technical difficulty of the operation. In a modified infarct exclusion technique, the right ventricle is left undisturbed and the free edge of the pericardial patch is incorporated in the sutures while closing the left ventriculotomy. This simplifies the procedure and decreases the chances of right ventricular dysfunction, any residual defect, and bleeding. Methods Study design A retrospective analysis of patients with VSR following AMI operated in our institute from January 2018 to June 2021 was done. Results Over the last 3 years, 16 patients with AMI VSR were treated with a modified infarct exclusion technique. Eight patients presented in cardiogenic shock preoperatively and were put on intra-aortic balloon pump support. All patients could be weaned successfully from the cardiopulmonary bypass, no patient had any residual defect, and none of the patients required re-exploration for bleeding. Postoperatively, 5 patients died within the first week and 2 more patients subsequently died due to intractable arrhythmias over the next 30 days. Conclusions In our centre, the mortality following repair of VSR after AMI was 43%. The modified infarct exclusion technique is a good technique with less chances of postoperative re-exploration and residual defect.
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Affiliation(s)
- Pankaj Aggarwal
- Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Sachin Mahajan
- Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Vikram Halder
- Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Vidur Bansal
- Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
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16
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Ning F, Liu H, Yan Y. Clinical characteristics, prognostic factors, and outcomes of ventricular septal rupture in patients with acute myocardial infarction. J Investig Med 2023; 71:361-371. [PMID: 36692151 DOI: 10.1177/10815589221149185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Feifei Ning
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, P.R. China
| | - Hui Liu
- The Biobank of the First Affiliated Hospital of Xian Jiaotong University, Xi'an, Shaanxi Province, P.R. China
| | - Yang Yan
- Department of Cardiovascular Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, P.R. China
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17
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Lee KT, Taliotis D, Hamilton M, Manghat N, Bedair R, Turner M. Transcatheter closure of large postinfarct ventricular septal defect: Initial results of prototype Occlutech® device including the first-in-human. Catheter Cardiovasc Interv 2023; 101:620-627. [PMID: 36841941 DOI: 10.1002/ccd.30571] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 01/08/2023] [Accepted: 01/11/2023] [Indexed: 02/27/2023]
Abstract
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.
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Affiliation(s)
- Kuo Ting Lee
- Department of Cardiology, Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Demetris Taliotis
- Department of Paediatric Cardiology, Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Mark Hamilton
- Department of Radiology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Nathan Manghat
- Department of Radiology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Radwa Bedair
- Department of Cardiology, Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Mark Turner
- Department of Cardiology, Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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18
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Ventricular Septal Rupture-The Resurgence of a Post-Myocardial Infarction Dreadful Complication during COVID-19 Pandemic. Case Rep Cardiol 2023; 2023:3521526. [PMID: 36644717 PMCID: PMC9836817 DOI: 10.1155/2023/3521526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 11/28/2022] [Accepted: 12/14/2022] [Indexed: 01/07/2023] Open
Abstract
In the midst of the coronavirus disease-2019 (COVID-19) pandemic, an 84-year-old female patient was admitted due to non-exertional syncope preceded by retrosternal pain. She had experienced a prolonged episode of oppressive chest pain 6 days before her presentation, but due to the concern of contracting COVID-19, she did not present for medical care. Upon admission to the emergency department, the patient was in circulatory shock, with her physical examination being remarkable for the presence of a holosystolic murmur. Admission electrocardiogram revealed an inferior ST-segment elevation with Q waves with extension to the posterior wall, consistent with subacute infarct in the right coronary artery (RCA) territory, and the patient was transferred for primary percutaneous coronary intervention. Upon arrival to the catheterization laboratory, a summary transthoracic echocardiogram was performed, which revealed inferior wall and infero-septal akinesia with an 18 mm ventricular septal rupture. Coronary angiography documented occlusion of the proximal segment of a dominant RCA. Due to a high perioperative risk, the patient underwent successful retrograde percutaneous closure with a 24 mm MemoPart™ device, with mild to moderate residual shunt. Despite an immediate clinical improvement, the patient died 12 hours after the procedure due to refractory cardiogenic shock.
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19
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Tratamiento intervencionista de las complicaciones mecánicas en el infarto agudo de miocardio. Rev Esp Cardiol 2023. [DOI: 10.1016/j.recesp.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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20
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Doost A, Chilmeran A, Gomes A, Dworakowski R, Eskandari M, MacCarthy P, Cockburn J, Byrne J, Hildick-Smith D. Single arterial access closure of post-infarction ventricular septal defect: A case series. Catheter Cardiovasc Interv 2023; 101:209-216. [PMID: 36478105 DOI: 10.1002/ccd.30510] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 09/23/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-infarction ventricular septal defect (PIVSD) carries a very poor prognosis. Surgical repair offers reasonable outcomes in patients who survive the initial healing period. Percutaneous device implantation remains a potentially effective earlier alternative. METHODS AND RESULTS From March 2018 to May 2022, 11 trans-arterial PIVSD closures were attempted in 9 patients from two centers (aged 67.2 ± 11.1 years; 77.8% male). Two patients had a second procedure. Myocardial infarction was anterior in four patients (44.5%) and inferior in five cases (55.5%). Devices were successfully implanted in all patients. There were no major immediate procedural complications. Immediate shunt grade postprocedure was significant (11.1%), minimal (77.8%), or none (11.1%). Median length of stay after the procedure was 14.8 days. Five patients (55%) survived to discharge and were followed up for a median of 605 days, during which time no additional patients died. CONCLUSION Single arterial access for percutaneous closure of PIVSD is a good option for these extremely high-risk patients, in the era of effective large-bore arterial access closure. Mortality remains high, but patients who survive to discharge do well in the longer term.
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Affiliation(s)
- Ata Doost
- Department of Cardiology, King's College Hospital, London, UK
| | - Ahmed Chilmeran
- Department of Cardiology, Sussex Cardiac Centre, Brighton, UK
| | | | | | - Mehdi Eskandari
- Department of Cardiology, King's College Hospital, London, UK
| | | | - James Cockburn
- Department of Cardiology, King's College Hospital, London, UK
| | - Jonathan Byrne
- Department of Cardiology, King's College Hospital, London, UK
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21
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Perez-Villa B, Cubeddu RJ, Brozzi N, Sleiman JR, Navia J, Hernandez-Montfort J. Transition to heart transplantation in post-myocardial infarction ventricular septal rupture: a systematic review. Heart Fail Rev 2023; 28:217-227. [PMID: 34674096 DOI: 10.1007/s10741-021-10161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 02/07/2023]
Abstract
Post-myocardial infarction ventricular septal rupture (MI-VSR) remains a dreadful complication with dismal prognosis. Surgical repair is the primary treatment strategy, whereas the role of heart transplantation (HT) as a primary option in MI-VSR is limited to case reports (CRs). We performed a systematic review of CRs to describe in-hospital mortality, and survival at 6 and 12 months in adult patients with MI-VSR treated with HT as a primary or bailout strategy. We performed a comprehensive search of Web of Science, PubMed, and Ovid Medline. The last search was completed on March 10, 2020. An aggregated score based on the CARE case report guideline was used to assess the quality of the CRs. We included CRs that described adult patients with MI-VSR treated with HT as a primary or bailout strategy. A total of 14 CRs between 1994 and 2015 were included, retrieving and analyzing the characteristics of 17 patients. A total of 12 patients underwent HT, with HT being the primary strategy in 8 patients and a bailout strategy for 4 patients following initial surgical repair, while 5 patients died awaiting HT under mechanical circulatory support (MCS), accounting for the total in-hospital mortality of this series (29%). Regarding long-term outcomes, 6 patients were reported to be alive at 6 months and 1 year after HT, while information was missing in the remaining 6 patients. In conclusion, HT supported by the use of temporary and durable MCS as a bridge to HT could be a feasible primary or bailout strategy to reduce the high in-hospital mortality of patients with MI-VSR.
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Affiliation(s)
- Bernardo Perez-Villa
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Florida, FL, Weston, USA.
| | | | - Nicolas Brozzi
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Florida, FL, Weston, USA
| | - Jose R Sleiman
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Florida, FL, Weston, USA
| | - Jose Navia
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Florida, FL, Weston, USA
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22
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Piriou PG, Guerin P, Plessis J, Senage T, Manigold T, Auffret V, Didier R, Le Ruz R, David CH, Roussel JC, Letocart V. Management and outcomes of ventricular septal defects after acute myocardial infarction: A multicenter retrospective study. J Card Surg 2022; 37:5019-5026. [PMID: 36378912 DOI: 10.1111/jocs.17151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 10/29/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIM The mortality rate of patients with post-myocardial infarction (MI) ventricular septal defects (VSDs) is high, and the benefit of surgery is unclear. We aimed to investigate the management and outcomes of post-MI VSD over a 10-year period in a large cohort. METHODS Data of patients with post-MI VSD admitted in three French university hospitals from 2008 to 2019 were examined. The characteristics of those who underwent surgery were compared with those who received medical treatment. Mortality risk factors, survival curves, and outcomes at 30 days and 1 year after treatment were determined. RESULTS Of the 92 patients whose data were examined, 50 underwent surgery and 42 received exclusive medical treatment. All patients were critically ill. Overall, 76.1% of patients received inotropic support, and 63% received mechanical ventilation. Circulatory assistance, mainly via intra-aortic balloon pump and extra-corporeal membrane oxygenation, was provided to 46.7% patients, with 14.1% requiring a second assistance. The median time to surgery was 4 days. At 1 year, mortality was 46% in those who underwent surgery and 83.3% in those treated medically (p < .001). Survival curves at 1 and 3 months showed major differences, and the survival rate showed little change 30 days after treatment. Cardiogenic shock and cardiac arrest emerged as risk factors for mortality. CONCLUSIONS In our retrospective, multicenter study, the mortality resulting from post-MI VSD did not seem to improve over the last decade. Although surgery carried considerable risks, it improved survival.
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Affiliation(s)
- Pierre-Guillaume Piriou
- Department of Cardiology, Nantes Université, CHU Nantes, l'institut du thorax, Nantes, France
| | - Patrice Guerin
- Department of Cardiology, Nantes Université, CHU Nantes, l'institut du thorax, Nantes, France
| | - Julien Plessis
- Department of Cardiology, Nantes Université, CHU Nantes, l'institut du thorax, Nantes, France
| | - Thomas Senage
- Department of Thoracic and Cardio-Vascular Surgery, Nantes Université, CHU Nantes, l'institut du thorax, Nantes, France
| | - Thibaut Manigold
- Department of Cardiology, Nantes Université, CHU Nantes, l'institut du thorax, Nantes, France
| | | | | | - Robin Le Ruz
- Department of Cardiology, Nantes Université, CHU Nantes, l'institut du thorax, Nantes, France
| | - Charles-Henri David
- Department of Thoracic and Cardio-Vascular Surgery, Nantes Université, CHU Nantes, l'institut du thorax, Nantes, France
| | - Jean-Christian Roussel
- Department of Thoracic and Cardio-Vascular Surgery, Nantes Université, CHU Nantes, l'institut du thorax, Nantes, France
| | - Vincent Letocart
- Department of Cardiology, Nantes Université, CHU Nantes, l'institut du thorax, Nantes, France
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23
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Shakir MA, Rambhujun VP, Fender EA, Siric F, Chandra A, Wimmer NJ. Ventricular septal rupture after delayed STEMI: A modern management approach. J Card Surg 2022; 37:5539-5544. [PMID: 36352812 DOI: 10.1111/jocs.17146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Myocardial infarction associated ventricular septal rupture (VSR) is a potentially catastrophic complication. Though surgical repair remains the definitive treatment, outcomes are poor with high mortality rates.Case and Management: We present the case of a 62-year-old male who presented with a delayed STEMI leading to a VSR and cardiogenic shock. His management strategy included early percutaneous VSR closure and use of an intra-aortic balloon pump and inotropes. This served as a bridge to definitive surgical VSR patch repair while allowing hemodynamic stabilization, end-organ recovery, and myocardial tissue stabilization. CONCLUSION Mechanical support devices such as intra-aortic balloon pump and Impella combined with percutaneous closure options can serve as a bridge to definitive surgery for VSR. This requires rapid mobilization of a multi-disciplinary structural heart team including advanced imagers, structural interventionalists, and surgeons.
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Affiliation(s)
| | | | - Erin A Fender
- Department of Cardiology, Christiana Care Health System, Newark, Delaware, USA
| | - Franjo Siric
- Department of Cardiac Surgery, Christiana Care Health System, Newark, Delaware, USA
| | - Avinash Chandra
- Department of Cardiology, Christiana Care Health System, Newark, Delaware, USA
| | - Neil J Wimmer
- Department of Cardiology, Christiana Care Health System, Newark, Delaware, USA
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24
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David TE. Post-infarction ventricular septal rupture. Ann Cardiothorac Surg 2022; 11:261-267. [PMID: 35733715 PMCID: PMC9207689 DOI: 10.21037/acs-2021-ami-111] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/08/2021] [Indexed: 11/12/2023]
Abstract
Coronary reperfusion therapies have led to a reduction in the incidence of mechanical complications of acute myocardial infarction (AMI), but the associated mortality of these complications has remained high. Ventricular septal rupture is the most common mechanical complication after myocardial infarction and occurs in approximately 0.21% with ST-segment elevation myocardial infarction and in 0.04% with non-ST-segment elevation myocardial infarction. Surgery is the only definitive treatment but it is associated with high operative mortality and morbidity and, in some centers, alternative treatment with mechanical support of circulation and trans-catheter closure of the defect is being used. We continue to believe that immediate surgery offers the best opportunity for long-term survival. Patients should be taken directly to the operating room or via the heart catheterization laboratory if the coronary artery anatomy is unknown. This should be done as soon as the diagnosis is made, as acute rupture of the interventricular septum is a surgical emergency. The operative technique of infarct exclusion has been our preferred method and when performed in hemodynamically stable patients, the operative mortality is around 10%, although much higher in patients in cardiogenic shock. Patch dehiscence and persistent shunts are uncommon after closure of the defect using this technique. Delaying operative intervention in hemodynamically stable patients frequently leads to cardiogenic shock and multi-organ failure. Transcatheter closure of these acute septal lesions is complex, not necessarily feasible in all patients, and there is no evidence that the results are superior to surgery.
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Affiliation(s)
- Tirone E David
- Division of Cardiac Surgery of the Peter Munk Cardiac Centre at Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
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25
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Firouzi A, Khalilipur E, Alemzadeh-Ansari MJ, Khajali Z, Baay M, Abdi A, Rahmanpour H, Ghourchian E, Hosseini Z. Percutaneous Transcatheter Closure of Post-Myocardial Infarction Ventricular Septal Rupture. Curr Probl Cardiol 2022:101237. [DOI: 10.1016/j.cpcardiol.2022.101237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 11/27/2022]
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26
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Postinfarction Ventricular Septal Rupture: Identification of the Failure Mechanism of a Percutaneous Closure Procedure. JACC Case Rep 2022; 4:255-261. [PMID: 35257098 PMCID: PMC8897053 DOI: 10.1016/j.jaccas.2021.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 09/10/2021] [Accepted: 09/20/2021] [Indexed: 02/08/2023]
Abstract
Ventricular septal rupture (VSR) is a rare but highly lethal (∼60%) mechanical complication of myocardial infarction (MI). Although surgical repair has been the gold standard to correct the structural anomaly, percutaneous closure of the defect may represent a valuable therapeutic alternative, with the advantage of immediate shunt reduction to prevent further hemodynamic deterioration in patients with prohibitive surgical risk. Nonetheless, catheter-based VSR closure has faced certain drawbacks that have hampered its application. We describe a clinical case of postinfarction VSR treated with a percutaneous closure device and discuss the procedure's failure mechanism. (Level of Difficulty: Intermediate.).
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Key Words
- ASD, atrial septal defect
- CMR, cardiac magnetic resonance
- CT, computed tomography
- IABP, intra-aortic balloon pump
- LAD, left anterior descending
- MI, myocardial infarction
- PCI, percutaneous coronary intervention
- STEMI, ST-segment myocardial infarction
- TEE, transesophageal echocardiography
- TTE, transthoracic echocardiography
- VSD, ventricular septal defect
- VSR, ventricular septal rupture
- acute myocardial infarction
- mechanical complication
- percutaneous closure device
- percutaneous septal defect closure
- ventricular septal defect
- ventricular septal rupture
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Russo G, Enriquez-Sarano M, Taramasso M. Post-Myocardial Infarction Ventricular Septal Defect. JACC Case Rep 2022; 4:262-264. [PMID: 35257099 PMCID: PMC8897050 DOI: 10.1016/j.jaccas.2021.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ma D, Zhang Z, Zhang S, Wang Z, Zhang G, Wang C, Xi J. Treatment Strategies for Ventricular Septal Rupture After Myocardial Infarction: A Single-Center Experience. Front Cardiovasc Med 2022; 9:843625. [PMID: 35265690 PMCID: PMC8899464 DOI: 10.3389/fcvm.2022.843625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 01/27/2022] [Indexed: 12/03/2022] Open
Abstract
Objective To analyze treatment strategies, prognosis, and related risk factors of patients with postinfarction ventricular septal rupture, as well as the impact of timing of surgical intervention. Methods A total of 23 patients diagnosed with postinfarction ventricular septal rupture who were non-selectively admitted to Shanxi Provincial Cardiovascular Hospital between October 2017 and August 2021 were included in this study. The relevant clinical data, operation-related conditions, and follow-up data were summarized for all patients. The Kaplan-Meier method and log-rank test were used for the cumulative incidence of unadjusted mortality in patients with different treatment methods. Multivariate logistic regression was used to evaluate the independent risk factors for in-hospital patient mortality. Results The mean age of the study patients was 64.43 ± 7.54 years, 12(52.2%) were females. There was a significant difference in terms of postoperative residual shunt between the surgical and interventional closure groups (5.9 vs. 100%, respectively; P < 0.001). The overall in-hospital mortality rate was 21.7%; however, even though the surgical group had a lower mortality rate than the interventional closure group (17.6 vs. 33%, respectively), this difference was not statistically significant (P = 0.576). Univariate analysis showed that in-hospital survival group patients were significantly younger than in-hospital death group patients (62.50 ± 6.53 vs. 71.40 ± 7.37 years, respectively; P = 0.016), and that women had a significantly higher in-hospital mortality rate than men (P = 0.037). The average postoperative follow-up time was 18.11 ± 13.92 months; as of the end of the study all 14 patients in the surgical group were alive, Two out of four patients survived and two patients died after interventional closure. Univariate analysis showed that interventional closure was a risk factor for long-term death (P < 0.05). Conclusion Surgical operation is the most effective treatment for patients with postinfarction ventricular septal rupture; however, the best timing of the operation should be based on the patient's condition and comprehensively determined through real-time evaluation and monitoring. We believe that delaying the operation time as much as possible when the patient's condition permits can reduce postoperative mortality. Interventional closure can be used as a supplementary or bridge treatment for surgical procedures.
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Affiliation(s)
- Dongliang Ma
- Department of Cardiovascular Surgery, Shanxi Provincial Cardiovascular Hospital, Shanxi Provincial Institute of Cardiovascular Diseases, Taiyuan, China
| | - Zhibiao Zhang
- Department of Cardiovascular Surgery, Shanxi Provincial Cardiovascular Hospital, Shanxi Provincial Institute of Cardiovascular Diseases, Taiyuan, China
| | - Shunye Zhang
- Department of Cardiovascular Surgery, Shanxi Provincial Cardiovascular Hospital, Shanxi Provincial Institute of Cardiovascular Diseases, Taiyuan, China
| | - Zhongchao Wang
- Department of Cardiology, Shanxi Provincial Cardiovascular Hospital, Shanxi Provincial Institute of Cardiovascular Diseases, Taiyuan, China
| | - Gang Zhang
- Department of Anesthesiology, Shanxi Provincial Cardiovascular Hospital, Shanxi Provincial Institute of Cardiovascular Diseases, Taiyuan, China
| | - Chongjun Wang
- Department of Cardiovascular Surgery, Shanxi Provincial Cardiovascular Hospital, Shanxi Provincial Institute of Cardiovascular Diseases, Taiyuan, China
| | - Jicheng Xi
- Department of Cardiovascular Surgery, Shanxi Provincial Cardiovascular Hospital, Shanxi Provincial Institute of Cardiovascular Diseases, Taiyuan, China
- *Correspondence: Jicheng Xi
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Belyaev AM, Popov AS, Alshibaya MD. Postmyocardial infarction ventricular septal defect and ventricular aneurysm repair with a "double-patch frame" technique. J Card Surg 2022; 37:515-523. [PMID: 35103349 DOI: 10.1111/jocs.16156] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/19/2021] [Accepted: 11/02/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Postmyocardial infarction intraventricular septal rupture is a life-threatening medical condition. Surgical management of postmyocardial infarction ventricular septal defects (PIVSDs) is associated with a 60% mortality and a 40% incidence of residual ventricular septal defects (rVSDs). Our study aimed to describe our modification of the "Double-patch" technique of PIVSD repair without using a biological glue and present its postoperative complications and survival. METHODS This was a retrospective observational study. The Bakoulev's Scientific Center of Cardiac Surgery patient admission and discharge database was reviewed from March 2002 to April 2021. The inclusion criterion was PIVSD. Exclusion criteria were conservative treatment, transcatheter closure of PIVSD, PIVSD closure with an interventricular septum patch, and chronic PIVSDs. The study outcomes were echocardiographic parameters of cardiac function, postoperative complications, and mortality. RESULTS Forty nine patients met the study eligibility criteria. Comparison of echocardiographic data of cardiac function demonstrated reduction in the postoperative period end-diastolic (201.4 ± 59.6 ml vs. 118 [range: 76-207] ml; p < .0005) and end-systolic volumes (106 [51-208] ml vs. 66 [40-147] ml; p < .0005). One (2%) patient developed hemodynamically significant rVSD that required the second run of cardiopulmonary bypass and rVSD closure. Thirteen (26.5%) patients died in the hospital. The overall mortality rate for the study period was 11.4/100 person-years (95% confidence interval [CI]: 6.9-19.0/100 person-years). In these patients, 1-year survival was 68.2% (95% CI: 52.3%-79.8%) and 5-year survival was 63.1% (95% CI: 45.1%-76.7%). CONCLUSION The "Double-patch frame" technique restores LV dimensions, has a low rate of hemodynamically significant rVSDs and mortality.
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Affiliation(s)
- Andrei M Belyaev
- Cardiac Surgery Department, Bakoulev's Scientific Center of Cardiac Surgery, Moscow, Russia
| | - Andrei S Popov
- Cardiac Surgery Department, Bakoulev's Scientific Center of Cardiac Surgery, Moscow, Russia
| | - Mikhail D Alshibaya
- Cardiac Surgery Department, Bakoulev's Scientific Center of Cardiac Surgery, Moscow, Russia
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Samsky MD, Morrow DA, Proudfoot AG, Hochman JS, Thiele H, Rao SV. Cardiogenic Shock After Acute Myocardial Infarction: A Review. JAMA 2021; 326:1840-1850. [PMID: 34751704 PMCID: PMC9661446 DOI: 10.1001/jama.2021.18323] [Citation(s) in RCA: 137] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Cardiogenic shock affects between 40 000 and 50 000 people in the US per year and is the leading cause of in-hospital mortality following acute myocardial infarction. OBSERVATIONS Thirty-day mortality for patients with cardiogenic shock due to myocardial infarction is approximately 40%, and 1-year mortality approaches 50%. Immediate revascularization of the infarct-related coronary artery remains the only treatment for cardiogenic shock associated with acute myocardial infarction supported by randomized clinical trials. The Percutaneous Coronary Intervention Strategies with Acute Myocardial Infarction and Cardiogenic Shock (CULPRIT-SHOCK) clinical trial demonstrated a reduction in the primary outcome of 30-day death or kidney replacement therapy; 158 of 344 patients (45.9%) in the culprit lesion revascularization-only group compared with 189 of 341 patients (55.4%) in the multivessel percutaneous coronary intervention group (relative risk, 0.83 [95% CI, 0.71-0.96]; P = .01). Despite a lack of randomized trials demonstrating benefit, percutaneous mechanical circulatory support devices are frequently used to manage cardiogenic shock following acute myocardial infarction. CONCLUSIONS AND RELEVANCE Cardiogenic shock occurs in up to 10% of patients immediately following acute myocardial infarction and is associated with mortality rates of nearly 40% at 30 days and 50% at 1 year. Current evidence and clinical practice guidelines support immediate revascularization of the infarct-related coronary artery as the primary therapy for cardiogenic shock following acute myocardial infarction.
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Affiliation(s)
- Marc D Samsky
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alastair G Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
- Clinic For Anesthesiology & Intensive Care, Charité-Universitätsmedizin Berlin corporate member of Free University Berlin and Humboldt University Berlin, Germany
- Department of Anaesthesiology & Intensive Care, German Heart Centre Berlin, Germany
| | - Judith S Hochman
- Cardiovascular Clinical Research Center, Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Leipzig Heart Institute, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Sunil V Rao
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Alfares F, Sandhu SK. Postinfarction ventricular septal rupture: Transcatheter intervention or surgical repair? J Card Surg 2021; 36:4634-4635. [PMID: 34499380 DOI: 10.1111/jocs.15987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/01/2021] [Indexed: 11/29/2022]
Abstract
Postinfarction ventricular septal rupture is an infrequent but potentially fatal complication of acute myocardial infarction. The 30-day mortality rate with the transcatheter approach when performed in the acute phase (<2 weeks) was 25.3% compared to 50% when surgery is performed in the acute phase (within 3 weeks). There is no correlation between defect size and mortality. New York Heart Association class IV and time to ventricular septal defect closure are risk predictors for transcatheter closure for a 30-day mortality rate of 31.5%.
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Affiliation(s)
- Fahad Alfares
- Division of Pediatric Cardiology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Satinder K Sandhu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
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Damluji AA, van Diepen S, Katz JN, Menon V, Tamis-Holland JE, Bakitas M, Cohen MG, Balsam LB, Chikwe J. Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e16-e35. [PMID: 34126755 DOI: 10.1161/cir.0000000000000985] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Over the past few decades, advances in pharmacological, catheter-based, and surgical reperfusion have improved outcomes for patients with acute myocardial infarctions. However, patients with large infarcts or those who do not receive timely revascularization remain at risk for mechanical complications of acute myocardial infarction. The most commonly encountered mechanical complications are acute mitral regurgitation secondary to papillary muscle rupture, ventricular septal defect, pseudoaneurysm, and free wall rupture; each complication is associated with a significant risk of morbidity, mortality, and hospital resource utilization. The care for patients with mechanical complications is complex and requires a multidisciplinary collaboration for prompt recognition, diagnosis, hemodynamic stabilization, and decision support to assist patients and families in the selection of definitive therapies or palliation. However, because of the relatively small number of high-quality studies that exist to guide clinical practice, there is significant variability in care that mainly depends on local expertise and available resources.
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Shimahara Y, Fukushima S, Yajima S, Tadokoro N, Kakuta T, Asaumi Y, Kobayashi J, Fujita T. Emergency sandwich patch repair via right ventricular incision for postinfarction ventricular septal defects: a case series. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab141. [PMID: 34268476 PMCID: PMC8276610 DOI: 10.1093/ehjcr/ytab141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/30/2020] [Accepted: 03/29/2021] [Indexed: 11/23/2022]
Abstract
Background The surgical treatment for postinfarction ventricular septal defect (VSD) remains
challenging, especially in emergency cases. Several authors have reported the efficacy
of a sandwich patch VSD repair via a right ventricular (RV) incision.
However, this procedure remains uncommon, and its efficacy is still unknown, especially
when performed under an emergency. Case summary We were able to perform sandwich patch VSD repair via an RV incision
on seven consecutive patients with VSD following an ST-segment elevation myocardial
infarction (STEMI) from March 2017 to December 2019. Bovine pericardial patches were
used for sandwich patches. Two patients developed inferior STEMI, and the other patients
developed anterior STEMI. Six patients received intra-aortic balloon pump prior to
surgery, and the other received extracorporeal membrane oxygenation with Impella. The
interval between the diagnosis of VSD and surgery was within 1 day in all patients
except one (5 days). All seven patients underwent VSD repair in the emergency status.
Four patients underwent concomitant coronary artery bypass grafting. The hospital
mortality rate was 14.3% (1/7). Early postoperative transthoracic echocardiography
revealed that only one patient developed more than trace residual shunt. The
postoperative right atrial pressure was not significantly elevated at ≤12 mmHg in all
patients. No patient developed early postoperative prolonged low cardiac output
syndrome. Discussion In patients with postinfarction VSD, a sandwich patch VSD repair via
an RV incision is a promising procedure with a low incidence of residual shunt
development and hospital mortality, even in emergency cases.
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Affiliation(s)
- Yusuke Shimahara
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular
Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565,
Japan
- Corresponding author. Tel: +81 6 6170 1070, Fax: +81 6 6170 1782,
| | - Satsuki Fukushima
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular
Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565,
Japan
| | - Shin Yajima
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular
Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565,
Japan
| | - Naoki Tadokoro
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular
Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565,
Japan
| | - Takashi Kakuta
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular
Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565,
Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular
Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565,
Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular
Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565,
Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular
Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565,
Japan
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Werdan K, Buerke M, Geppert A, Thiele H, Zwissler B, Ruß M. Infarction-Related Cardiogenic Shock- Diagnosis, Monitoring and Therapy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:88-95. [PMID: 33827749 DOI: 10.3238/arztebl.m2021.0012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 08/26/2020] [Accepted: 10/27/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The second edition of the German-Austrian S3 guideline contains updated evidence-based recommendations for the treatment of patients with infarction-related cardiogenic shock (ICS), whose mortality is several times higher than that of patients with a hemodynamically stable myocardial infarction (1). METHODS In five consensus conferences, the experts developed 95 recommendations-including two statements-and seven algorithms with concrete instructions. RESULTS Recanalization of the coronary vessel whose occlusion led to the infarction is crucial for the survival of patients with ICS. The recommended method of choice is primary percutaneous coronary intervention (pPCI) with the implantation of a drug-eluting stent (DES). If multiple coronary vessels are diseased, only the infarct artery (the "culprit lesion") should be stented at first. For cardiovascular pharmacotherapy-primarily with dobutamine and norepinephrine-the recommended hemodynamic target range for mean arterial blood pressure is 65-75 mmHg, with a cardiac index (CI) above 2.2 L/min/m2. For optimal treatment in intensive care, recommendations are given regarding the type of ventilation (invasive rather than non-invasive, lungprotective), nutrition (no nutritional intake in uncontrolled shock, no glutamine supplementation), thromboembolism prophylaxis (intravenous heparin rather than subcutaneous prophylaxis), und further topics. In case of pump failure, an intra-aortic balloon pump is not recommended; temporary mechanical support systems (Impella pumps, veno-arterial extracorporeal membrane oxygenation [VA-ECMO], and others) are hemodynamically more effective, but have not yet been convincingly shown to improve survival. CONCLUSION Combined cardiological and intensive-care treatment is crucial for the survival of patients with ICS. Coronary treatment for ICS seems to have little potential for further improvement, while intensive-care methods can still be optimized.
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Affiliation(s)
- Karl Werdan
- * Guideline group see eBox 1; Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany; Department of Cardiology, Angiology and Internal Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany; Department of Cardiology, Clinic Ottakring, Vienna Healthcare Group, Vienna, Austria; Department of Cardiology, University of Leipzig, Heart Center Leipzig, Leipzig, Germany; Department of Anesthesiology, University Hospital, LMU, Munich, Germany; Internists at the Maxplatz, Traunstein/Affiliate Cardiology Traunstein, Traunstein, Germany
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Belov YV, Lysenko AV, Lednev PV, Salagaev GI, Grabuzdov AM. [Simultaneous surgical correction of post-infarction left ventricular aneurysm and residual ventricular septal defect in long-term period after transcatheter implantation of occluders]. Khirurgiia (Mosk) 2021:73-77. [PMID: 33759473 DOI: 10.17116/hirurgia202104173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Post-infarction ventricular septal defect (VSD) is a rare but formidable complication of myocardial infarction following mortality rate up to 90% without invasive treatment. Surgical closure is preferred for VSD. The authors report successful surgical treatment of a patient with post-infarction LV aneurysm and residual post-infarction VSD in 5 years after implantation of two occluders.
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Affiliation(s)
- Yu V Belov
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia.,Sechenov First Moscow State Medical University, Moscow, Russia
| | - A V Lysenko
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| | - P V Lednev
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| | - G I Salagaev
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| | - A M Grabuzdov
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
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Gong FF, Vaitenas I, Malaisrie SC, Maganti K. Mechanical Complications of Acute Myocardial Infarction: A Review. JAMA Cardiol 2021; 6:341-349. [PMID: 33295949 DOI: 10.1001/jamacardio.2020.3690] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Mechanical complications of acute myocardial infarction include left ventricular free-wall rupture, ventricular septal rupture, papillary muscle rupture, pseudoaneurysm, and true aneurysm. With the introduction of early reperfusion therapies, these complications now occur in fewer than 0.1% of patients following an acute myocardial infarction. However, mortality rates have not decreased in parallel, and mechanical complications remain an important determinant of outcomes after myocardial infarction. Early diagnosis and management are crucial to improving outcomes and require an understanding of the clinical findings that should raise suspicion of mechanical complications and the evolving surgical and percutaneous treatment options. Observations Mechanical complications most commonly occur within the first week after myocardial infarction. Cardiogenic shock or acute pulmonary edema are frequent presentations. Echocardiography is usually the first test used to identify the type, location, and hemodynamic consequences of the mechanical complication. Hemodynamic stabilization often requires a combination of medical therapy and mechanical circulatory support. Surgery is the definitive treatment, but the optimal timing remains unclear. Percutaneous therapies are emerging as an alternative treatment option for patients at prohibitive surgical risk. Conclusions and Relevance Mechanical complications present with acute and dramatic hemodynamic deterioration requiring rapid stabilization. Heart team involvement is required to determine appropriate management strategies for patients with mechanical complications after acute myocardial infarction.
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Affiliation(s)
- Fei Fei Gong
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Inga Vaitenas
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - S Chris Malaisrie
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kameswari Maganti
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Hua K, Peng Z, Yang X. Long-Term Survival and Risk Factors for Post-Infarction Ventricular Septal Rupture. Heart Lung Circ 2021; 30:978-985. [PMID: 33495129 DOI: 10.1016/j.hlc.2020.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/02/2020] [Accepted: 11/19/2020] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Kun Hua
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Vessel Disease, Beijing, China
| | - Zhan Peng
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Vessel Disease, Beijing, China
| | - Xiubin Yang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Vessel Disease, Beijing, China.
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Trivedi DP, Chigarapalli SR, Gangahar DM, Machiraju VR. The impact of advances in percutaneous catheter interventions on redo cardiac surgery. Indian J Thorac Cardiovasc Surg 2021; 37:61-69. [PMID: 33442208 PMCID: PMC7778657 DOI: 10.1007/s12055-020-01029-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/24/2020] [Accepted: 07/30/2020] [Indexed: 10/23/2022] Open
Abstract
Toward the end of the twentieth century, redo cardiac surgery accounted for approximately 15-20% of total cardiac surgical volume. Major risk factors for redo cardiac surgery include young age at time of the first operation, progression of native coronary artery disease (CAD), vein graft atherosclerosis, bioprosthetic valve failure and endocarditis, and transplantation for end stage heart failure. Historically, redo coronary artery bypass grafting (CABG) alone carried a mortality risk of around 4%. Factors such as older age, female sex, comorbidities, combined procedures, hemodynamic instability, and emergency procedures contributed to even higher mortality and morbidity. These poor outcomes made it necessary to look for less invasive alternate methods of treatment. Advances in catheter-based interventions have made a major impact on redo cardiac surgeries, making it no longer the first option in a majority of cases. Percutaneous interventions for recurrence following CABG, transcutaneous aortic valve replacement (TAVR) for calcific aortic stenosis, valve in valve (VIV) implantations, device closure of paravalvular leaks (PVL), and thoracic endovascular aortic repair (TEVAR) for residual and recurrent aneurysms and mitral clip to correct mitral regurgitation (MR) in heart failure are rapidly developing or developed, obviating the need for redo cardiac surgery. Our intent is to review these advances and their impact on redo cardiac surgery.
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Affiliation(s)
- Dhaval Pravin Trivedi
- Department of Cardiothoracic Surgery, Los Angeles Medical Center, Kaiser Permanente, Los Angeles, CA USA
| | - SukeshKumar Reddy Chigarapalli
- Department of Cardiothoracic Surgery, Asian Institute of Gastroenterology Hospitals, Gachibowli, Hyderabad, TG 500031 India
| | - Deepak Mohan Gangahar
- Department of Thoracic Surgery, University of Nebraska Medical Center, Omaha, NE USA
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Bakhshi H, Gattani R, Ekanem E, Singh R, Desai M, Speir AM, Sinha SS, Sherwood MW, Tehrani B, Batchelor W. Ventricular septal rupture and cardiogenic shock complicating STEMI during COVID-19 pandemic: An old foe re-emerges. Heart Lung 2020; 50:292-295. [PMID: 33387761 PMCID: PMC7756170 DOI: 10.1016/j.hrtlng.2020.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 12/13/2022]
Abstract
The COVID 19 pandemic resulted in a total reduction in the number of hospitalizations for acute coronary syndromes. A consequence of the delay in coronary revascularization has been the resurgence of structural complications of myocardial infarctions. Ventricular septal rupture (VSR) complicating late presenting acute myocardial infarction (AMI) is associated with high mortality despite advances in both surgical repair and perioperative management. Current data suggests a declining mortality with delay in VSR repair; however, these patients may develop cardiogenic shock while waiting for surgery. Available options are limited for patients with VSR who develop right ventricular failure and cardiogenic shock. The survival rate is very low in patients with cardiogenic shock undergoing surgical or percutaneous VSR repair. In this study we present two late presenting ST elevation MI patients who were complicated by rapidly declining hemodynamics and impending organ failure. Both patients were bridged with venoarterial extracorporeal membrane oxygenation (ECMO) to cardiac transplant.
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Affiliation(s)
- Hooman Bakhshi
- Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA 22042, United States.
| | - Raghav Gattani
- Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA 22042, United States
| | - Emmanuel Ekanem
- Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA 22042, United States
| | - Ramesh Singh
- Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA 22042, United States
| | - Mehul Desai
- Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA 22042, United States
| | - Alan M Speir
- Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA 22042, United States
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA 22042, United States
| | - Matthew W Sherwood
- Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA 22042, United States
| | - Behnam Tehrani
- Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA 22042, United States
| | - Wayne Batchelor
- Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA 22042, United States
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40
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Cormican DS, Sonny A, Crowley J, Sheu R, Sun T, Gibson CM, Núñez-Gil IJ, Ramakrishna H. Acute Myocardial Infarction Complicated by Cardiogenic Shock: Analysis of the Position Statement From the European Society of Cardiology Acute Cardiovascular Care Association, With Perioperative Implications. J Cardiothorac Vasc Anesth 2020; 35:3098-3104. [PMID: 33234469 DOI: 10.1053/j.jvca.2020.10.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 12/28/2022]
Abstract
Effective management of cardiogenic shock (CS) is hampered by a lack of evidence-based information. This is a high-mortality condition, without clear, evidence-based guidelines for perioperative management, specifically-a lack of target endpoints for treatment (e.g.: mean arterial pressure or oxygenation), utility of regional care systems or the benefits of palliative care. The Acute Cardiovascular Care Association (ACCA) of the European Society of Cardiology (ESC) recently published a position statement that aimed to offer contemporary guidance on the diagnosis and treatment of acute myocardial infarction (AMI) complicated by CS. Herein, we review this complex clinical topic and review the ACCA statement on AMI associated with CS, with a focus on relevance to perioperative management.
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Affiliation(s)
- Daniel S Cormican
- Department of Anesthesiology, Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA
| | - Abraham Sonny
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Jerome Crowley
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Richard Sheu
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA
| | - Terri Sun
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA
| | | | - Iván J Núñez-Gil
- Interventional Cardiology. Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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41
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Durães Campos I, Bonnefoy-Cudraz E, Pozzi M, Hayek A. Postmyocardial infarction ventricular septal rupture as a potentially fatal complication: when time is the best medicine. BMJ Case Rep 2020; 13:13/9/e237648. [PMID: 32912893 DOI: 10.1136/bcr-2020-237648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Isabel Durães Campos
- Cardiology Department, Hospital de Braga, Braga, Portugal .,Cardiac Intensive Care Unit, Hôpital Cardiologique Louis Pradel, Lyon, France
| | | | - Matteo Pozzi
- Cardiovascular Surgery Department, Hôpital Cardiologique Louis Pradel, Lyon, France
| | - Ahmad Hayek
- Cardiac Intensive Care Unit, Hôpital Cardiologique Louis Pradel, Lyon, France
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42
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Goldberg SL, Don CW. The Ongoing - and Resurgent - Challenge of Post-Infarct Ventricular Septal Defect Management. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1097-1098. [PMID: 32654984 PMCID: PMC7336122 DOI: 10.1016/j.carrev.2020.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 06/29/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Steven L Goldberg
- Tyler Heart Institute, Community Hospital of the Monterey Peninsula, Montage Cardiology, United States of America.
| | - Creighton W Don
- Veterans Administration Puget Sound Health Care System, University of Washington, United States of America
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43
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Gaballa S, AlJaf A, Patel K, Lindsay J, Hlaing KM. COVID-19 Fears May Be Worse Than the Virus: A Case of Cardiogenic Shock Secondary to Post-Myocardial Infarction Ventricular Septum Rupture. Cureus 2020; 12:e8809. [PMID: 32724754 PMCID: PMC7381854 DOI: 10.7759/cureus.8809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, there has been a growing and justifiable fear of catching the virus from the emergency rooms, thus decreasing the hospital visits. With Virginia State slowly reopening and HCA local hospitals resuming elective procedures, the number of emergency room visits, are recovering and increasing. We report a sad and unfortunate case of an 87-year-old female who was experiencing pressure-like chest pain but presented to the emergency room five days later out of fear of catching COVID-19 from the hospital. On presentation to the ED, she was found to have an non-ST-elevation myocardial infarction, which required urgent stenting of the left anterior descending artery. Unfortunately, several hours later, she developed fatal cardiogenic shock due to ventricular septal rupture. We are reporting this case to highlight one of the many potential bad outcomes as a result of a delay in seeking necessary medical attention due to the fear of contracting the virus.
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Affiliation(s)
- Salem Gaballa
- Internal Medicine, LewisGale Medical Center, Salem, USA
| | - Avan AlJaf
- Internal Medicine, LewisGale Medical Center, Salem, USA
| | - Kashyap Patel
- Internal Medicine, LewisGale Medical Center, Salem, USA
| | - Jane Lindsay
- Internal Medicine, LewisGale Medical Center, Salem, USA
| | - Kyaw M Hlaing
- Internal Medicine, LewisGale Medical Center, Salem, USA
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44
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Gu Y, Panda K, Bensimhon A, Bernstein W. Hybrid Approach to Post-Myocardial Infarction Ventricular Septal Rupture Repair and Its Early Complications. J Cardiothorac Vasc Anesth 2020; 35:274-280. [PMID: 32660928 DOI: 10.1053/j.jvca.2020.06.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/11/2020] [Accepted: 06/13/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Yang Gu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Kunal Panda
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Ariel Bensimhon
- Department of Anesthesiology, University of Vermont School of Medicine, Burlington, VT
| | - Wendy Bernstein
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
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45
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Abstract
Structural heart disease (SHD) emergencies include acute deterioration of a stable lesion or development of a new critical lesion. Structural heart disease emergencies can produce heart failure and cardiogenic shock despite preserved systolic function that may not respond to standard medical therapy and typically necessitate surgical or percutaneous intervention. Comprehensive Doppler echocardiography is the initial diagnostic modality of choice to determine the cause and severity of the underlying SHD lesion. Patients with chronic SHD lesions which deteriorate due to intercurrent illness (eg, infection or arrhythmia) may not require urgent intervention, whereas patients with an acute SHD lesion often require definitive therapy. Medical stabilization prior to definitive intervention differs substantially between stenotic lesions (aortic stenosis, mitral stenosis, left ventricular outflow tract obstruction) and regurgitant lesions (aortic regurgitation, mitral regurgitation, ventricular septal defect). Patients with regurgitant lesions typically require aggressive afterload reduction and inotropic support, whereas patients with stenotic lesions may paradoxically require β-blockade and vasoconstrictors. Emergent cardiac surgery for patients with decompensated heart failure or cardiogenic shock carries a substantial mortality risk but may be necessary for patients who are not eligible for catheter-based percutaneous SHD intervention. This review explores initial medical stabilization and subsequent definitive therapy for patients with SHD emergencies.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, 4352Mayo Clinic Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, 4352Mayo Clinic Rochester, MN, USA
| | - Bradley Ternus
- Division of Cardiovascular Medicine, 5228University of Wisconsin, Madison, WI, USA
| | - Mackram Eleid
- Department of Cardiovascular Medicine, 4352Mayo Clinic Rochester, MN, USA
| | - Charanjit Rihal
- Department of Cardiovascular Medicine, 4352Mayo Clinic Rochester, MN, USA
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46
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Zeymer U, Bueno H, Granger CB, Hochman J, Huber K, Lettino M, Price S, Schiele F, Tubaro M, Vranckx P, Zahger D, Thiele H. Acute Cardiovascular Care Association position statement for the diagnosis and treatment of patients with acute myocardial infarction complicated by cardiogenic shock: A document of the Acute Cardiovascular Care Association of the European Society of Cardiology. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:183-197. [DOI: 10.1177/2048872619894254] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Most of the guideline-recommended treatment strategies for patients with acute coronary syndromes have been tested in large randomised clinical trials. Still, a major challenge is represented by patients with acute myocardial infarction admitted with impending or established cardiogenic shock. Despite early revascularization the mortality of cardiogenic shock remains high and roughly half of patients do not survive until hospital discharge or 30-day follow-up. However, there is only limited evidence-based scientific knowledge in the cardiogenic shock setting. Therefore, recommendations and actual treatments are often based on retrospective or prospective registry data and extrapolations from randomised clinical trials in acute myocardial infarction patients without cardiogenic shock. This position statement will summarise the current consensus of the diagnosis and treatment of patients with acute myocardial infarction complicated by cardiogenic shock based on current evidence and will provide advice for clinical practice.
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Affiliation(s)
- Uwe Zeymer
- Klinikum Ludwigshafen, Germany
- Institut für Herzinfarktforschung, Germany
| | - Hector Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain
| | | | | | - Kurt Huber
- Wilhelminenhospital, Austria
- Sigmund Freud University, Austria
| | | | | | | | | | - Pascal Vranckx
- Hartcentrum Hasselt, Belgium
- Department of Medicine and Life Sciences, University of Hasselt, Belgium
| | - Doron Zahger
- Soroka University Medical Center, University of the Negev, Israel
| | - Holger Thiele
- Heart Center Leipzig, University of Leipzig, Germany
- Leipzig Heart Institute, Germany
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47
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Giblett JP, Jenkins DP, Calvert PA. Transcatheter treatment of postinfarct ventricular septal defects. Heart 2020; 106:878-884. [DOI: 10.1136/heartjnl-2019-315751] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 01/31/2020] [Accepted: 02/04/2020] [Indexed: 11/03/2022] Open
Abstract
Postinfarct ventricular septal defects (VSDs) are a mechanical complication of acute myocardial infarction (AMI) with a very poor prognosis. They are estimated to occur in 0.2% of patients presenting with AMI, with 1-month survival of 6% without intervention. Guidelines recommend surgical repair, but recent advances in transcatheter technology, and bespoke device development, mean it is increasingly viable as a closure option. Surgical mortality is between 30% and 50% for all-comers, while in series of transcatheter closure, mortality was 32%. Transcatheter closure appears durable, with no evidence of late leaks and low long-term mortality in series with up to 5-year follow-up. Guidelines recommend early closure, which is likely to provide most benefit for patients regardless of the closure method. Multimodality cardiac imaging including echocardiography, CT and cardiac MRI can define size, shape, location of defects and their relationship to other cardiac structures, assisting with treatment decisions. Brief delay to allow stabilisation of the patient is appropriate, but untreated patients risk rapid deterioration. Mechanical circulatory support may be helpful, although the preferred modality is unclear. Transcatheter closure involves large bore venous access and the formation of an arteriovenous loop (under fluoroscopic and trans-oesophageal echocardiographic guidance) in order to facilitate deployment of the device in the defect and close the postinfarct VSD. Guidelines suggest transcatheter closure as an alternative to surgical repair in centres where appropriate expertise exists, but decisions for all patients with postinfarct VSD should be led by the multidisciplinary heart team.
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48
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Via G, Buson S, Tavazzi G, Halasz G, Quagliana A, Moccetti M, Demertzis S, Cassina T. Early cardiac unloading with ImpellaCP™ in acute myocardial infarction with ventricular septal defect. ESC Heart Fail 2020; 7:708-713. [PMID: 32043814 PMCID: PMC7160491 DOI: 10.1002/ehf2.12622] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/12/2019] [Accepted: 01/03/2020] [Indexed: 11/29/2022] Open
Abstract
Despite a relative contraindication, mechanical support with Impella™ left ventricular assist device has already been described for ischaemic ventricular septal defect treatment, either as a bridge to surgery, as intraoperative mechanical haemodynamic support, or to ensure intraprocedural haemodynamic stability during device closure. We describe two cases of ventricular septal defect complicating acute myocardial infarction, where the percutaneous ImpellaCP was implanted early (differently than previously described) with the aim of preventing haemodynamic instability, while deferring surgical repair. We present a report of haemodynamic, echocardiographic, biochemical, and clinical data of two consecutive cases of ImpellaCP use, within a minimally invasive monitoring and therapeutic approach. In two cases of subacute myocardial infarction‐related ventricular septal defect not amenable to percutaneous device closure, the use ImpellaCP was successful: it was followed by effective and rapid right and left ventricular unloading, by major haemodynamic instability prevention and protection from systemic venous congestion, from kidney and splanchnic organ failures. This allowed bridging to appropriately timed surgical repair. These cases suggest a potentially effective, clinically grounded strategy in the early management of ischaemic ventricular septal defect patients, with the aim of deferring surgery beyond the safer 7 days cutoff associated with a lower perioperative mortality.
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Affiliation(s)
- Gabriele Via
- Department of Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Stefania Buson
- Department of Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Guido Tavazzi
- Anesthesia, Intensive Care and Pain Therapy, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.,Anesthesia and Intensive Care, Emergency Department, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Geza Halasz
- Department of Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Angelo Quagliana
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland.,Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Italy
| | - Marco Moccetti
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Stefanos Demertzis
- Department of Cardiac Surgery, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Tiziano Cassina
- Department of Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, Lugano, Switzerland
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49
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Ishiyama M, Kurita T, Ishiura J, Yamamoto N, Sugiura E, Ito H, Tada N, Fujimoto N, Ito M, Dohi K. Successful percutaneous treatment of recurrent post-infarction ventricular septal rupture using an Amplatzer duct occluder. J Cardiol Cases 2019; 21:12-15. [PMID: 31933699 DOI: 10.1016/j.jccase.2019.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/25/2019] [Accepted: 08/25/2019] [Indexed: 10/25/2022] Open
Abstract
A 78-year-old woman was brought to our hospital for chest pain with shock status. An electrocardiogram showed ST elevation in the precordial leads. Echocardiography showed an anteroseptal wall motion abnormality with left-to-right shunt at the apex. Emergency coronary angiography revealed occlusion in the mid portion of the left anterior descending artery, and left ventriculography showed ventricular septal rupture (VSR). Despite successful emergency surgical VSR repair, the VSR recurred 10 days after surgery, and the patient required intra-aortic balloon pumping and mechanical ventilation. Although reoperation for VSR closure was attempted 33 days after admission, open heart surgery was not completed due to severe tissue adhesions from the prior cardiac surgery. The patient ultimately underwent transcatheter closure for VSR using an Amplatzer duct occluder 56 days after hospital admission, and her hemodynamics markedly improved. She was transferred to a regional hospital for rehabilitation without oxygen therapy or intravenous treatments 81 days after the percutaneous intervention. In conclusion, percutaneous device closure of post-infarction VSR may be an alternative treatment to surgical repair for inoperable cases. <Learning objective: Ventricular septal rupture (VSR) is a rare but frequently fatal complication of acute myocardial infarction and often requires early surgery. However, the recurrence rate of VSR after surgery is high, and reoperation is often difficult because of the critical nature of the patients' condition. The present case report highlights the effectiveness of percutaneous closure of VSR using Amplatzer devices for seriously ill patients with a high risk of reoperation.>.
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Affiliation(s)
- Masaki Ishiyama
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Mie, Japan
| | - Tairo Kurita
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Mie, Japan
| | - Junko Ishiura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Mie, Japan
| | - Naoki Yamamoto
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Emiyo Sugiura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Mie, Japan
| | - Hisato Ito
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Norio Tada
- Department of Cardiology, Sendai Kousei Hospital, Sendai, Japan
| | - Naoki Fujimoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Mie, Japan
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Mie, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Mie, Japan
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50
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Zhukova NS, Merkulova IN, Shakhnovich RM, Merkulov EV, Osiev AG, Pevzner DV, Sukhinina TS, Staroverov II. [Endovascular closure of a ventricular septal defect from Takotsubo Syndrome]. TERAPEVT ARKH 2019; 91:115-123. [PMID: 32598822 DOI: 10.26442/00403660.2019.09.000363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 01/18/2023]
Abstract
Takotsubo Syndrome is a transient condition characterized by left ventricular systolic dysfunction. Although the prognosis is excellent in most cases, rare cases of serious complications can occur. We present a case of a 81-year - old woman with Takotsubo Syndrome complicated by ventricular septal rupture that was successfully closed with an occluder Occlutech with good immediate and long - term outcomes.
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Affiliation(s)
- N S Zhukova
- National Medical Research Center of Cardiology
| | | | | | | | - A G Osiev
- National Medical Research Center of Cardiology
| | - D V Pevzner
- National Medical Research Center of Cardiology
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