Surgical management of postinfarction ventricular septal rupture

Early and Late Surgical Outcomes after Geometrical Infarct Exclusion for Post-Infarct Ventricular Septal Perforation

PURPOSE

Ventricular septal perforation (VSP) is a critical complication of acute myocardial infarction. Various surgical procedures for it have been developed; however, surgical outcomes remain unsatisfactory. In 2010, we introduced geometrical infarct exclusion (GIE) as a modification of the Komeda-David technique. This retrospective study compared the surgical outcomes of our geometric infarct exclusion technique to those of other surgical procedures.

METHODS

This study included 38 patients who underwent surgery for VSP. They were divided into patients who underwent GIE (GIE group; n = 17) and those who underwent other procedures (non-GIE group; n = 21). The clinical outcomes of the two groups were compared.

RESULTS

Operation, cardiopulmonary bypass, and cardiac arrest times in the GIE group were significantly longer than those in the non-GIE group (p <0.001). A residual shunt was observed in one patient (5.8%) in the GIE group and eight (38.0%) in the non-GIE group (p = 0.026). No patients in the GIE group required a reoperation for the residual shut, while two patients required it in the non-GIE group (p = 0.492). Operative mortality was insignificantly different between the two groups.

CONCLUSION

Geometric infarct exclusion has a longer procedural time than does other surgical procedures but can reduce the rates of residual shunts and reoperations.

Transcatheter closure of post-myocardial infarction ventricular septal defect: A systematic review and single-arm meta-analysis

Background

Ventricular septal defects (VSDs) are one of the mechanical complications of acute myocardial infarction (AMI). Because of the high risks of mortality and postoperative complications, a new alternative method is needed. With the development of interventional medicine, transcatheter closure has been increasingly performed for postmyocardial infarction ventricular septal defects (PMIVSDs). The aim of this study is to explore the feasibility and safety of transcatheter closure of PMIVSDs by meta-analysis.

Methods

The included studies were mainly single-arm studies of transcatheter closure of PMIVSDs. We compared VSD size, device size, preoperative risk factors and interventions among PMIVSD patients. We analysed the transcatheter closure success rate, the 30-day mortality rate, and the incidence of residual shunts.

Results

A total of 12 single-arm articles (284 patients) were included. The combined incidences of preoperative hypertension, hyperlipidaemia, and diabetes were 66% [95% CI 0.56-0.75], 54% [95% CI 0.40-0.68], and 33% [95% CI] 0.21-0.46], respectively. Multiple studies reported the combined incidences of preoperative PCI, IABP, and CABG, which were 46% [95% CI 0.15-0.80], 60% [95% CI 0.44-0.75], and 8% [95% CI 0.02-0.18]. Eleven studies reported the number of successful closures and the 30-day mortality rate; the success rate was 90% [95% CI 0.86-0.94], and the 30-day mortality rate reached 27% [95% CI 0.86-0.94].

Conclusion

For patients with PMIVSD, transcatheter closure in the acute phase can be used as a rescue measure, while in the chronic phase, it is more effective and has a lower mortality rate, but the effect of selection bias should be considered. Residual shunts are a long-term complication that have a high incidence and long-lasting effects on patients. More large, multicentre, randomized controlled trials are needed in the future to confirm the safety and reliability of transcatheter closure of PMIVSDs.

Management and outcome of post-myocardial infarction ventricular septal rupture-A Low-Middle-Income Country Experience

BACKGROUND

Ventricular septal rupture (VSR) is a rare complication after acute myocardial infarction (AMI) especially in the reperfusion era but its associated mortality has remained high. This case series evaluated in-hospital and intermediate-term mortality in VSR patients. Additionally, we also analyzed risk factors, clinical presentation, intervention, and predictors of in-hospital mortality in VSR patients.

METHODS

Data of 67 patients with echocardiography confirmed diagnosis of VSR from January 2011 to April 2020 was extracted from hospital medical records. Records were also reviewed to document 30 day and 1-year mortality, recurrent heart failure admission, repeat myocardial infarction, and revascularization. In addition, telephonic follow-up was done to assess health-related quality of life(HRQOL) assessed by KCCQ-12. SCAI shock classification was used to categorize severity of cardiogenic shock. Univariate and multivariable logistic regression was used to determine predictors of in-hospital mortality. Survival function was presented using the Kaplan-Meier survival curve.

RESULTS

Mean age of patients was 62.7 ± 11.1 years, 62.7% were males. 65.7% of the patients presented more than 24 hours after MI and did not receive reperfusion therapy. Median time from AMI to VSR diagnosis was 2 (1-5) days. VSR closure was attempted in 53.7% patients. In-hospital mortality was 65.7%. At univariate level, predictors of in-hospital mortality were non-surgical management, basal VSR, right ventricular dysfunction, early VSR post-MI, and severe cardiogenic shock at admission (class C, D, or E). Adjusted predictors of in-hospital mortality included non-surgical management, basal VSR and advanced cardiogenic shock. There were 5 deaths during median followup of 44.1 months. HRQOL in patients available on followup was good (54.5%) or excellent (45.5%).

CONCLUSION

High in-hospital mortality was seen in VSR patients. VSR closure is the preferred treatment to get long-term survival, however, timing of repair as well as severity of cardiogenic shock plays a significant role in determining prognosis.

Ventricular Septal Rupture Following Acute Myocardial Infarction

ST-segment elevation myocardial infarction (STEMI) is a known medical exigency that has seen considerable advances in medical treatment, dramatically boosting survival rates. Post myocardial infarction ventricular rupture is a major serious mechanical complication following myocardial infarction. We present a case of a 68-year-old male admitted to the emergency department with heaviness in the chest, for which electrocardiography was done and it was suggestive of anterior and lateral wall myocardial infarction. After six hours he experienced breathlessness, jugular venous pressure (JVP) was raised, and auscultation revealed early systolic murmur at apex suggestive of ventricular septal rupture. An urgent echocardiogram was done and it confirmed the diagnosis of ventricular septal rupture (VSR). To enhance the prognosis, early identification and appropriate care are required, which necessitate a thorough clinical evaluation that raises the possibility of mechanical problem, as late presentation is one of the major risk factors for developing VSR. VSR can manifest itself in numerous ways, based on the patient's condition. Right clinical judgement and ECG are required to establish a quick diagnosis, as a result, to determine the most appropriate treatment at the appropriate time.

Post-infarction ventricular septal rupture

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.

Post Myocardial Infarction Ventricular Septal Rupture Revealed By Acute Liver Failure Symptoms: A Case Report

Introduction:

The mechanical complications of acute myocardial infarction (AMI) still kill despite the evolution of medicine. Early diagnosis and adequate management are necessary to improve the prognosis, and this requires first, a good clinical examination that should raise the suspicion of a mechanical complication, then the echocardiography is performed to confirm the diagnosis.

Case Presentation:

We present a case of a 64-year-old patient admitted to the emergency room for jaundice with delayed ST-segment elevation myocardial infarction (STEMI). Physical examination revealed signs of right heart failure, which led us to associate jaundice with signs of acute liver failure secondary to right heart failure. Echocardiography confirmed the diagnosis of a ventricular septal rupture (VSR) with left-right shunt, and a significant dilation of the right ventricle. The patient underwent surgical closure of the VSR with fatal evolution.

Discussion:

VSR is a rare life-threatening mechanical complication of AMI. The clinical signs depend on the left-right shunt and the onset of heart failure, which are 2 major determinants of the therapeutic strategy and the timing of the surgery. Despite surgical closure of the VSR, the mortality remains high, but the prognosis is better in patients treated with surgery than in patients who are treated medically only.

Conclusion:

The clinical presentation of VSR may differ from a patient to another. Good clinical sense and echocardiography are essential to set early diagnosis, and thus decide on the adequate management at the right time.

Not all Postmyocardial Infarction Ventricular Septal Rupture Need Immediate Surgery: Role of Cardiogenic Shock Classification

A 56-year-old man presented with acute anterior ST elevation myocardial infarction. Initially he was thrombolysed at a peripheral hospital and a transthoracic echocardiography revealed multiple (2-3 mm) apical muscular ventricular septal defects suggesting ventricular septal rupture (VSR), with the largest measuring 10mm with left to right shunt and max gradient was 74 mmHg. His left ventricular ejection fraction was 45%. A coronary angiogram revealed tight proximal (95%) and mid segments (80%) stenosis in the left anterior descending artery (LAD) but diffusely diseased distally. Another significant stenosis (80%) was present at the ostium of the right posterior descending artery (r-PDA). He was in Society for Cardiovascular Angiography and Intervention (SCAI) cardiogenic shock Stage B, hence cardiac surgeons advised conservative medical treatment in order to stabilize the infarct area with view of good surgical outcome. Although, there was a dilemma between the surgeon and the cardiologist regarding timing VSR closure, classification of shock stages helped to delay surgery. Eventually, he was taken for surgery at the 18^th day of admission with a graft to r-PDA rather to LAD (due to difficult visualization) and repair of VSR with Gortex patch. In conclusion, in all patients with post MI VSR, SCAI shock stages classification has to be applied in determining the timing of surgery.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

COVID-19 Fears May Be Worse Than the Virus: A Case of Cardiogenic Shock Secondary to Post-Myocardial Infarction Ventricular Septum Rupture

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.

The evaluation of a tissue-engineered cardiac patch seeded with hips derived cardiac progenitor cells in a rat left ventricular model

BACKGROUND

Ventricular septal perforation and left ventricular aneurysm are examples of potentially fatal complications of myocardial infarction. While various artificial materials are used in the repair of these issues, the possibility of associated infection and calcification is non-negligible. Cell-seeded biodegradable tissue-engineered patches may be a potential solution. This study evaluated the feasibility of a new left ventricular patch rat model to study neotissue formation in biodegradable cardiac patches.

METHODS

Human induced pluripotent stem cell-derived cardiac progenitor cells (hiPS-CPCs) were cultured onto biodegradable patches composed of polyglycolic acid and a 50:50 poly (l-lactide-co-ε-caprolactone) copolymer for one week. After culturing, patches were implanted into left ventricular walls of male athymic rats. Unseeded controls were also used (n = 10/group). Heart conditions were followed by echocardiography and patches were subsequently explanted at 1, 2, 6, and 9 months post-implantation for histological evaluation.

RESULT

Throughout the study, no patches ruptured demonstrating the ability to withstand the high pressure left ventricular system. One month after transplantation, the seeded patch did not stain positive for human nuclei. However, many new blood vessels formed within patches with significantly greater vessels in the seeded group at the 6 month time point. Echocardiography showed no significant difference in left ventricular contraction rate between the two groups. Calcification was found inside patches after 6 months, but there was no significant difference between groups.

CONCLUSION

We have developed a surgical method to implant a bioabsorbable scaffold into the left ventricular environment of rats with a high survival rate. Seeded hiPS-CPCs did not differentiate into cardiomyocytes, but the greater number of new blood vessels in seeded patches suggests the presence of cell seeding early in the remodeling process might provide a prolonged effect on neotissue formation. This experiment will contribute to the development of a treatment model for left ventricular failure using iPS cells in the future.

Report of five cases: sandwich repair for post infarction ventricular septal rupture with right ventricular approach

Background

Different techniques have been described to repair post myocardial infarction ventricular septal rupture (VSR), each method may result in residual shunting, bleeding, and suboptimal left ventricular (LV) performance secondary to change in LV geometry. The aim of this report is to describe early and mid-term results of sandwich technique through right ventricle in five consecutive patients.

Case presentation

Five consecutive patients (3 women and 2 men) with VSR (mean age 62.8 years, range 51-70) underwent surgical repair for postinfarction ventricular septal rupture by sandwich technique performed through right ventricle from August 2012 to April 2019 in our institute. Reconstruction of the septum was performed by two patches of 0.6 mm Gore-Tex on each side of the septal defect through right ventricular incision, according to the method described by Isoda et al. Coronary artery bypass grafting was performed in two patients.

The mean aortic clamp time was 90 min (range, 64 to 157 min). The mean extracorporeal circulation time was 146.6 min (range, 108 to 240 min). Postoperative intensive care unit (ICU) stay averaged 12 days (range, 4-40 days). There was no hospital mortality. No postoperative residual shunting was detected, and no patient needed re-operation for bleeding. Patients have been followed up for a mean of 24.4 months (range, 1 week to 7 years). There was one death seven days after discharge due to arrhythmia (40 days after surgery).

Conclusion

Sandwich technique through right ventricular approach is simple and extendable to all VSRs irrespective of their locations. Residual shunting and bleeding are negligible or zero. It may be considered as standard of repair for patient with post infarction ventricular septal rupture.

Post-myocardial infarction ventricular septal rupture in a patient with large secundum atrial septal defect: a case report

Background

Ventricular septal rupture (VSR) is an uncommon but potentially fatal complication of acute myocardial infarction (AMI). The management of VSR is challenging, and its surgical correction is associated with the highest mortality among all cardiac surgery procedures.

Case summary

A 57-year-old man with a history of smoking presented with AMI with a large apical VSR in addition to a large secundum atrial septal defect (ASD). His left ventricular ejection fraction was 30%, and the right ventricle was moderately dilated with normal systolic function. Cardiac catheterization revealed that the left anterior descending artery was diffusely diseased with total mid occlusion, whereas other coronary arteries had non-obstructive disease. This unique combination resulted in distinctive presentation with paradoxically better outcomes. After stabilization, the patient’s interventricular septum was reconstructed, and the ASD was closed with a pericardial patch. The post-operative period was uneventful, and the patient was discharged 1 week after surgery. A follow-up echocardiography revealed no residual shunt.

Discussion

Post-myocardial infarction VSR presents differently in patients with pre-existing right ventricular volume overload. In such cases, the absence of significant cardiogenic shock at presentation may result in better surgical outcomes.

Inferior Wall ST-elevation Myocardial Infarction Complicated by Ventricular Septal Defect and Free Wall Pseudoaneurysm with Rupture

Myocardial infarction (MI) is associated with complications in spite of appropriate management. The incidence of mechanical complications declined over time secondary to reperfusion therapies, improved control of blood pressure, the use of beta blockers and angiotensin-converting enzyme inhibitors, and aspirin. A high degree of suspicion is required, especially in elderly patients with complications post-PCI (percutaneous coronary intervention). Herein, we present a case of elderly male diagnosed with an inferior wall MI who had a PCI. He was found to have a post-infarction ventricular septal rupture (VSR) and basal inferior wall aneurysm that progressed over three weeks to a myocardial free wall rupture with hemopericardium. This case emphasizes the need for close monitoring of complications.

Spontaneous closure of ventricular septal perforation following percutaneous coronary intervention for acute myocardial infarction

We report on an 84-year-old woman with anteroseptal acute myocardial infarction. Emergency coronary angiography revealed the occlusion of proximal left anterior descending artery without collateral circulation, and percutaneous coronary intervention was performed. Two drug eluting stents were implanted, and the procedure was concluded with thrombolysis in myocardial infarction grade 3 without complications. Postoperatively, no murmur was audible on auscultation and no shunt flow was observed on transthoracic echocardiography (TTE), and normal blood pressure was maintained. On day 2, however, the patient's vital signs deteriorated to a state of shock and systolic murmur appeared at the apical region. TTE showed a left-to-right shunt in the apical septal region, and ventricular septal perforation was diagnosed. Although emergency surgery was considered, the patient's vital signs improved the following day. The disappearance of the cardiac murmur and the shunt was confirmed. The clinical course was uneventful thereafter, and the patient was discharged.

Effect of thrombolytic therapy on the patterns of post myocardial infarction ventricular septal rupture

OBJECTIVES

Ventricular septal rupture (VSR) is a rare but feared complication after myocardial infarction (MI). The objective of this study was to investigate the effects of thrombolytic therapy on the patterns of VSR following MI.

METHODS

30 consecutive patients admitted to a single tertiary level cardiac hospital with a diagnosis of acute MI and developed VSR in the hospital were included. The effect on thrombolytic therapy on the formation of VSR and its clinical outcome was studied.

RESULTS

Out of 30 patients, 15 patients received thrombolytic therapy.10 received early (<12h) and 5 received late (>12h). The median time to post MI VSR formation was significantly shorter in thrombolysis group compared to non thrombolysis group at 1 vs 3 days(p=0.026). The median time for VSR formation was shorter in early thrombolysis group compared to late thrombolysis group at 1 vs 3 days (p=0.022). There was no difference between late and no thrombolytic therapy (3 vs 3 days, p=0.672). There was no significant difference in the mortality between thrombolytic and no thrombolytic therapy (p=0.690). Patients treated medically had a significant higher mortality compared to patients treated surgically (p=0.005).

CONCLUSION

Thrombolytic therapy results in an earlier presentation of VSR after MI. This earlier presentation may be due to reduction in the number of patients developing late VSR after thrombolytic therapy, while the number of patients developing an early VSR remaining unaffected. Despite improvements in medical therapy and percutaneous and surgical techniques, mortality with this complication remains extremely high.

Repairing the posterior postinfarction ventricular septal defect: a left ventricular approach with a sealant reinforced multipatch technique

An uncommon complication of acute myocardial infarction (AMI), postinfarction ventricular septal defect (PI-VSD), often yields devastating outcomes. Because of the strikingly poor quality of the residual tissue, the repair of PI-VSD poses a surgical challenge and is associated with high operative mortality as well as residual or recurrent shunting. Among the various techniques that have been developed, we prefer a left ventricular approach to repairing PI-VSD by using a multipatch technique reinforced with a sealant as an adjunct to surgical repair. In this method, 3 patches are used: two overlay the left side of the VSD with a sealant (composed of albumin cross-linked to glutaraldehyde) sandwiched between them, whereas a third patch is used to cover the ventriculotomy defect. The rationale is that the use of such a sealant decreases the complications of PI-VSD repair by providing a sturdier surface for suture placement, thereby decreasing suture dehiscence and consequent recurrence of septal rupture. This multipatch technique offers hope in improving the results of the surgical management of PI-VSD.

Determinants of in-hospital death in patients with postinfarction ventricular septal perforation

Ventricular septal perforation (VSP) is a serious complication associated with acute myocardial infarction (MI). The purpose of this study was to investigate the determinants of in-hospital death in patients with postinfarction VSP. Between January 1990 and April 2010, we identified 37 patients from our hospital records. Univariate analysis and multivariate logistic regression analysis were performed to find the determinants of in-hospital death. In-hospital mortality was 35% (13/37 patients). History of hypertension (P = 0.03), percutaneous coronary intervention (P = 0.04), and preoperative percutaneous cardiopulmonary support (P = 0.04) were associated with in-hospital death, whereas history of hyperlipidemia was associated with in-hospital survival. The interval from MI to VSP in survivors was significantly longer than that in nonsurvivors (P < 0.01). In multivariate logistic regression analysis, a shorter interval from MI to VSP (odds ratio 0.57, 95% confidence interval 0.34-0.95, P = 0.03) was found to be an independent predictor of in-hospital death. In conclusion, in-hospital mortality was high in patients with postinfarction VSP. A shorter interval from MI to VSP was a significant independent predictor of in-hospital death.

Postinfarction ventricular septal defects: towards a new treatment algorithm?

BACKGROUND

We reviewed our experience at the Montreal Heart Institute with early surgical and percutaneous closure of postinfarction ventricular septal defects (VSD).

METHODS

Between May 1995 and November 2007, 51 patients with postinfarction VSD were treated. Thirty-nine patients underwent operations, and 12 were treated with percutaneous closure of the VSD.

RESULTS

Half of the patients were in systemic shock, and 88% were supported with an intraaortic balloon pump before the procedure. Before the procedure, 14% of patients underwent primary percutaneous transluminal coronary angioplasty. The mean left ventricular ejection fraction was 0.44 +/- 0.11, and mean Qp/Qs was 2.3 +/- 1. Time from acute myocardial infarction to VSD diagnosis was 5.4 +/- 5.1 days, and the mean delay from VSD diagnosis to treatment was 4.0 +/- 4.0 days. A moderate to large residual VSD was present in 10% of patients after correction. Early overall mortality was 33%. Residual VSD, time from myocardial infarction to VSD diagnosis, and time from VSD diagnosis to treatment were the strongest predictor of mortality. Twelve patients were treated with a percutaneous occluder device, and the hospital or 30-day mortality in this group was 42%.

CONCLUSION

Small or medium VSDs can be treated definitively with a ventricular septal occluder or initially to stabilize patients and allow myocardial fibrosis, thus facilitating delayed subsequent surgical correction.

Long-term survival with acquired ventricular septal defect after myocardial infarction

Acquired ventricular septal defects (VSD) are rare and devastating complications after myocardial infarction. The long-term prognosis with medical therapy is extremely poor. We report on a patient who developed progressive heart failure within 3 months after myocardial infarction due to an unknown VSD. The left ventricular function was severely impaired. After diagnosing VSD by echocardiography, surgical occlusion was performed. In addition, a biventricular pacemaker was applied using epicardial leads. The patient recovered almost completely 6 weeks postoperative. Beside hemodynamic changes, biventricular pacing is potentially sufficient to improve the postoperative outcome of patients with severe heart failure in these conditions.

The Potential Impact of Primary Percutaneous Coronary Intervention on Ventricular Septal Rupture Complicating Acute Myocardial Infarction

BACKGROUND

Recent data suggest that the risk of acquired ventricular septal defect (VSD), a complication of acute myocardial infarction (AMI), could be reduced using thrombolytic therapy. There are, however, still no available data regarding the potential impact of primary percutaneous coronary intervention (PCI) on AMI-related VSD in a clinical setting. The purposes of this study were to delineate the incidence and the potential risk factors of AMI-related VSD in the Chinese population, and to determine whether primary PCI could reduce such risk.

METHODS AND RESULTS

From May 1993 through March 2003, a total of 1,321 patients with AMI (for < 12 h) underwent primary PCI in our hospital. Of these 1,321 patients, 3 patients (0.23%) developed VSD after undergoing a primary PCI, with a mean (+/- SD) time of occurrence of 25.3 +/- 12.2 h. During the same period, a total of 616 consecutive, unselected patients with early AMI [ie, > 12 h and < or = 7 days] or recent myocardial infarction (MI) [ie, > or = 8 days and < 30 days] who had not received thrombolytic therapy underwent elective PCI. Of these 616 patients, 18 (2.9%) had VSD either on presentation or during hospitalization, with a mean time of occurrence of 71.1 +/- 64.2 h. Clinical variables were utilized to statistically analyze the potential risk factors. Univariate analysis demonstrated that the enrollment variables strongly related to this complication were advanced age, hypertension, nonsmokers, anterior infarction, female gender, and lower body mass index (BMI) [all p < 0.005]. Using multiple stepwise logistic regression analysis, the only variables independently related to VSD were advanced age, female gender, anterior infarction, and low BMI (all p < 0.05). The in-hospital mortality rate was significantly higher in patients with this complication than in patients without this complication (47.6% vs 8.0%; p < 0.0001). The incidence of this complication was significantly lower in patients with AMI who underwent primary PCI than in those with early or recent MI who underwent elective PCI (3.0% vs 0.23%, respectively; p = 0.0001).

CONCLUSION

Primary PCI had a striking impact on reducing the incidence of VSD after AMI compared to elective PCI in patients who did not receive thrombolytic therapy. Advanced age, female gender, anterior infarction, and low BMI had potentially increased the risk of this catastrophic complication after AMI in this Chinese population.

Ventricular Septal Rupture After Early Successful Thrombolytic Therapy in Acute Myocardial Infarction: A Case Report

Ventricular septal defect (VSD) is a severe complication of acute myocardial infarction and has a high mortality rate. This complication appears to have declined in the reperfusion era. It has mostly been reported in elderly or female patients who suffer from anterior wall infarction, patients with multivessel coronary artery disease (CAD) or occluded infarct-related artery (IRA) without collateral circulation, or patients who have had delayed reperfusion therapy. Here, we report the case of a 60-year-old male patient who presented with persistent chest pain and Killip I ST-segment-elevation myocardial infarction. Thrombolytic therapy was started 3 hours after the onset of chest pain. Based on the subsidence of chest pain, resolution of the elevated ST segment, and early peak of cardiac enzymes, reperfusion was thought to be successful. However, on the third day of admission, the patient complained of dyspnea after defecation and was found to have new-onset grade 3 pansystolic murmur over the left sternal border. Cardiac echography showed an apical VSD. A Swan-Ganz catheter was inserted into the right side of the heart; analysis of blood oxygen saturation revealed a 6% step-up of oxygen in the right ventricle. Coronary angiography showed only one-vessel CAD and TIMI 3 flow in the IRA. The patient received intensive medical management and underwent VSD repair and internal mammary artery bypass grafting to the left anterior descending artery. His recovery was uneventful. This case illustrates that VSD can be found in patients receiving early successful reperfusion therapy, with one-vessel CAD, and TIMI 3 flow in the IRA.

Matrix metalloproteinases: from biology to therapeutic strategies in cardiovascular disease

In this comprehensive review of matrix remodeling, one central theme that bears re-emphasis is the extensivecross-talk and dynamic interactions that exist between terminally differentiated, postmitotic cells, proliferative cells, and the ECM of the cardiovascular system. The activities of MMPs and TIMPs constitute a well-orchestrated contest to maintain tissue integrity and homeostasis. Overexpression of MMPs tilts the balance in favor of irreversible tissue destruction of joints (eg, as in rheumatic disease), and efforts to curtail such errant pathways are ongoing (123). Thrombolytic therapy and percutaneous transluminal coronary angioplasty represent effective strategies for restoring antegrade flow in occluded vessels, but multiple factors preclude most patients with AMI from receiving either of these treatments. Tissue healing and remodeling is a process in which the biology of MMPs becomes universally applicable. Basic lessons from the biochemistry and enzymology of MMPs, combined with the mechanisms of gene expression, will undoubtedly impact the development of future therapies involving MMPs and their endogenous inhibitors. In addition, formidable challenges, ranging from bioavailability to tissue penetration and toxicity in animal models, face investigators using existing pharmacotherapeutics. For congenital diseases, such as Marfan syndrome, which primarily affects the connective tissue, future therapies may be targeted to the underlying pathobiology involving MMPs. Strategies aimed at correction of the genetic defect may be complemented by those to prevent or ameliorate fundamental imbalances in matrix turnover and deposition. The future challenge for cardiovascular medicine is to appropriately shift the pendulum, not to the exclusion of, but to the recognition of the dynamic interaction that exists between myocyte and nonmyocyte populations, which clearly affect the pathogenesis of many acquired and genetic disorders.

Ventricular septal defect and left ventricular aneurysm: late occurrence as complications of an acute myocardial infarction

Mechanical complications of acute myocardial infarction (AMI) such as a ventricular septal defect (VSD) usually occur within the first week. In the thrombolytic era, the incidence of a VSD has not increased, but has been reported to occur earlier than previously described. We report an unusual case of an elderly Caucasian female with an acute anterior wall myocardial infarction treated with thrombolytic therapy. Her AMI was complicated by pulmonary edema secondary to a VSD and a left ventricular aneurysm five weeks later. Prompt diagnosis, immediate surgical closure of the VSD, and aneurysmectomy resulted in her complete recovery.

Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators

BACKGROUND

Ventricular septal defect (VSD) complicating acute myocardial infarction has been studied primarily in small, prethrombolytic-era trials. Our goal was to determine clinical predictors and angiographic and clinical outcomes of this complication in the thrombolytic era.

METHODS AND RESULTS

We compared enrollment characteristics, angiographic patterns, and outcomes (30-day and 1-year mortality) of patients enrolled in the Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries (GUSTO-I) trial with and without a confirmed diagnosis of VSD. Univariable and multivariable analyses were used to assess relations between enrollment factors and the development of VSD. In all, 84 of the 41 021 patients (0.2%) developed VSD, a smaller percentage than reported in the prethrombolytic era. The median time from symptom onset to VSD diagnosis was 1 day. Enrollment factors most associated with this complication were advanced age, anterior infarction, female sex, and no previous smoking. The infarct artery was more often the left anterior descending and more likely to be totally occluded in patients who developed VSD. Mortality at 30 days was higher in patients with VSDs than in those without this complication (73.8% versus 6.8%, P<0.001). Patients with VSDs selected for surgical repair (n=34) had better outcomes than patients treated medically (n=35; 30-day mortality, 47% versus 94%).

CONCLUSIONS

Compared with historical control subjects, patients who undergo thrombolysis within 6 hours of infarction onset may have a reduced risk of later VSD. If patients develop this mechanical complication, however, it typically occurs sooner than described in the prethrombolytic era. Despite improvements in medical therapy and percutaneous and surgical techniques, mortality with this complication remains extremely high.

Post-infarction ventricular septal defect: percutaneous transvenous temporary closure using a Swan-Ganz catheter

We report on a case of temporary closure of a post-infarction ventricular septal defect (VSD) using a Swan-Ganz catheter through a femoral transvenous approach. This resulted in substantial improvement in the hemodynamic status of the patient. Six hr later, the patient underwent surgery for VSD closure. When immediate surgical intervention is not possible, it may be helpful to stabilize the patient until surgery can be performed. Thus, such a treatment has potential as a temporary measure for patients awaiting surgical repair of post-infarction VSD.

Urgent surgical repair of postinfarction ventricular septal rupture: early and late outcome

AIM

This retrospective analysis focuses on predictive factors of operative mortality and long-term survival after surgical repair of postinfarction ventricular septal rupture (VSR).

METHODS

Sixty-seven patients (43 males, 24 females) with VSR underwent surgical repair between December 1977 and December 1995. The site of the rupture was anterior in 44 patients and posterior in 23. The mean interval between myocardial infarction (MI) and VSR was 3.6+/-4.1 days. Clinical condition on admission was critical in 63 patients (49 in cardiogenic shock). An intra-aortic balloon pump was inserted preoperatively in 54 patients.

RESULTS

Operative mortality was 25% (17 patients). The main cause of death was cardiac failure. Factors influencing early deaths in univariate analysis were preoperative hemodynamic status (cardiogenic shock present in 30%; absent in 8%; p = 0.001), the location of the MI (anterior in 11.6%, posterior in 45.4%), the interval between infarction and surgery (<1 week was 33%, >1 week was 6.2%), and the response to initial active therapy. All patients were available for follow-up. The actuarial survival rates at 1 and 5 years are 74.6%+/-5.3% and 66.2%+/-6.2%, respectively. There were 12 late deaths and 40% were cardiac related. Two patients presented residual VSD (one reoperation). The left ventricular ejection fraction (LVEF) was mildly impaired in 9 patients. Three patients had moderate mitral insufficiency and two had moderate tricuspid insufficiency.

CONCLUSION

Repair of the postinfarction VSR remains a challenge. Improvement should be rendered possible by optimizing techniques. Postoperative morbidity is high, and these patients require intensive hospital resources. The late results have been satisfactory.

Early mortality after surgical repair of postinfarction ventricular septal rupture: importance of rupture location

BACKGROUND

The aim of this study was to identify factors influencing early outcome after surgical treatment of postinfarction ventricular septal rupture. We investigated the influence of proximal or distal rupture location.

METHODS

Between 1980 and 1992 109 patients were treated surgically for ventricular septal rupture using a standardized technique. A division in time periods was made. The rupture was categorized according to its anterior or posterior site and proximal or distal location.

RESULTS

The 30-day mortality rate was 27.5%. Multivariate logistic regression analysis identified preoperative shock (p = 0.0007) and right atrial oxygen saturation less than 60% (p = 0.021) as predictors for early death; the risk for early death declined over the time periods from 50% to 12.8% (p = 0.0007). Proximal ventricular septal rupture location (p = 0.0092) and interval between infarction and ventricular septal rupture less then 1 day (p = 0.034) were risk factors for the occurrence of preoperative shock.

CONCLUSIONS

Proximal ventricular septal rupture location was the main determinant of preoperative cardiogenic shock, which in turn was the strongest predictor of early mortality. Over the time periods a decrease in early mortality was reached.

Repair of ventricular septal rupture through the right atrium

The right atrial approach for repair of ventricular septal rupture associated with myocardial infarction is an alternative technique to the conventional approach of exposing the septum through the left ventricle. This technique may be combined with mitral valve replacement, infarct excision, or aneurysm resection, by avoiding a direct incision in the ventricle reduce postrepair bleeding and impairment of ventricular contractile function. We present a case of ventricular septal rupture repaired through the right atrium and review our surgical technique. This technique may be applied to most cases of ventricular septal rupture, and is particularly useful when the ventricular wall is not infarcted or aneurysmal, and the defect involves the central portion of the muscular septum, the inlet septum, and the subaortic and membranous area.

Good long-term outcome following surgical repair of post-infarction ventricular septal defect

BACKGROUND

A post-infarction ventricular septal defect (VSD) is a serious complication of a myocardial infarction with 90% of patients dying by two months, in published series. Urgent surgical repair improves the prognosis.

AIMS

To assess the Green Lane Hospital experience over a ten year period, especially with regard to hospital mortality and long-term follow up.

METHODS

A retrospective case note review of all 35 consecutive patients undergoing post-infarct VSD repair from 1981 to 1990. Long-term follow up was obtained in all but one patient (97%).

RESULTS

Twenty-one male and 14 female patients presented with a mean age of 67 years (range 51-75). All were in NYHA class 3 or 4, 14 (40%) were in cardiogenic shock. Following urgent surgical repair, 30 day mortality was 31% (11 patients). A further three patients died at two, 33 and 39 months; one patient was lost to follow up. At a mean follow up of 61 months (range 16-111), 15 patients were in NYHA class 1 or 2, five in NYHA class 3 or 4. For the whole group (n = 35) the actuarial survival was 66% at one year, 62% at three years and 58% at nine years.

CONCLUSION

Post-infarct VSD surgery is of major prognostic benefit with patients obtaining a good long-term outcome.

Postinfarction ventricular septal defect in the elderly: analysis and results

Fifteen elderly patients (age more than 70 years) underwent surgical repair of postinfarction ventricular septal defects during the years 1980 through 1992. The operative (to discharge or < 30 days) mortality rate was 47%, and the complication rate among survivors was 63%. The probability of survival at 1 year was 47% +/- 13%. Because of the small sample size of our patient population, predictive preoperative risk factors associated with early mortality could not be identified with certainty. However, there is a trend suggesting that high right atrial pressures (p = 0.15) and the need of an intraaortic balloon pump preoperatively (p = 0.12) influence 30-day mortality, as previously described in larger series. Of 5 long-term survivors, 3 are in New York Heart Association functional class I and 2 are in class II. Our experience in this group of patients suggests that in the elderly, a very aggressive approach should be taken in recommending early surgical intervention for postinfarction ventricular septal defect before hemodynamic deterioration ensues and severely compromises chances for survival.

Post-myocardial infarction ventricular septal defect: an angiographic study

Clinical and angiographic findings are reported in a consecutive series of nineteen patients with post infarction ventricular septal defect (PIVSD). In all patients PIVSD complicated a first myocardial infarct and none had a history of angina pectoris prior to presentation. In over 50% of the patients PIVSD occurred within three days of infarction. The mean patient age was 65 years. Single vessel disease was noted in 63% of the patients. The mean left ventricular ejection fraction was 27%. Contrast left ventriculography localised the defect in all patients. Although a comprehensive cardiac ultrasound examination will generally confirm the diagnosis of PIVSD, preoperative coronary angiography is essential for the selection of those patients most likely to benefit from concomitant coronary artery bypass grafting at the time of surgical repair of the interventricular septum.

Surgical treatment of postinfarction ventricular septal defect with aortic stenosis

A 69-year-old man with an acute postinfarction ventricular septal defect was also found to have aortic stenosis. Successful management required closure of the postinfarction ventricular septal defect and replacement of the stenotic aortic valve. The contribution of aortic stenosis to the cause of the infarction and the postinfarction ventricular septal defect, as well as the implications for surgical management, are discussed.

Postinfarct ventricular septal defect repair: effect of coronary artery bypass grafting

Between June 1968 and April 1991, 75 patients who had undergone coronary angiography underwent repair of a postinfarction ventricular septal defect. Group 1 (n = 33) includes patients who had two- or three-vessel serious (> 75% narrowing) proximal coronary artery disease and underwent complete revascularization in addition to repair of the ventricular septal defect. Group 2 (n = 19) patients also had two- or three-vessel coronary artery disease but bypass grafting was not performed; only the ventricular defect was repaired. Group 3 (n = 23) patients had only single-vessel coronary artery disease that corresponded to the region of the infarct; they underwent ventricular septal defect repair only. Follow-up of hospital survivors was 96% complete at a mean of 86.2 months (range, 1 to 288 months). Hospital mortality after ventricular septal defect repair was 21.2% in the cohort with bypassed coronary artery disease (group 1), 26.3% in those with unbypassed disease (group 2), and 26.1% in those with only single-vessel coronary artery disease (group 3) (p = 0.88). With follow-up after 5 and 10 years, the actuarial survival was 72.2% +/- 8% and 47.8% +/- 10%, respectively, in the bypassed group, 29.2% +/- 11% and 0%, respectively, in the unbypassed group, and 52.2% +/- 10% and 36.5% +/- 11%, respectively, in the cohort with single-vessel disease. Bypassing associated coronary artery disease significantly increased long-term survival when compared with patients with unbypassed coronary artery disease (p = 0.0015).

Technical improvements in the repair of acute postinfarction ventricular septal rupture

Postinfarction ventricular septal rupture (VSR) is a high-risk complication following myocardial infarction (MI). Surgical treatment has evolved to improve an otherwise poor prognosis. Certain subsets of patients remain a formidable challenge. The presence of cardiogenic shock has consistently been found to have the highest risk. Over a 10-year period, our technique of repair has evolved from established procedures to one we believe confers superior results. Endocardial patching to viable myocardium reinforced with an epicardial patch not only corrects the shunt but maintains ventricular geometry and avoids tension on friable muscle. We report on a series of nine consecutive patients in cardiogenic shock. The operative mortality was 22%, none due to low cardiac output syndrome, shunt recurrence, or bleeding. All patients have been followed with transesophageal echocardiography at a mean period of 14 months (range 3-31 months). One patient is in New York Heart Association (NYHA) Class I, four are in NYHA Class II, and two in NYHA Class III.

Percutaneous transaortic closure of postinfarctional ventricular septal rupture

We report a case of successful closure of a postinfarctional ventricular septal defect by means of the transaortic approach with a balloon catheter. This method brought about substantial improvement in cardiopulmonary function before an elective operation and made it possible to successfully perform the operation on the patient, an 81-year-old woman, on the 22nd day of admission.

Postinfarction ventricular septal defect repair: retrospective thoughts and historical perspectives

Evolution of surgical techniques for repair of postinfarction ventricular septal rupture initially involved differentiation of these lesions from prior experience with surgical approaches to congenital ventricular septal defects, which were in the main not applicable. Second, understanding of the differing anatomical locations of postinfarction ventricular septal defects required innovation in terms of the location of the cardiotomy and type of repair necessary to achieve a successful result in any given patient. The gradual appreciation of different clinical courses pursued by patients after postinfarction ventricular septal rupture both in terms of location of the defect and the degree of right ventricular functional impairment has led to increased urgency relative to the timing of surgical repair. The incorporation of specific anatomical concepts of surgical repair and better understanding of the time course of physiological deterioration of patients can ultimately lead to an integrated approach aimed toward improved salvage of patients suffering this catastrophic complication of acute myocardial infarction.