Septal rupture after myocardial infarction: is very early surgery really worthwhile?

Optimal Time Repair of Ventricular Septal Rupture Post Myocardial Infarction

Ventricular septal rupture (VSR) is an uncommon complication of myocardial infarction (MI). The mortality rate of VSR is high. The management of VSR is including the stabilization of the hemodynamic status and surgical closure of the rupture. In spite of the agreement of experts on the necessity of surgical repair, the timing of VSR repair management remains unclear. In this review article, we evaluate the optimal time repair of VSR. To collect the data, Pubmed, EMBASE, and Cochrane Central Registry databases were searched for potentially suitable studies. Search terms were including “Ventricular Septal Rupture”, “Myocardial Infarction”, “Timing”, and “MI”. According to the result of the studies, it seems that the time between VSR detection and its repair is a determining factor in the survival or mortality of patients in post-myocardial infraction VSR. Studies showed that earlier surgical repair in VSR increases the risk of mortality, because in the early phase after MI, infarcted myocardium is very fragile, and it is very difficult surgical repair and increases the risk of recurrent septal defects. The longer time is needed for the heart and different body systems to adapt to the hemodynamic results of the abrupt left to right shunt. It seems that the best time for the operation is after the maturation of VSR with scarring at the edges of the defect. Moreover, in a large number of patients, it is not possible to delay the operation since they are at risk of severe heart failure and organ dysfunction. In these cases operation immediately after diagnosis of VSR is recommended to prevent further hemodynamic deterioration. In hemodynamically compromised patients, it may be considered to use a ventricular assist device, requiring an intra-aortic balloon pump (IABP), or extracorporeal membrane oxygenation (ECMO) preoperative to postpone the operation which leads to higher survival in post-MI-VSD.

Early repair of postinfarction ventricular septal rupture

BACKGROUND

Postinfarction rupture of the interventricular septum is usually fatal without surgical intervention. The optimal timing and the most appropriate technique of surgical repair remain unsettled.

METHODS

The results of surgical closure of postinfarction ventricular septal defect in a consecutive series of patients seen over a 24-year period were reviewed and analyzed. Late follow-up was obtained in all patients who survived the operation.

RESULTS

Sixty of 76 patients treated surgically exhibited cardiogenic shock, low cardiac output syndrome, or both at the time of operation. A plan of early operative intervention was followed in these unstable patients, with 60% of them undergoing repair within 24 hours of septal rupture. For the entire series of patients, the hospital mortality rate was 40.8%; survival was 41.5% at 5 years and 25.6% at 10 years postoperatively.

CONCLUSIONS

Significant trends observed during the period of study were a more aggressive stance regarding surgical intervention in all patients who presented with hemodynamic instability and improved survival in those patients who presented with septal rupture complicating an inferior myocardial infarction.

Myocardial rupture after myocardial infarction is related to the perfusion status of the infarct-related coronary artery

Acute or subacute myocardial rupture is a serious and often lethal complication of acute myocardial infarction. The role of an occluded or open culprit coronary artery on the occurrence of this complication is not clear. We therefore reviewed the perfusion status of the infarct-related coronary artery retrospectively in 57 patients who had an initially nonfatal rupture (group A) and 28 patients (including 9 patients from group A) with a postmortem diagnosis of myocardial rupture (group B). In 35 of the 57 patients in group A, a coronary angiogram was available. Complete occlusion or ineffective reperfusion was present in 30 (89%) of 35 patients. The remaining 22 patients of group A showed no clinical signs of reperfusion. All 28 patients of group B had inadequate reperfusion of the infarcted area on postmortem angiography and macroscopic examination of the coronary artery. Our observations suggest that myocardial rupture typically occurs in an infarcted area without reperfusion.