Mechanical circulatory support for early surgical repair of postinfarction ventricular septal defect with cardiogenic shock

Abstract

Postinfarction ventricular septal defect (pVSD) due to acute myocardial infarction complicated by cardiogenic shock (CS) is associated with high mortality. The aim of this study was to determine the outcome of primary surgical repair of pVSD in patients with CS and examine whether it is influenced by the use of mechanical circulatory support (MCS) devices. Between October 1994 and April 2016, primary surgical repair of pVSD complicated by CS was performed in 53 patients. Thirty‐six (68%) were implanted pre‐operatively with an intra‐aortic balloon pump (IABP), 4 (8%) with extracorporeal life support (ECLS), and 13 (24%) received no MCS device. Prospectively collected demographic and perioperative data were analyzed retrospectively. All‐cause, 30‐day mortality rates were analyzed and multivariate analysis was performed to differentiate independent risk factors. No pre‐operatively implanted MCS device was able to improve 30‐day survival, whereas pre‐operatively implanted ECLS tended to have a positive effect (P = .106). The post‐operative need for a MCS device or escalation of MCS invasiveness (IABP upgrade to ECLS) was associated with a higher 30‐day mortality (P = .001) compared with patients without any MCS device or those with pre‐operatively implanted MCS devices. An independent risk factor for 30‐day mortality was the interval between acute myocardial infarction and surgery <7 days (OR 5.895, CI 1.615‐21.515; P = .007). Pre‐operative implantation of ECLS for CS tends to improve the outcome of early primary surgical pVSD repair. The need for a post‐operative MCS device is associated with a worse 30‐day survival after early primary surgical pVSD repair.

Surgical outcomes of post‐infarct ventricular septal defect repair: Insights from the UK national adult cardiac surgery audit database

“…This is consistent with what was reported by Vondran et. al 14 . who recently investigated the role of mechanical support in 53 patients with VSD and cardiogenic shock and found that use of preoperative IABP was not of further benefit for patients waiting for surgery.…”

Mechanical Circulatory Support in Delayed Surgery of Post-Infarction Ventricular Septal Rupture in Patients in Cardiogenic Shock—A Review

“…After analyzing the data on 53 patients with post-infarcted ventricular septal defect complicated by cardiogenic shock, Vondran et al found that the time from infarction to surgery was the predictor of mortality in the 30-day observation [ 14 ]. Performing surgery up to 7 days after the infarction is associated with worse results (OR 5.894; p = 0.007); preoperative use of IABP does not reduce mortality rate (of the 36 patients, 16 survived) whereas preoperative use of ECMO tends to improve the early survival rate among patients with post-infarction VSD (used in four patients, three of whom survived).…”

“…Several publications do not provide data relevant for this review. Some studies reveal incomplete data concerning duration of mechanical circulatory support without precise distinction on pre- and postoperative use of MCS (Mateucci et al [ 41 ], Huang et al [ 40 ], Ronco et al [ 38 ], Rob et al [ 39 ], Vondran et al [ 14 ]) and, in some cases, the temporal possibilities of postponing the surgery. In addition, some retrospective studies include patients not only with VSR but also with other mechanical complications of myocardial infarction (Mateuci et al [ 41 ], Fujimoto et al [ 42 ]).…”

“…Surgical intervention remains the treatment of choice, with a mortality rate ranging from 20 to 88%, depending on initial hemodynamic status [ 11 , 14 , 15 ]. There is no agreement concerning optimal time of cardiac surgery [ 15 ].…”

Incidence, management, and prognosis of post-ischaemic ventricular septal defect: Insights from a 12-year tertiary centre experience

“…During this time frame, physicians should be able to stabilize the patient's hemodynamics, correct any organ failure, and unload the ventricles in order to promote myocardial recovery before VSD correction. Acute mechanical circulatory support (aMCS) is thus often discussed for this purpose; however, the type and timing of its deployment are still a matter of debate ( 10 ).…”