Optimal management of acute ventricular septal rupture

Abstract

E ach year in the UK since 1988, an average of 165 patients have undergone surgical repair of interventricular septal rupture complicating myocardial infarction (cardiac surgical registry of the Society of Cardiothoracic Surgeons of Great Britain and Ireland). From each surgeon's viewpoint this operation is a rare event. Given that there are now some 200 or so consultant cardiac surgeons in the UK, the current workload averages out at less than one case per surgeon per year.The overall hospital mortality of patients undergoing surgical repair in the UK in the same time period was 38%. So that it is not only a rare operation but it is also difficult to end up with a survivor. The national figures suggest that hospital mortality has increased with time (fig 1). In addition, in the last five years for which data are available, the number of patients undergoing repair has decreased. These two statistics are almost certainly associated with the increasing use of thrombolytic agents in the management of patients with acute myocardial infarction.So ventricular septal rupture is a rare surgical intervention with a high complication rate. On the other hand, it is a condition that when untreated has such a high mortality 1 that each survivor is something to treasure. This article will attempt to describe best practice and the evidence on which such practice is based. PATHOLOGY cAcute ventricular septal rupture only rarely comes to the attention of each surgeon, but it is a relatively common condition. Before the introduction of thrombolysis it complicated 1-2% of all myocardial infarctions. The incidence has declined to about 0.2% in the thrombolysis era. At this rate, of the 270 000 myocardial infarctions suffered in the UK in 2002, approximately 550 will be complicated by a ventricular septal rupture. Considerably less than 50% of these come to surgery.Ventricular septal rupture results from full thickness infarction of the interventricular septum followed by sufficient necrosis to result in the septal rupture. It is one of the three mechanical complications that can occur following myocardial infarction. The others are free wall rupture, which is usually rapidly fatal, and papillary muscle rupture, which results in sudden onset of mitral regurgitation. The respective frequencies of these complications are in approximate proportion to the respective volumes of muscle that are available to be involved, so that free wall rupture is most common, ventricular septal rupture next, and papillary muscle rupture least.The two pathological types of ventricular rupture are simple and complex. In a simple rupture there is a through and through opening connecting the two ventricles, without gross haemorrhage or laceration and with the right and left ventricular openings at about the same horizontal level of the ventricular septum. A complex rupture is an interventricular communication with a convoluted course, with a tract that might extend into regions remote from the primary acute myocardial infarction site, and with haemorrhage a...

Acute Ischaemic Ventricular Septal Defect—A Formidable Surgical Challenge

“…With time, margins of the VSD become fibrotic making surgical or device closure easier however; medical management alone carries prohibitive mortality. The current incidence of 0.3% of AMI [1] is lower than in the pre-thrombolysis era [3] contributing to falling experience of surgical teams. The high incidence and importance of RV infarction towards poor outcome for patients with AIVSD was elegantly demonstrated by Cummings et al [6].…”

“…Surgical repair is the treatment of choice as medical management has 30 day mortality approaching 100% [1]. Surgical management is characterised by complex repairs with mortality in multicentre reports approaching 50% [2][3][4]. Right ventricular (RV) dysfunction, inferior VSD and shock predict poor outcome.…”

“…Multi centre experience[2,3,9] as seen from the GUSTO trial[1] and Shock trial[4] data has demonstrated an early mortality ranging from 35% to 50%. More recently, mortality in the same range has been demonstrated by Lundblad et al…”

“…comparison, the entire UK registry averages two patients per consultant per year[3]. Multi centre experience[2,3,9] as seen from the GUSTO trial[1] and Shock trial[4] data has demonstrated an early mortality ranging from 35% to 50%.…”

A case of ventricular septal rupture associated with major septal branch occlusion after percutaneous coronary intervention

“…Most patients require surgical intervention because the rupture site can expand abruptly, resulting in sudden hemodynamic collapse [1].We usually observe this complication in the setting of AMI associated with major coronary artery occlusion [2]. However, ventricular septal rupture associated with side branch occlusion due to coronary stenting for stable angina pectoris is uncommon.…”