What is the best timing of surgery in patients with post-infarct ventricular septal rupture?

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'in which patients with a post-infarct ventricular septal rupture (PIVSR) might immediate surgery give better results than delayed surgery in terms of mortality'? Altogether, 88 papers were found using the reported search criteria, of which 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The recommendations are based on outcomes from 3238 patients undergoing surgery for PIVSR. Mean age was 67.5 ± 8.8 (40-88 years). Left ventricular function was compromised in most patients with mean ejection fraction of 40%. All papers carried out univariate and/or multivariate analyses of variables that contributed to different in-hospital mortalities. Early surgery, i.e. from >3 days to within 4 weeks after MI, had an overall in-hospital mortality of 52.4%; delayed surgery, typically from 1 week to after 4 weeks post-myocardial infarction, had an overall operative in-hospital mortality of 7.56%. Most authors observe that a shorter time between rupture and surgery is an unfavourable predictor of outcome independent of haemodynamic status. The consensus was that nearly all patients with PIVSR, particularly if >15 mm diameter with a significant shunt and resultant haemodynamic deterioration, should undergo early surgical repair. The precise timing of surgery depends on patients' haemodynamic status. Exclusion from surgery should be considered if life expectancy or quality is severely limited by another limiting underlying pathology. If the patient is in cardiogenic shock, due to pulmonary to systemic blood flow ratio shunt rather than infarct size, immediate surgery should follow resuscitation measures and cardiac support. If the patient is haemodynamically stable, surgery could be performed after 3-4 weeks of medical optimization with inotropic and mechanical cardiac support. If there is clinical deterioration, immediate surgery is indicated.

Acute Complications of Myocardial Infarction in the Current Era

“…Emergent surgery should be performed if there is clinical deterioration. 73 Mortality is highest in patients with basal septal rupture associated with inferior wall MI (70%, compared with 30% in patients with anterior infarcts). The mortality rate is higher because of increased technical difficulty and the frequent need for mitral valve repair or replacement in the patients with MR. 18 Data about concomitant revascularization along with septal repair are rather controversial; however, revascularization reduces the ischemic burden, increases the collateral blood flow, and should be performed whenever indicated.…”

Incidence and predictors of 30-day mortality in patients with ventricular septal rupture complicating acute myocardial infarction

“…Surgical repair of VSR has an intuitive prognostic impact and is recommended by guideline-writing authorities regardless of haemodynamic stability at the time of diagnosis 5. However, the optimal timing of surgical repair is subject to ongoing debate 6. In addition, pending anatomical feasibility, percutaneous closure of VSR complicating AMI has attracted considerable interest as a valuable and less invasive, alternative procedure to surgery, although mortality remains high 7 8…”

Endovascular treatment of postinfarction ventricular septal defects

“…Перегородка становится более фиброзированной, и в ней развиваются рубцовые изме-нения [9], в связи с чем многие хирурги предпочитают откладывать операцию на несколько недель для обес-печения адекватной аппозиции краев и крепления швов во время операции [19]. То же самое применимо и к эн-доваскулярному вмешательству.…”