Retrospective Analysis of Surgical Treatment Results of Postinfarction Ventricular Septal Rupture
Ventricular septal rupture (VSR) is the most dramatic complication of acute myocardial infarction (MI). It manifests itself most often in the first week after infarction, with the maximum fatal complications occurring on day 1 and day 3–5 after MI. Patients receiving conservative treatment mostly die of progressive heart failure within few hours or days. Even now, in the era of endovascular interventions, surgical treatment remains the gold standard for the treatment of this pa-thology. Our research is mainly aimed at studying the factors of operative mortality, describing our methods of treatment and analyzing the survival rate and long-term outcomes after surgical treatment of this pathology.
We studied 90 patients with postinfarction VSR who underwent surgical intervention in 2002–2019. Twelve of them were operated at the Central Clinical Hospital in Baku, and 78 at the National Amosov Institute of Cardiovascular Surgery in Ukraine. The mean age of the patients was 59.9 ± 9.59 years, 65 (72.2%) were men and 25 (27.8 %) were women. Fifteen (16.6%) patients were smokers, 31 (34.4%) were diabetic, 70 (77.7%) patients had arterial hypertension, 62% of patients had NYHA class III heart failure with average ejection fraction of 43.9 ± 10.4%. According to the results of coronary angiography, single vessel stenosis of the coronary arteries was detected in 18 (20%), two-vessel lesion in 32 (35.5%), and three-vessel lesion in 40 (44.4%) patients. There were no patients with left main coronary artery (LMCA) stenosis.
Long-term results of surgical treatment were followed for 1 to 8 years, on average in 18 (28.6%) patients. Within 1, 3 and 8 years 17, 12 and 2 patients were examined, respectively. Good results within 5 and 10 years after surgical treatment were observed in 87.5% and 64.3% patients, respectively.
Repeated complaints in our group and those observed in the literature are associated with worsening of heart failure after venticulotomy and changes in the geometry of the left ventricle.
Recurrence of heart failure and coronary symptoms within 3 years and after 3 to 8 years were observed in 6 (33.3%) and 3 (25%) patients, respectively. Repeated endovascular revascularization was performed in 5 patients. ICD was im-planted in 4 patients, and in 2 patients CRT-D was implanted within 4 years 2 months and 7 years, respectively.
There were no hemorrhagic complications within 8 years. Four (22.2%) patients died in the long-term period, the cause of death was unknown.
In intensive care department the treatment strategy suggested hemodynamic stabilization with the help of conserva-tive therapy and IABP.
The patients who underwent surgery in ≥ 3 weeks after the diagnosis of postinfarction VSR survived within 30 days after surgery. Delayed planned recovery is stipulated by the formation of scar tissue in the myocardium, which enables to facilitate the technical aspects of recovery. The time of the operation depends mainly on hemodynamic status of the patient. Patients with cardiogenic shock should undergo immediate surgical treatment.
- World Health Organization [Internet]. Geneva: WHO; c2020 [cited 2020 Nov 17]. Cardiovascular diseases (CVDs); [about 1 screen]. Available from: https://www.who.int/ru/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)
- lshibaya MM, Mamalyga ML, Gagloeva AS, Ly-syy RN. [Correction of multiple postinfarction interventricular septum rupture]. The Bulletin of Bak-oulev Center. 2020;21(1):72-76. Russian. https://doi.org/10.24022/1810-0694-2020-21-1-72-76
- French JK, Hellkamp AS, Armstrong PW, Cohen E, Klei-man NS, O’Connor CM, et al. Mechanical complications after percutaneous coronary intervention in ST-eleva-tion myocardial infarction (from APEX-AMI). Am J Car-diol. 2010;105(1):59-63. https://doi.org/10.1016/j.amj-card.2009.08.653
- Crenshaw BS, Granger CB, Birnbaum Y, Pieper KS, Morris DC, Kleiman NS, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect compli-cating acute myocardial infarction. GUSTO-I (Global Utiliza-tion of Streptokinase and TPA for Occluded Coronary Arter-ies) Trial Investigators. Circulation. 2000 Jan 4-11;101(1):27-32. https://doi.org/10.1161/01.cir.101.1.27
- Khelimskiy DA, Krestyaninov OV, Osiev AG, Shermuk AA, Grankin DS, Kretov EI, et al. [Endovascular treatment of postinfarction ventricular septal defects]. Circulation Pa-thology and Cardiac Surgery. 2016;20(2):80-6. Russian. https://doi.org/10.21688-1681-3472-2016-2-80-86
- Daggett WM, Guyton RA, Mundth ED, Buckley MJ, McEnany MT, Gold HK, et al. Surgery for post-myocardial infarct ventricular septal defect. Ann Surg. 1977;186(3):260-71. https://doi.org/10.1097/00000658-197709000-00004
- David TE, Dale L, Sun Z. Postinfarction ventricular septal rupture: repair by endocardial patch with infarct exclu-sion. J Thorac Cardiovasc Surg. 1995 Nov;110(5):1315-22. https://doi.org/10.1016/S0022-5223(95)70054-4
- Dor V, Saab M, Coste P, Kornaszewska M, Montiglio F. Left ventricular aneurysm: A new surgical approach. Thorac Cardiovasc Surg 1989;37(1):11-9. https://doi.org/10.1055/s-2007-1013899
- Cooley DA, Belmonte BA, Zeis LB, Schnur S. Surgical repair of ruptured interventricular septum following acute myocardial infarction. Surgery. 1957;41(6):930-7. PMID: 13442860.
- Arnaoutakis GJ, Zhao Y, George TJ, Sciortino CM, McCarthy PM, Conte JV. Surgical repair of ventricular septal defect after myocardial infarction: outcomes from the Society of Thoracic Surgeons National Database. Ann Thoracic Surg. 2012;94(2):436-443. https://doi.org/10.1016/j.athorac-sur.2012.04.020
- Labrousse L, Choukroun E, Chevalier JM, Madonna F, Robertie F, Merlico F, et al. Surgery for post infarction ventricular septal defect (VSD): risk factors for hospital death and long term results. Eur J Cardiothorac Surg. 2002 Apr;21(4):725-31; discussion 731-2. https://doi.org/10.1016/s1010-7940(02)00054-4
- Hartley A, Marshall DC, Salciccioli JD, Sikkel MB, Maruthappu M. Trends in mortality from ischemic heart disease and cerebrovascular disease in Europe: 1980 to 2009. Circulation. 2016;133(20):1916-26. https://doi.org/10.1161/CIRCULATIONAHA.115.018931
- Takahashi H, Arif R, Almashhoor A, Ruhparwar A, Karck M, Kallenbach K. Long-term results after surgical treatment of postinfarction ventricular septal rupture. European Journal of Cardio-Thoracic Surgery. 2015 Apr;47(4):720-4. https://doi.org/10.1093/ejcts/ezu248
- Huang SM, Huang SC, Wang CH, Wu IH, Chi NH, Yu HY, et al. Risk factors and outcome analysis after surgical management of ventricular septal rupture complicating acute myocardial infarction: a retrospective analysis. J Cardiothorac Surg. 2015;10:66. https://doi.org/10.1186/s13019-015-0265-2
- David TE, Armstrong S. Surgical repair of postinfarction ventricular septal defect by infarct exclusion. Semin Tho-rac Cardiovasc Surg. 1998;10(2):105-10. https://doi.org/10.1016/s1043-0679(98)70003-6
- Deville C, Fontan F, Chevalier JM, Madonna F, Ebner A, Besse P. Surgery of post-infarction ventricular septal defect: risk factors for hospital death and long-term results. Eur J Cardiothorac Surg. 1991;5(4):167-75. https://doi.org/10.1016/1010-7940(91)90026-g
- Deja MA, Szostek J, Widenka K, Szafron B, Spyt TJ, Hickey MS, et al. Post infarction ventricular septal defect - can we do better? Eur J Cardiothorac Surg. 2000;18(2):194-201. https://doi.org/10.1016/s1010-7940(00)00482-6
- Jeppsson A, Liden H, Johnsson P, Hartford M, Rådegran K. Surgical repair of post infarction ventricular septal defects: A national experience. Eur J Cardiothorac Surg. 2005;27(2):216-21. https://doi.org/10.1016/j.ejcts.2004.10.037