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

Abstract

Post-infarction ventricular septal rupture (VSR) is a serious complication of myocardial infarction, which, in its natural course or treated medically, is related to high mortality rate. Surgical intervention remains the treatment of choice. Recent studies have shown that delayed surgery is related to better outcomes in comparison with urgent surgery; however, in many studies the impact of the patients’ initial hemodynamic status on the treatment outcomes often remains unclear. In this review, we analyze the outcomes of delayed surgical treatment of patients in cardiogenic shock in the course of post-infarction ventricular septal defect stabilized with preoperative use of mechanical circulatory support. We evaluate the importance of various types of mechanical circulatory devices (MCD), such as extracorporeal membrane oxygenation, Tandem Heart, Impella, and intra-aortic baloon pump (IABP) in preoperative stabilization of patients, and the most suitable time for surgery, and we also present the features of ideal MCD for patients with VSR. A search of Pubmed to identify studies concerning the use of MCD in patients in cardiogenic shock in the course of VSR qualified for delayed surgery was conducted in January 2022. A total of 16 articles with three or more patients described were analyzed in this study. The preoperative use of MCD in patients in cardiogenic shock and delayed surgery as a main part of treatment seems to be a promising direction, however, it requires further research.

Intra-aortic balloon pump still has a role in late-onset myocardial infarction complicated by ventricular septal rupture with intractable heart failure: a case report

“…Compensatory increase in systemic vascular resistance, thus the LV afterload, leads to an even more rigorous left-to-right shunt [ 18 ]. The management should be directed at reducing the vicious left-to-right shunt with afterload-reducing pharmacological agents and MCSs [ 9 , 14 ]. Inotropes and vasopressors may worsen left-to-right shunting, whereas vasodilators decrease shunting at the expense of hypotension [ 19 ].…”

“…Its application results in a significant reduction in left-to-right shunt volume and shunt flow ratio, with a concomitant increase in effective systemic CO [ 20 ]. These outcomes are mainly achieved from afterload reduction [ 14 , 21 ]. IABP also increases coronary perfusion and decreases myocardial oxygen consumption.…”

“…However, delayed surgical strategy may be considered in patients who respond well to heart failure therapy, allowing infarcted tissue maturation for better surgical outcomes [ 8 , 13 ]. Preoperative optimization of the already poor cardiac function and hemodynamic status during the deferred period is a serious challenge [ 14 ]. Various types of MCS have been shown to be feasible and effective during the preoperative period [ 15 – 17 ].…”

Intra-Aortic Balloon Pump Support in Patients with Acute Myocardial Infarction with Ventricular Septal Rupture

“…mortality for VSR surgery remain controversial, and better outcomes have been reported with delayed surgery. Mechanical circulatory support (MCS) strategies now offer new opportunities to achieve hemodynamic stabilization in patients in more critical condition, thus allowing for delayed surgery and potentially contributing to improved survival [2]. An intra-aortic balloon pump (IABP) is the most frequently used device as a bridge to surgical repair and is recommended by guidelines (class IIa, level C) in cases of mechanical complications of myocardial infarction [3].…”