Surgical Treatment of Postinfarction Ventricular Septal Rupture

Abstract

IMPORTANCE Ventricular septal rupture (VSR) is a rare but life-threatening mechanical complication of acute myocardial infarction associated with high mortality despite prompt treatment. Surgery represents the standard of care; however, only small single-center series or national registries are usually available in literature, whereas international multicenter investigations have been poorly carried out, therefore limiting the evidence on this topic. OBJECTIVESTo assess the clinical characteristics and early outcomes for patients who received surgery for postinfarction VSR and to identify factors independently associated with mortality. DESIGN, SETTING, AND PARTICIPANTS The Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort (CAUTION) Study is a retrospective multicenter international cohort study that includes patients who were treated surgically for mechanical complications of acute myocardial infarction. The study was conducted from January 2001 to December 2019 at 26 different centers worldwide among 475 consecutive patients who underwent surgery for postinfarction VSR. EXPOSURES Surgical treatment of postinfarction VSR, independent of the technique, alone or combined with other procedures (eg, coronary artery bypass grafting). MAIN OUTCOMES AND MEASURESThe primary outcome was early mortality; secondary outcomes were postoperative complications. RESULTSOf the 475 patients included in the study, 290 (61.1%) were men, with a mean (SD) age of 68.5 (10.1) years. Cardiogenic shock was present in 213 patients (44.8%). Emergent or salvage surgery was performed in 212 cases (44.6%). The early mortality rate was 40.4% (192 patients), and it did not improve during the nearly 20 years considered for the study (median [IQR] yearly mortality, 41.7% [32.6%-50.0%]). Low cardiac output syndrome and multiorgan failure were the most common causes of death (low cardiac output syndrome, 70 [36.5%]; multiorgan failure, 53 [27.6%]). Recurrent VSR occurred in 59 participants (12.4%) but was not associated with mortality. Cardiogenic shock (survived: 95 [33.6%]; died, 118 [61.5%]; P < .001) and early surgery (time to surgery Ն7 days, survived: 105 [57.4%]; died, 47 [35.1%]; P < .001) were associated with lower survival. At multivariate analysis, older age (odds ratio [

Effects of concomitant coronary artery bypass grafting on early and late mortality in the treatment of post-infarction mechanical complications: a systematic review and meta-analysis

“…Most studies included in our meta-analysis showed no difference in early mortality between CABG and non-CABG groups, while some authors reported a better survival for patients undergoing CABG (6,14,40,54,62). Takahashi et al observed a higher early mortality for patients undergoing cCABG, explaining such results with a more severe CAD and ventricular dysfunction in that group of patients (43).…”

“…When cardiac rupture occurs, it's not always possible to perform PCI nor just coronarography either, thereby precluding any possibility of surgical revascularization (20,24,54). Indeed, most patients with post-AMI mechanical complications are admitted to hospital in poor hemodynamic conditions or even in cardiac arrest, as demonstrated by the 58.2% of subjects developing cardiogenic shock preoperatively and by the 64.3% and 8.6% requiring IABP and ECMO support, respectively (6,18,26,30,41,44).…”

Postinfarction ventricular septal rupture repair: Is it just a matter of the surgical technique?

“… 1 , 3 In fact, while most studies traditionally reported in‐hospital mortality ranging from 20% to 60%, as confirmed by the recently published results from the CAUTION multicenter study, where early mortality among 475 patients was 40.4%, their observed rate of in‐hospital deaths was 26.5%. 4 The series by Belyaev et al has several peculiarities which deserve specific comments and analysis. Indeed, only five patients presented a nonhemodynamically significant postoperative rVSR, with two of them dying during hospitalization, and one patient required emergent reoperation due to hemodynamically relevant rVSR.…”

“…Despite some studies reporting an rVSR rate as high as 40%, the relatively low incidence of VSR recurrence observed by Belyaev et al is not far from the 12.9% reported in the CAUTION study, where, however, almost half of patients required reoperation, although not impacting on in‐hospital mortality. 4 , 5 , 6 Nevertheless, while all the patients considered for this paper underwent a repair through the “double‐patch frame” technique, in the population considered in the CAUTION study a quite variable set of techniques was adopted. 1 , 4 …”

“… 4 , 5 , 6 Nevertheless, while all the patients considered for this paper underwent a repair through the “double‐patch frame” technique, in the population considered in the CAUTION study a quite variable set of techniques was adopted. 1 , 4 …”