EReply. Re: Percutaneous closure of post-myocardial infarction septal defect

Abstract

We thank Hajj-Chahine et al. for the the eComment on the topic of 'What is the best timing of surgery in patients with post-infarct ventricular septal rupture?' [1-2] Contrary to what the authors conclude, the message from the published review on the management of post-infarction ventricular septal rupture (PIVSR) is clear, 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. Additionally we state, If there is clinical deterioration, immediate surgery is indicated. The data from the literature suggests that the only clinical scenario for which one can delay surgery is in patients with complete haemodynamic stability (a small cohort for this condition), where the outcomes of surgery are demonstrably better as scar tissue at infarct site is matured to allow durable repair. This subgroup invariably involves haemodynamically stable patients with multiple co-morbidities and a high-risk of operative death. At 2-3 weeks a lower-risk elective procedure can be performed that allows myocardial scar tissue to form facilitating PIVSR repair. This group can only be judged on a case-by-case basis by the heart team for the most optimal intervention and its timing. Additionally the authors should note that the guidelines were published in 2004 [3]. Three out of the six papers we based our conclusions on were published since the guidelines. The largest one of this is the series by Arnoutakis et al. that analysed outcomes in 2876 patients from the STS national database where operative mortality was 54.1% if they were operated on within 7 days from acute myocardial infarction and 18.4% if the repair took place after that. As the time interval between AMI and PIVSR repair became longer, the odds of dying became progressively lower (<6 h: odds ratio [OR] = 6.18; 6-24 h: OR = 5.53; 1-7 days: OR = 4.59; 8-21 days: OR = 2.37, all P <0.01) [4]. With regard to the transcatheter options in such patients we have previously published a BET review on this topic that specifically asked, Which patients might be suitable for a septal occluder device closure of postinfarction ventricular septal rupture rather than immediate surgery? [5]. In addition to the case reports mentioned by Hajj-Chahine et al. the current published cases of percutaneous closure of PIVSR rupture stand at less than 150. These repairs fail for the same reason as surgical failures and the outcomes are not necessarily improved. Procedure-related complications included major residual shunting, left ventricular rupture and device embolization, occurring in up to 41% of patients [5]. Despite the minimally invasive nature of transcatheter techniques, mortality was very high, mainly attributed to disease severity and comorbidities. At present early definitive surgical correction remains the gold standard for PIVSR. Transcatheter techniques have a role in selected patients with simple defects that are 3.5 weeks post AMI) setting where an Amplatzer device may provide definitive treatment. In some patients who are too unwell to be expected to survive an operation, an Amplatzer device may provide stabilization before urgent surgery is undertaken [5]. Conflict of interest: none declared