Prognosis in rupture of the ventricular septum after acute myocardial infarction and role of early surgical intervention

Abstract

Since 1944, 91 patients (50 men and 41 women, mean age 68 years [range 39 to 86]) with ventricular septal rupture after acute myocardial infarction were seen at the Mayo Clinic. Patients were divided into 4 groups according to therapy and timing of surgical intervention. Fourteen patients seen before 1965, when surgery was not performed for such a complication or not readily available, were excluded from the analysis. Group 1 (n = 22) had surgery within 48 hours of septal rupture, group 2 (n = 6) underwent operation between 2 and 14 days, group 3 (n = 24) had surgery after 14 days, and group 4 (n = 25) only received medical treatment. Short-term (30 days) survivors (45%, 35 of 77 patients) were compared with nonsurvivors. Using logistic regression, by univariate analysis, 3 variables were significantly associated with outcome: age (p < 0.01), cardiogenic shock (p < 0.00001), and long delay between ventricular septal rupture and surgical intervention (p < 0.004). By multivariate analysis, however, only cardiogenic shock (p < 0.00001) and age (p < 0.007) correlated with an adverse outcome. In patients with cardiogenic shock after septal rupture, the prognosis was uniformly fatal unless patients undergo early surgery. None of the 23 patients in groups 2, 3 or 4 survived, whereas 5 of 13 patients (38%) who had surgery within 48 hours of septal rupture survived. In patients with congestive heart failure, the long-term outcome was similar among patients who underwent early surgery; 3 of 6 patients (50%) survived compared with 8 of 15 patients (53%) in whom surgery was delayed. In group 4 patients (no surgery), 12 of the 19 patients who were nonsurvivors were in cardiogenic shock and died within 48 hours of septal rupture, but in the remaining 7 patients, death occurred between 3 and 9 days in 5 patients, and at 20 and 30 days in 2 others. Thus, in patients with cardiogenic shock after septal rupture, only those who underwent operation within 48 hours survived; the potential for rapid and unpredictable deterioration in the nonsurgical group and the good surgical results warrant early repair for most patients with ventricular septal defect after acute myocardial infarction.