Abstract
ObjectiveThe study aimed to identify the factors affecting the prognosis of post myocardial infarction (MI) ventricular septal rupture (VSR) and to develop a protocol for its management.MethodsThis was a single center, retrospective-prospective study (2009-2014), involving 55 patients with post MI VSR. The strengths of association between risk factors and prognosis were assessed using multivariate logistic regression analysis. The UNM Post MI VSR management and prognosis scoring systems (UPMS & UPPS) were developed.ResultsThirty-day mortality was 52.5% (35% in the last 3 years). Twenty-eight (70%) patients underwent concomitant coronary artery bypass grafting. Residual ventricular septal defect was found in 3 (7.5%) patients. The multivariate analysis showed low mean blood pressure with intra-aortic balloon pump (OR 11.43, P=0.001), higher EuroSCORE II (OR 7.47, P=0.006), higher Killip class (OR 27.95, P=0.00), and shorter intervals between MI and VSR (OR 7.90, P=0.005) as well as VSR and Surgery (OR 5.76, P=0.016) to be strong predictors of mortality. Concomitant coronary artery bypass grafting (P=0.17) and location (P=0.25) of VSR did not affect the outcome. Mean follow-up was 635.8±472.5 days and 17 out of 19 discharged patients were in NYHA class I-II.ConclusionThe UNM Post-MI VSR Scoring Systems (UPMS & UPPS) help in management and prognosis, respectively. They divide patients into 3 groups: 1) Immediate Surgery - Patients with scores of <25 require immediate surgery, preferably with extracorporeal membrane oxygenation support, and have poor prognosis; 2) Those with scores of 25-75 should be managed with "Optimal Delay" and they have intermediate outcomes; 3) Patients with scores of >75 can undergo Elective Repair and they are likely to have good outcomes.
Highlights
In spite of advances in surgical techniques, surgical repair of post myocardial infarction (MI) ventricular septal rupture (VSR) is still associated with a high mortality rate of 20%50%[1,2,3]
This phenomenon has been documented by Labrousse et al.[2] and GUSTO-I trial[4], which suggest that cardiologists themselves decide about suitability of patients for surgery, leading to fewer patients being referred for surgery
We found that single vessel disease (45%) was the most common type of coronary artery disease associated with post-MI VSR, followed by double vessel disease (37.5%)
Summary
In spite of advances in surgical techniques, surgical repair of post myocardial infarction (MI) ventricular septal rupture (VSR) (post-MI VSR) is still associated with a high mortality rate of 20%50%[1,2,3]. The available literature is very scant and scattered due to the rarity, discrepancy in clinical presentation, and complex natural history of the condition[9]. Due to advances in interventional cardiology, extracorporeal membrane oxygenation (ECMO) and intensive care unit (ICU) care, a multitude of options have become available to the ‘heart team’ to do either an immediate surgery or delay/defer surgery. Objective guidelines for proper management of this entity are still not available due to the relative rarity of this highly fatal condition
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