Repair Of Ventricular Septal Rupture Research Articles

Delayed ventricular septal rupture complicated with ventricular aneurysm in a case of myocardial infarction with non-obstructive coronary arteries

BackgroundMyocardial infarction with non-obstructive coronary arteries (MINOCA) is a rare cause of heart attack, which may not receive sufficient attention from patients during post-discharge treatment, especially among those with normal coronary angiography results.Case presentationWe present the case of a 65-year-old woman who was readmitted to the hospital with ventricular septal rupture (VSR) complicated by ventricular aneurysm, occurring 2 weeks after myocardial infarction. During the initial admission, coronary angiography revealed normal coronary arteries, leading to a diagnosis of MINOCA. Epicardial coronary vasospasm or coronary embolism was considered as potential causes; however, the patient did not adhere to standardized treatment upon initial discharge. The delayed VSR led to a decline in cardiac function but did not result in severe hemodynamic impairment. Following correction of heart failure with medications, the patient underwent percutaneous VSR repair 19 days after diagnosis and was discharged with a favorable recovery.ConclusionsThe occurrence of delayed VSR complicated with ventricular aneurysm in patients with MINOCA is rare, highlighting the possibility of serious complications in MINOCA cases. Both cardioprotective therapies and cause-targeted therapies are essential in the management of patients with MINOCA.

Effect of Delayed Surgery for Ventricular Septal Rupture on Postoperative Outcomes.

The prognosis of ventricular septal rupture (VSR) after acute myocardial infarction remains poor; hence, surgical repair is essential. However, the appropriate timing for surgical intervention remains unclear. We aimed to compare the prognosis between early (<96 hours) and delayed (≥96 hours) surgery for VSR. This single-center, retrospective cohort study used data from 49 patients who underwent VSR repair after acute myocardial infarction (AMI) between 2007 and 2022 at our institution. In-hospital and one-, three-, and 10-year mortality and major adverse cardiac and cerebrovascular events were compared between the early (group A) and delayed (group B) surgery after AMI. No significant differences were found between the patients' backgrounds of the two groups. The in-hospital mortality rates were 37.5 and 16.0% for groups A and B, respectively (P = 0.114). The overall survival rates estimated using Kaplan-Meier analysis were 66.5 ± 6.9, 58.2 ± 7.5, and 28.8 ± 10.6% after one, three, and 10 years, respectively. The mortality rates in group B at three (hazard risk ratio: 2.691; 95% confidence interval: 1.02-7.097) and 10 (hazard risk ratio: 2.575; 95% confidence interval: 1.125-5.891) years were significantly better than those in group A. Major adverse cardiac and cerebrovascular events were significantly different between the two groups at all time points. These results showed that patients who underwent surgery for VSR 96 hours afterAMI had better long-term survival than those who underwent surgery within 96 hours.

Left ventricular unloading therapy using Impella 5.5 after emergency surgery for acute myocardial infarction mechanical complication: a case report

BackgroundFollowing an acute myocardial infarction (AMI), surgery for left ventricular free wall rupture (LVFWR) and ventricular septal rupture (VSR) has a high in-hospital mortality rate, which has not improved significantly over time. Unloading the LV is critical to preventing excessive stress on the repair site and avoiding problems such as bleeding, leaks, patch dehiscence, and recurrence of LVFWR and VSR because the tissue is so fragile. We present two cases of patients who used Impella 5.5 for LV unloading following emergency surgery for AMI mechanical complications.Case presentationA 76-year-old male STEMI patient underwent fibrinolysis of the distal right coronary artery. Three days later, he passed out and went into shock. Echocardiography revealed a cardiac tamponade. We found an oozing-type LVFWR on the posterolateral wall and treated it with a non-suture technique using TachoSil. Before the patient was taken off CPB, Impella 5.5 was inserted into the LV via a 10 mm synthetic graft connected to the right axillary artery. We kept the flow rate above 4.0 to 4.5 L/min until POD 3 to reduce LV wall tension while minimizing pulsatility. On POD 6, we weaned the patient from Impella 5.5. A postoperative cardiac CT scan showed no contrast leakage from the LV. However, a cerebral hemorrhage on POD 4 during heparin administration complicated his hospitalization. Case 2: A diagnosis of cardiogenic shock caused by STEMI occurred in an 84-year-old male patient, who underwent PCI of the LAD with IABP support. Three days after PCI, echocardiography revealed VSR, and the patient underwent emergency VSR repair with two separate patches and BioGlue applied to the suture line between them. Before weaning from CPB, we implanted Impella 5.5 in the LV and added venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for right heart failure. The postoperative echocardiography revealed no residual shunt.ConclusionsPatients undergoing emergency surgery for mechanical complications of AMI may find Impella 5.5 to be an effective tool for LV unloading. The use of VA-ECMO in conjunction with Impella may be an effective strategy for managing VSR associated with concurrent right-sided heart failure.

Abstract 16172: Impella Use in Large Post-Infarct Ventricular Septal Rupture

Background: Ventricular Septal Rupture (VSR) is a deleterious complication associated with myocardial infarction (MI). The most common form of mechanical circulatory support (MCS) utilized in post-MI complications is intra-aortic balloon pump (IABP). Impella is a far less commonly used modality as there is the potential for right-to-left shunting and a chance of mechanical perforation of the heart. Below is a case where an Impella 5.5 catheter was necessary to bridge a patient for surgical repair. Case presentation: A 76-year-old male patient presented to an outside hospital with an acute inferior ST-elevation myocardial infarction. He was treated with thrombolysis and was emergently taken to the catheterization lab where he underwent stenting of his RCA with plan to medically manage his non-culprit disease. His hospital course was complicated by cardiogenic shock with an echocardiogram that demonstrated a large VSR (Figure 1). A right heart catheterization demonstrated a significant left-to-right shunt (Qp/Qs ratio of 6:1) which necessitated mechanical support with an IABP as per standard of care. Post-IABP his Qp/Qs ratio improved to 1.6:1 but he continued to be under supported and remained in cardiogenic shock. Surgical repair of the VSR was planned for 1-week post-MI so he was transitioned to an Impella 5.5 catheter in order to stabilize and bridge him for surgery. Patient underwent surgical VSR repair and CABG on hospital day 7. Post-op he did well and was later discharged to rehabilitation center with subsequent recovery. Conclusions: If properly managed, utilization of an Impella catheter can be an effective tool to stabilize patients in post-MI VSR with refractory cardiogenic shock and bridge patients towards surgical repair. It is particularly effective when additional MCS support is required beyond the contemporary IABP and it can be used to stabilize patients for longer durations to ultimately avoid emergent surgery.

Advent of severe mitral regurgitation in surgical ventricular restoration and ventricular septal rupture repair

BackgroundPer-procedural severe mitral regurgitation is a rare complication in concomitant surgical ventricular restoration and postinfarction ventricular septal rupture repair. It is challenging to discover the underlying etiology and adopt an appropriate strategy, in particular, in a high-risk patient.Case presentationSemi-emergent surgical ventricular restoration combined with ventricular septal rupture closure and coronary artery bypassing was performed in a 67-year-old male patient. Severe mitral regurgitation was detected after the weaning of cardiopulmonary bypass. Two key questions arose in the management of this condition: did the regurgitation exist previously and was dissimulated by significant left-to-right shunt, or it occurred secondarily to the Dor procedure? Which was the better management strategy, chordal-sparing mitral valve replacement or mitral plasty? We believed that severe mitral regurgitation was under-estimated pre-operatively and we performed an downsizing annuloplasty to treat mitral regurgitation. The outcomes were promising and the patient did well in follow-up.ConclusionsOur case brought out an open discussion on the etiology and therapeutic strategies of this complicated condition.

Timing of repair of ischemic ventricular septal rupture; results of early vs. late repair

Background: The optimal time to repair ischemic ventricular septal rupture (VSR) is debatable. We compared the outcomes, including operative mortality, between patients who underwent early vs. late VSR repair.&#x0D; Methods: Twenty-eight patients presented with VSR were included in this study. Patients were grouped according to the timing of repair into two groups; the early repair group (n= 12) and the late repair group (n= 16). The primary endpoint was operative mortality.&#x0D; Results: There was no difference in age, gender, and associated comorbidities between between early and late repair. Anteroapical VSR was the most common type in both groups. There was no difference in the number of bypass grafts in both groups. Ischemic (95 (88- 142.5) vs. 137 (120- 147.5) min; P= 0.028) and cardiopulmonary bypass times (123.5 (115.5- 177.5) vs. 172.5 (152.5- 185) min; P= 0.023) were significantly shorter in patients who had delayed repair. Nine patients (75%) had operative mortality in the early repair group versus three patients (18.75%) in the late repair group (P= 0.006). There were no differences in blood loss, stroke, wound infection, ICU, and ward stay among the surviving patients.&#x0D; Conclusion: Delayed repair of ischemic ventricular septal rupture could be associated with lower mortality in properly selected patients. Additionally, the delayed repair could decrease the ischemic and cardiopulmonary bypass times.

Early surgical outcomes of a modified infarct exclusion technique in acute post-myocardial infarction ventricular septal rupture: a single-centre experience.

Operative mortality in an acute post-myocardial infarction (AMI) ventricular septal rupture (VSR) is high. In addition to ventricular dysfunction, friable myocardium adds to the technical difficulty of the operation. In a modified infarct exclusion technique, the right ventricle is left undisturbed and the free edge of the pericardial patch is incorporated in the sutures while closing the left ventriculotomy. This simplifies the procedure and decreases the chances of right ventricular dysfunction, any residual defect, and bleeding. A retrospective analysis of patients with VSR following AMI operated in our institute from January 2018 to June 2021 was done. Over the last 3years, 16 patients with AMI VSR were treated with a modified infarct exclusion technique. Eight patients presented in cardiogenic shock preoperatively and were put on intra-aortic balloon pump support. All patients could be weaned successfully from the cardiopulmonary bypass, no patient had any residual defect, and none of the patients required re-exploration for bleeding. Postoperatively, 5 patients died within the first week and 2 more patients subsequently died due to intractable arrhythmias over the next 30days. In our centre, the mortality following repair of VSR after AMI was 43%. The modified infarct exclusion technique is a good technique with less chances of postoperative re-exploration and residual defect.

Clinical Outcomes of Ventricular Septal Rupture Complicating ST-Segment Elevation Myocardial Infarction: A Case Series from Siriraj Hospital and Literature Review

Objective: To access the clinical outcomes of ventricular septal rupture (VSR) complicating acute myocardial infarction (AMI) patients in the Faculty of Medicine Siriraj Hospital, Bangkok, Thailand. Materials and Methods: The authors retrospectively reviewed the medical records of Siriraj Hospital between January 2005 and December 2021 in line with the International Classification of Disease, version 10 (ICD-10) code I23.2, which revealed 18 patients who matched the search. Among these, three patients were excluded from the present study as one patient could not access the admission data and the other two were not truly VSR. Results: In total, 15 VSR patients were included in the analysis, comprising eight males and seven females, with mean age of 67.53±7.95 years old. Of all the patients, 60% had anterior ST-segment elevation myocardial infarction. The mean left ventricular ejection fraction was 53.13±14.98%. Coronary angiography was performed in 14 patients (93.37%). In 50% of the patients, left anterior descending artery was the culprit lesion. Ten patients had multi-vessel diseases. Six patients underwent percutaneous coronary intervention (PCI), with the rate of successful reperfusion at 83.33%. For the six patients who underwent PCI, the procedure was performed before the VSR surgical repair. Ten patients underwent coronary artery bypass graft. For the 12 patients who underwent VSR surgical repair, the in-hospital survival rate was 100%. The overall in-hospital mortality rate was 20%. The non-survival patients did not receive the VSR surgical repair. After the median follow-up of three years, no additional mortality rate was reported. Conclusion: The mortality rate of VSR complicating AMI is high, especially, for patients who are not feasible for VSR repair. However, given the limitation in the number of patients involved in the present analysis, the authors could not identify the risk factors for developing in-hospital adverse outcomes. Keywords: Ventricular septal rupture; Acute myocardial infarction; Mechanical complications of myocardial infarction

Delayed Surgical Repair of Ventricular Septal Rupture with CABG following Acute Myocardial Infraction- A Case Report

Ventricular septal rupture (VSR) is a rare but often life-threatening mechanical complication after acute myocardial infarction. Although surgical intervention is challenging and associated with high mortality and morbidity, but it is still now the gold standard treatment. Percutaneous device closure of VSR is an option in selected patients with suitable anatomy and when surgery is contraindicated. Optimally medically managed patients who survive at least 4 weeks before elective surgery to generate scar formation at the edges of the defect in a viable infarcted tissue have the greatest outcomes. Here we report a case of VSR following acute myocardial infarction. About 3 weeks after the occurrence of ventricular septal rupture following acute myocardial infraction, surgery was successfully performed with good outcome. Cardiovasc j 2022; 15(1): 100-105

Optimal surgical timing after post-infarction ventricular septal rupture.

BackgroundVentricular septal rupture (VSR) following acute myocardial infarction (AMI) is a dangerous condition. Surgical VSR closure is the definitive therapy, but there is controversy regarding the surgical timing and the bridging therapy between diagnosis and intervention. The objective of this study is to analyze the ideal time of surgical repair and to establish the contribution of mechanical circulatory support (MCS) devices on the prognosis.MethodsWe designed an observational, retrospective, multicenter study, selecting all consecutive patients with post-AMI VSR between January 1, 2008 and December 31, 2018, with non-exclusion criteria. The main objective of this study was to analyze the optimal timing for surgical repair of post-AMI VSR. Secondary endpoints were to determine which factors could influence mortality in the patients of the surgical group.ResultsA total of 141 patients were included. We identified lower mortality rates with an odds ratio of 0.3 (0.1–0.9) in patients operated on from day 4 compared with the surgical mortality in the first 24 hours after VSR diagnosis. The use of MCS was more frequent in patients treated with surgery, particularly for intra-aortic balloon pump (IABP; 79.6% vs. 37.8%, p < 0.001), but also for veno-arterial extracorporeal membrane oxygenation (VA-ECMO; 18.2% vs. 6.4%, p = 0.134). Total mortality was 91.5% for conservative management and 52.3% with surgical repair (p < 0.001).ConclusionsIn our study, we observed that the lowest mortality rates in patients with surgical repair of post-AMI VSR were observed in patients operated on from day 4 after diagnosis of VSR, compared to earlier interventions.

Survival and risk factors associated with surgical repair of ventricular septal rupture after acute myocardial infarction: A single-center experience.

ObjectiveTo analyze the survival and risk factors associated with the surgical treatment of ventricular septal rupture (VSR) after acute myocardial infarction (AMI).MethodsWe retrospectively analyzed 45 consecutive patients with VSR after AMI whose procedures were performed in the Department of Cardiovascular Surgery at the General Hospital of Northern Theater Command between January 2012 and December 2021. Relevant clinical data, surgery-related conditions, and follow-up data of all patients were summarized. Patients were divided into the survival group and the death group. The Kaplan–Meier method and log-rank test were used to determine the cumulative incidence of all-cause mortality. Multivariate logistic regression was used to evaluate the independent risk factors for all-cause mortality.ResultsThe average postoperative follow-up time was 42.1 ± 34.1 months. The overall mortality rate was 20% (9/45 patients) and the operative mortality rate was 8.9% (4/45 patients). Logistic analysis showed that the death group had higher serum creatinine (127.32 ± 47.82 vs. 82.61 ± 27.80 μmol/L, respectively; P = 0.0238) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) [8,654.00 pg/mL (6,197.00–11,949.00 pg/mL) vs. 4,268.96 pg/mL (1,800.00–7,894.00 pg/mL), respectively; P = 0.0134] levels than the survival group. The cardiopulmonary bypass time (CPB) was longer in the death group than in the survival group [131.00 min (121.00–184.00 min) vs. 119.00 min (103.00–151.50 min), respectively; P = 0.0454]. Significantly more red blood cells were transfused in the death group than in the survival group [11.60 units (6.10–16.50) vs. 3.75 units (0.00–7.00 units), respectively; P = 0.0025]. Intra-aortic balloon pump (IABP) implantation (P = 0.016) and ventilation time (P = 0.0022) were risk factors for mortality. A 1-month landmark analysis showed that compared with patients with VSR to surgical time >14 days, patients who underwent surgery within 14 days had a higher rate of all-cause mortality (25.00 vs. 3.33%; log-rank P = 0.023). Patients with VSR within 14 days also had a higher rate of residual shunts that were higher than moderate. Multivariate analysis showed that transfusion of red blood cells and NT-proBNP level were risk factors for all-cause mortality, as well as major adverse cardiovascular and cerebrovascular events.ConclusionsSurgical repair resulted in good outcomes for patients with VSR after AMI. Patients with VSR to surgical time >14 days had a lower rate of all-cause mortality. Treatment strategies for VSR should be based on the patient's condition and comprehensively determined through real-time evaluation and monitoring.

Transesophageal Echocardiographic Illustration of Postinfarction Ventricular Septal Rupture

AbstractPostinfarction ventricular septal rupture (VSR) is a rare but dreaded mechanical complication of myocardial infarction. Moreover, patient develops cardiogenic shock or congestive heart failure requiring early surgical intervention. To optimize surgical repair, perioperative confirmation, determining location of VSR and adequacy of repair, is mandatory. Assessment can be obtained by the transesophageal echocardiography (TEE). Use of two- and three-dimensional TEE techniques clearly delineate size and shape of septal rupture and involvement of other cardiac structures. We report a patient presenting with postinfarction VSR for elective VSR repair and surgical revascularization and implication of TEE in perioperative management.

Hyperlactatemia as a Risk Stratification for Postinfarction Ventricular Septal Rupture.

Surgical repair for postinfarction ventricular septal rupture (VSR) is a challenging operation, especially in the acute phase with unstable hemodynamics. We retrospectively examined the value of measuring lactate, which can be a quantitative indicator of end-organ ischemia caused by multiple factors including ineffective cardiac output, for risk stratification in patients undergoing surgical repair. From April 2008 to December 2018, 33 consecutive patients were admitted to our hospital with a diagnosis of VSR and underwent VSR repair surgery within 24 hours of admission. We categorized patients into 3 groups based on the distribution of preoperative blood lactate level: <5 mmol/L (n = 16), 5 to 10 mmol/L (n = 11), and >10 mmol/L (n = 6). There was no intraoperative death, but the prognosis for patients with lactate >10 mmol/L was extremely poor, with a median postoperative survival time of only 23 days [25th percentile 6, 75th percentile 30]. Five of 6 patients (83%) died within 30 days after surgery. The risk-adjusted hazard ratio (95% confidence interval) for mortality per 1 SD (0.41-unit) increase in log-transformed preoperative lactate level (equivalent to a 4.10-fold increase) was 2.85 (1.57 to 5.19). Patients with lactate 5 to 10 mmol/L had 3.95-fold and those with lactate >10 mmol/L had 6.03-fold higher risk of mortality than those with lactate <5 mmol/L. Elevation of preoperative serum lactate is significantly associated with mortality in patients who underwent VSR repair. The findings of this study highlight the value of measuring lactate level for risk stratification.

Triple patch technique to repair ventricular septal rupture.

Postinfarction ventricular septal rupture (VSR) remains an important and life-threatening complication of myocardial infarction (MI). Although several techniques have improved surgical outcomes of postinfarction VSR, the treatment is still challenging with a high mortality rate. In addition, it is well known that a postoperative residual shunt after VSR repair is associated with poor outcomes; however, late outcomes involving patients with a residual shunt after VSR repair are lacking. This paper presents the early and late outcomes of patients who underwent the triple patch technique to repair a VSR and the usefulness in reducing a postoperative residual shunt. The main process of this technique is that the patch is gently placed on the myocardium with over and over suture and is firmly attached using glue. Therefore, the triple patch technique is simple and easy to perform, and is designed to minimize residual shunt and exclude infarcted myocardium. In the present keynote lecture, we describe our surgical technique and the results of VSR repair.

Outcomes of surgical repair of anterior or posterior ventricular septal rupture after myocardial infarction.

Ventricular septal rupture (VSR) is a rare and fatal complication of myocardial infarction. Surgery is the main treatment for the condition. It is currently believed that surgery is less effective for posterior VSR than for anterior VSR. The objective of this study was to investigate the clinical outcomes of surgical treatment for myocardial infarction combined with an anterior or posterior VSR. This was a single-center, retrospective, observational, cohort study. Clinical data of 68 patients with myocardial infarction combined with VSR were retrospectively analyzed. According to the site of the VSR, patients were divided into the anterior (43 cases) and posterior (25 cases) VSR groups, and the general clinical data, preoperative examination results, surgery, and follow-up results were compared between the two groups. Compared with the anterior VSR group, the operative time in the posterior VSR group was longer {300 [240, 360] vs. 360 [300, 400] min; P=0.003}, and the cardiopulmonary bypass time was longer (142.0±52.2 vs. 180.2±52.3 min; P=0.005), and the aortic clamp time was longer (84.0±32.5 vs. 115.9±39.8 min; P=0.001). There were no significant differences in the incidence of perioperative complications, including bleeding, low cardiac output, pulmonary, and cerebrovascular complications, and the incidence of perioperative death between the two groups (P>0.05). The patients were followed up for 1.0-10.5 (median, 4.2) years. There were no significant differences in the survival rate and the incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) including myocardial infarction, heart failure, revascularization, and cerebrovascular events between the two groups (P>0.05). The perioperative risks and medium- and long-term outcomes of the surgical repair of anterior or posterior VSR after myocardial infarction were similar.

Two-patch technique with BioGlue for ventricular septal rupture resulting from acute anterior myocardial infarction.

Surgery for postinfarction ventricular septal rupture (VSR) remains associated with high mortality.1-5 In cases of VSR resulting from acute myocardial infarction (AMI), we often encounter challenges in closing the VSR and the repair of the ventriculotomy made through the wide necrotic ventricular muscle. To simplify the procedure and reinforce the suture line, we perform VSR repair with 2 separate patches with BioGlue, which is applied on the suture line between 2 patches. If ventricular free-wall defect following excision of necrotic ventricular muscle becomes large, free-wall repair is performed using an inner patch covered by a prosthetic patch from the outside (Video 1).

Surgical repair of ventricular septal rupture following myocardial infarction: analysis of risk factors

<h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Определить наиболее значимые факторы риска госпитальной и 30-дневной летальности у пациентов с постинфарктным разрывом межжелудочковой перегородки (ПРМЖП) для оптимизации тактики хирургического лечения таких больных. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> Проведен ретроспективный анализ результатов комплексного обследования и хирургического лечения 88 пациентов с ПРМЖП за период с 2002 по 2019 г. <h3>РЕЗУЛЬТАТЫ</h3> Снижение оперативной летальности с 3-й недели после острого инфаркта миокарда (ОИМ) с 42,1% до 10,5—15,8% у пациентов с ПРМЖП указывает на целесообразность использования выжидательной тактики в плане хирургического лечения. Дальнейшее наблюдение себя не оправдывает, так как не уменьшает летальность у пациентов с ПРМЖП, оперированных в ранние сроки после ОИМ. <h3>ВЫВОД</h3> Определены независимые прогностические факторы 30-дневной летальности у пациентов с ПРМЖП. Выявленные факторы объединены в шкалу для стратификации риска неблагоприятных исходов у пациентов с ПРМЖП. Моделирование исходов оперативного вмешательства предоставляет возможность оптимизации тактики хирургического лечения больных с ПРМЖП.

The enlargement rate of ventricular septal rupture is a risk factor for 30-day mortality in patients with delayed surgery

BackgroundPostinfarction ventricular septal rupture (VSR) is an uncommon but challenging mechanical complication for surgeons. This study analyzed the impacts of rupture size on surgical outcomes in patients with VSR.MethodsDuring a 15-year period, from January 2006 to December 2020, 112 patients underwent repairs of postinfarction VSR. Patient clinical data, including angiographic and echocardiographic findings, operative procedures, early morbidity and mortality, and survival time were collated. Univariable and multivariable analyses were performed to identify the risk factors of 30-day mortality.ResultsThe 30-day mortality rate was 7.1% for the whole cohort. The mean survival time estimate was 147.2 months [95% confidence interval (CI): 135.6 to 158.9 months], with a 3-year survival rate of 91.2% and a 5-year survival rate of 89.0%. Multivariable analysis revealed that rupture enlargement rate is an independent risk factor of 30-day mortality. The receiver operating characteristic (ROC) curve indicated that the rupture enlargement rate could predicted the 30-day mortality with high accuracy.ConclusionsDelayed surgery may be considered for patients who respond well to aggressive treatment. The rupture enlargement rate is an independent risk factor for postoperative 30-day morality in patients with delayed VSR repair. Furthermore, the rupture enlargement rate has good predictive value for the prognosis of VSR patients.

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

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

Abstract 17034: Acute Ventricular Septal Rupture Management By The Cardiac Intensivist

Case Presentation: A 59-year-old male presented with chest pain and electrocardiogram showed convex ST elevations in the inferior leads. He underwent emergent coronary angiography revealing a 99% mid-distal right coronary artery thrombotic occlusion followed by placement of a drug-eluting stent. Transthoracic echocardiogram (TTE) revealed a 2.5 cm muscular ventricular septal rupture (VSR) with a calculated pulmonary-systemic flow ratio (Qp/Qs) of 2.4 in the setting of normal right and left ventricular systolic function. In the intensive care unit, he still had nausea and chest discomfort, along with acute kidney injury and elevated lactate levels. A trial of aggressive medical management was pursued to avoid emergent cardiac surgery. We placed an arterial line and initiated afterload reduction with sodium nitroprusside, utilizing serial bedside TTEs to monitor his Qp/Qs, which trended down to 1.8 over the subsequent 12 hours followed by normalization of lactate and kidney function. His symptoms resolved and he remained stable while transitioning to oral vasodilators. After four weeks of medical therapy, he underwent timely surgical repair of his VSR and discharged home. Discussion: Ventricular septal rupture is a serious complication of inferior myocardial infarctions (MI). From a cardiac intensivist perspective, we maintained the patient at a euvolemic state while using systemic vasodilators to divert the left-to-right shunt flow and augment his systemic flow. We want to highlight the utility of serial bedside TTEs to guide therapy for VSR (Figure 1). Fortunately, our patient did not require mechanical circulatory support to maintain his hemodynamics. We also discussed with our cardiothoracic surgeons about the optimal timing for surgical repair. The guidelines suggest urgent VSR repair following an MI; however, the exact timing is debatable given the fragility of the inflamed post-MI myocardium and better surgical outcomes with maturation of the VSR.