Ventricular Septal Rupture Research Articles

Low incidence of mechanical complications in patients with AMI

Abstract Background Despite early and currently effective epicardial coronary recanalization in patients with acute myocardial infarction (AMI), the mortality rate after mechanical complication (MC) remains high. Despite its impact on the prognosis of patients with AMI, up-to-date real life data regarding to epidemiology and management of patients with MC following AMI still scarce and most studies exclude patients with MC. Methods Using the National Inpatient Sample database from 2015 to 2018 to identify patients with AMI, we aimed to determine the epidemiology, predictors and outcomes of patients with MC following AMI in the US. Results We identified 2,427,315 patients with AMI; 2345 (0.1 %) developed MC. Regarding subtypes, 960 (40.9 %) had ventricular septal rupture (VSR), 540 (23.0 %) papillary muscle rupture (PMR), 530 (22.6 %) pseudoaneurysm, and 315 (13.4 %) free wall rupture FWR). Mortality was 12 times higher (OR: 11.663, CI: 10.582–12.855,p< 0.001) in patients with MC compared to patients without MC (49.7% vs. 4.6 %,p< 0.001) and all subtypes of MC showed a significant increase in mortality. Conclusions Nowadays, the incidence of MC after an AMI is lower than in the past, nonetheless the in-hospital mortality rate remains very high. It tends to occur more in older patients and in those with fewer comorbidities. The subtype with the highest frequency and highest mortality rates was VSR.

Impella Support for Postmyocardial Infarction Ventricular Septal Rupture.

Impella Support for Postmyocardial Infarction Ventricular Septal Rupture.

Use of Intra-Aortic Balloon Pump (IABP) in Patient with Ventricular Septal Rupture

Use of Intra-Aortic Balloon Pump (IABP) in Patient with Ventricular Septal Rupture

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.

Abstract 18676: Aneurysmectomy or No Aneurysmectomy - An Unknown Heart Failure Terrain

Case Report: A 40-year male with a history of traumatic inferoapical ventricular septal rupture after a motor vehicle accident status post patch repair and left ventricular thrombus on Rivaroxaban presented to the ED with hemoptysis. The patient on arrival was hemodynamically stable. CTA revealed a new 6.9 cm left ventricular pseudoaneurysm and an echocardiogram revealed an EF of 30% with a pseudoaneurysm involving the entire distal septum, lateral wall, and apex and a ventricular septal rupture into the intraventricular septum. Cardiac MRI revealed a pseudoaneurysm from the inferoseptal wall measuring 9.6 x 6.9 x 10.0 cm and a stroke volume of 123 mL. A right heart catheterization revealed no evidence of left-to-right shunting. Given heart failure with reduced ejection fraction in the setting of a pseudoaneurysm and the complexity of aneurysm repair, advanced heart failure and cardiothoracic surgery teams were consulted for conventional surgical and transplant evaluation. Due to social barriers, the patient was declined from transplant and ultimately proceeded with patch repair. Intraoperative echocardiography revealed a post-operative EF of 25%. Discussion: This case highlights the need for further data on pseudoaneurysms that are confounded with concurrent heart failure. For this patient, the concerns were for adequate stroke volume given the extent of the pseudoaneurysm and whether improvement in systolic function could be seen with repair or result in further decline. It was postulated that surgical repair would raise his effective stroke volume, and thus improve cardiac function. Postoperative EF changes could have been further explained by myocardial stunning during anesthesia or rapid changes in end-diastolic volume with aneurysmectomy altering Frank-Starling hemodynamics. With isolated case report data, further aneurysmectomy outcome characterization is thus imperative to guide advanced heart failure treatment and improve patient mortality.

Role of echocardiography in the management of ventricular septal rupture after acute myocardial infarction.

Ventricular septal rupture (VSR) is a rare and devastating complication of acute myocardial infarction. Early detection, assessment of the hemodynamic impact, and illustration of the pathophysiological context are crucial functions of echocardiography in decision-making for intensive management and reparative intervention. To evaluate this entity, echocardiography exhibits two strengths: its bedside nature and its multiple modalities. This document reviews the comprehensive use of echocardiography in the study of post-infarction VSR.

A large ventricular septal rupture detected by cardiac point-of-care ultrasound.

A large ventricular septal rupture detected by cardiac point-of-care ultrasound.

Role of ECLS in Managing Post-Myocardial Infarction Ventricular Septal Rupture.

The aim of this study was to analyze outcomes in patients undergoing surgery for ventricular septal rupture (VSR) after myocardial infarction (MI) and the preoperative use of extracorporeal life support (ECLS) as a bridge to surgery. We included patients undergoing surgery for VSR from January 2009 until June 2021 from two centers in Germany. Patients were separated into two groups, those with and without ECLS, before surgery. Pre- and intraoperative data, outcome, and survival during follow-up were evaluated. A total of 47 consecutive patients were included. Twenty-five patients were in the ECLS group, and 22 were in the group without ECLS. All the ECLS-group patients were in cardiogenic shock preoperatively. Most patients in the ECLS group were transferred from another hospital [n = 21 (84%) vs. no-ECLS (n = 12 (57.1%), p = 0.05]. We observed a higher number of postoperative bleeding complications favoring the group without ECLS [n = 6 (28.6%) vs. n = 16 (64%), p < 0.05]. There was no significant difference in the persistence of residual ventricular septal defect (VSD) between groups [ECLS n = 4 (16.7%) and no-ECLS n = 3 (13.6%)], p = 1.0. Total in-hospital mortality was 38.3%. There was no significant difference in in-hospital mortality [n = 6 (27.3%) vs. n = 12 (48%), p = 0.11] and survival at last follow-up between the groups (p = 0.50). We detected no statistical difference in the in-hospital and long-term mortality in patients who received ECLS as supportive therapy after MI-induced VSR compared to those without ECLS. ECLS could be an effective procedure applied as a bridge to surgery in patients with VSR and cardiogenic shock.

Technical Considerations for the Percutaneous Management of Post-MI Ventricular Septal Rupture

Percutaneous techniques in managing post-MI ventricular septal rupture (VSR) have given recourse to patients deemed at high or prohibitive risk. Given the rarity of this catastrophic complication, experience is limited. VSR anatomy – with its complex 3D shape and more emergent presentation – is dissimilar to its congenital counterparts, leading to unique imaging and procedural challenges. We review the literature on percutaneous device closure of post-infarction VSR and, using practical illustrative cases, describe a systematic planning and technical approach for performing this complex procedure.

Effect of early thrombolysis on the clinical outcome of ventricular septal rupture in patients with myocardial infarction

Background: Ventricular septal rupture is one of the most lethal complications of myocardial ischemia with timely treatment preventing the catastrophic results for the patients.1 Objective: To determine whether early thrombolysis’ in patients with VSR increases or decreases mortality and to assess the risk factors for development of VSR in patients with ST elevation MI. Materials and Methods: This cross-sectional study was done at Peshawar Institute of Cardiology after the approval of synopsis from ethical research committee of the institution bearing IRC/23/54 dated 28 September 2023. The sample size was 34 and method was non-probability convenient. The inclusion criteria were all those patients who had acute myocardial infarction and detectable VSR on ECHO. Data collection will be started after IRB approval. All patients admitted via ER to CCUs and diagnosed as cases of VSR through clinical exam and ECHO findings. Descriptive analysis was employed to find out the mean age and Chi Square test and Pearson Correlation was employed to compare the outcomes of the patients after receiving thrombolysis with a p value of less than 0.05 as significant.

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.

Long-Term Results and Risk Factors of Treatment for Post-Infarction Ventricular Septal Rupture: A Single-Center Experience

Background: Ventricular septal rupture (VSR) following myocardial infarction (MI) is a rare but lethal complication. We analyzed the long-term results and risk factors for survival in the treatment of VSR. Methods: From January 2012 to December 2021, 115 consecutive patients with post-MI VSR were admitted to our hospital. Depending on different treatment methods patients were divided into following three groups: medical, transcatheter intervention, and surgical repair. During the study, relevant clinical data, operation-related conditions, and follow-up data were analyzed. The Kaplan–Meier method and log-rank test were used to determine the cumulative incidence of mortality. The independent risk factors for patient mortality were evaluated by multivariate logistic regression. Results: The mean follow-up time was 43.4 ± 34.7 months. The overall in-hospital, 30-day, and long-term mortality rates were 24.3%, 38.3%, and 51.3%, respectively. In the medical group, the in-hospital and 30-day mortality rates were 46.7 % (21/45) and 82.2 % (37/45), respectively, with only three patients alive at follow-up. In the transcatheter intervention group, 30-day and long-term mortality rates were 12% and 28%, respectively. In the surgical repair group, 30-day and long-term mortality rates were 8.9% and 22.2%, respectively. Compared with the surgery-group patients, patients with transcatheter intervention had a longer time from VSR to intervention. Logistic regression analysis revealed that age, previous infarction, Killip class, serum creatinine, Troponin T, N-terminal pro-B-type natriuretic peptide, and medical strategy were risk factors for all-cause mortality. Conclusions: The 30-day and long-term outcomes of patients treated with surgical repair and transcatheter intervention were significantly better than medically treated patients.

The current clinical practice for management of post-infarction ventricular septal rupture: a European survey.

Many historical and recent reports showed that post-infarction ventricular septal rupture (VSR) represents a life-threatening condition and the strategy to optimally manage it remains undefined. Therefore, disparate treatment policies among different centres with variable results are often described. We analysed data from European centres to capture the current clinical practice in VSR management. Thirty-nine centres belonging to eight European countries participated in a survey, filling a digital form of 38 questions from April to October 2022, to collect information about all the aspects of VSR treatment. Most centres encounter 1-5 VSR cases/year. Surgery remains the treatment of choice over percutaneous closure (71.8% vs. 28.2%). A delayed repair represents the preferred approach (87.2%). Haemodynamic conditions influence the management in almost all centres, although some try to achieve patients stabilization and delayed surgery even in cardiogenic shock. Although 33.3% of centres do not perform coronarography in unstable patients, revascularization approaches are widely variable. Most centres adopt mechanical circulatory support (MCS), mostly extracorporeal membrane oxygenation, especially pre-operatively to stabilize patients and achieve delayed repair. Post-operatively, such MCS are more often adopted in patients with ventricular dysfunction. In real-life, delayed surgery, regardless of the haemodynamic conditions, is the preferred strategy for VSR management in Europe. Extracorporeal membrane oxygenation is becoming the most frequently adopted MCS as bridge-to-operation. This survey provides a useful background to develop dedicated, prospective studies to strengthen the current evidence on VSR treatment and to help improving its currently unsatisfactory outcomes.

Discussion to: Infarct exclusion repair of postmyocardial infarction ventricular septal rupture with a hybrid patch and septal occluder device compared with patch only

Discussion to: Infarct exclusion repair of postmyocardial infarction ventricular septal rupture with a hybrid patch and septal occluder device compared with patch only

Infarct exclusion repair of postmyocardial infarction ventricular septal rupture with a hybrid patch and septal occluder device compared with patch only

ObjectiveWe developed a hybrid technique for repairing post-myocardial infarction (MI) ventricular septal defect (VSD) that combines infarct exclusion with patch and a nitinol-mesh septal occluder device (SOD) to provide a scaffold to support the damaged septal wall. Here, we compare outcomes of patients with post-MI VSD repaired using patch only or hybrid patch/SOD. MethodsPatients undergoing post-MI VSD repair at our institution from 2013 to 2022 who received patch alone or patch/SOD repair were analyzed. Primary outcome was survival to hospital discharge. Clinical outcomes and echocardiograms were also analyzed. ResultsOver a 9-year period, 24 patients had post-MI VSD repair at our institution with either hybrid patch/SOD (n = 10) or patch only repair (n = 14). VSD size was 18 ± 5.8 mm for patch/SOD and 17 ± 4.6 mm for patch only. In the patch/SOD repair cohort, average size of SOD implant was 23.6 ± 5.6 mm. Mild left ventricular dysfunction was present prerepair and was unchanged postrepair in both groups; however, moderate-to-severe right ventricular (RV) dysfunction was common in both groups before repair. RV function worsened or persisted as severe in 10% of hybrid versus 54% of patch-only patients postrepair. Tricuspid annular systolic excursion and RV:left ventricle diameter ratio, quantitative metrics of RV function, improved after patch/SOD repair. No intraoperative mortality occurred in either group. Postoperative renal, hepatic, and respiratory failure requiring tracheostomy was common in both groups. Survival to hospital discharge in both cohorts was 70%. ConclusionsPost-MI VSD repair with patch/SOD has comparable short-term outcomes with patch alone. Addition of a SOD to patch repair provides a scaffold that may enhance the repair of post-MI VSD with patch exclusion.

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.

Clinical assessment of VSR site and size and its relation to the severity of heart failure in post-myocardial infarction ventricular septal rupture patients.

Ventricular septal rupture (VSR) is a rare but well-known mechanical consequence of an acute myocardial infarction (AMI). Even in the later stages of re-perfusion therapy, the result of VSR remains poor. Our aim is to assess the site and size of VSR in relation to the severity of cardiac failure. From January 2016 to December 2022, a total of 71 patients with a diagnosis of post-myocardial infarction VSR were admitted to the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China. Data records were retrospectively included in this registry. In all patients, clinical and echocardiographic data were gathered, and statistical analyses were performed. A total of 71 consecutive patients (mean age: 66.27 ± 8.88 years); 50.7% male, 49.3% female, with (M:F) ratio of almost (1:1). Left ventricular ejection fraction (LVEF) was (48.55 ± 10.44%) on echocardiography, and apical VSR was the most common site (69.0%). Overall, the VSD site was strongly related to the VSD size (p = .016), LVEF (p = .012), AMI site (p = .001), and affected coronary vessel (p = .004). Prodromal angina (p = .041), intra-aortic balloon pump (p = .002), affected coronary vessels (p = .020), pro-BNP (p = .000), and LVEF (p = .017) were predictors of the severity of heart failure. Diabetes mellitus is a common risk factor for post-myocardial infarction VSR. VSR site and size had no relation to the severity of heart failure. A presentation with prodromal angina predicted severe heart failure and a worse prognosis.

Ventricular Septal Rupture Management in Patients With Acute Myocardial Infarction: A Review.

Untreated myocardial infarction (MI) can potentially lead to many fatal complications which require immediate management. One of them is ventricular septal rupture (VSR) which necessitates the hemodynamic stabilization and closure of the septal rupture. Conventional treatment strategy involves surgical repair; however, percutaneous transcatheter repair using an occluder device is a promising upcoming approach. We conducted a detailed review of various published articles and examined the trends in incidence, risk factors, and pathophysiology of MI leading to VSR followed by an in-depth analysis of the various management strategies for the same. In the current clinical scenario, thrombolysis is an imperative management strategy that has been shown to decrease the occurrence of VSR by manifolds, more specifically in patients having ST-elevated MI. Delayed surgical closure remains the main treatment for post-infarction VSR. Other newer modalities, such as percutaneous closure devices and mechanical circulatory supports, are attractive alternative or complementary strategies to treat such patients, both postoperatively and perioperatively. However, earlier surgical repair in VSR increases the risk of mortality, and the optimal timing for VSR closure remains controversial. Despite surgical closure of VSR being the traditional treatment, it presents a considerably high operative risk. Although newer interventions such as percutaneous closure devices and mechanical circulatory supports provide impressive outcomes, their efficacy in high-risk patients remains inconclusive.

Echocardiographic features of myocardial rupture after acute myocardial infarction on emergency echocardiography.

Myocardial rupture is a fatal complication of acute myocardial infarction (AMI). Early diagnosis of myocardial rupture is feasible when emergency physicians (EPs) perform emergency transthoracic echocardiography (TTE). The purpose of this study was to report the echocardiographic features of myocardial rupture on emergency TTE performed by EPs in the emergency department (ED). This was a retrospective and observational study involving consecutive adult patients presenting with AMI who underwent TTE performed by EPs in the ED of a single academic medical center from March 2008 to December 2019. Fifteen patients with myocardial rupture, including eight (53.3%) with free wall rupture (FWR), five (33.3%) with ventricular septal rupture (VSR), and two (13.3%) with FWR and VSR, were identified. Fourteen of the 15 patients (93.3%) were diagnosed on TTE performed by EPs. Diagnostic echocardiographic features were found in 100% of the patients with myocardial rupture, including pericardial effusion for FWR and a visible shunt on the interventricular septum for VSR. Additional echocardiographic features indicating myocardial rupture were thinning or aneurysmal dilatation in 10 patients (66.7%), undermined myocardium in six patients (40.0%), abnormal regional motions in six patients (40.0%), and pericardial hematoma in six patients (40.0%). Early diagnosis of myocardial rupture after AMI is possible using echocardiographic features on emergency TTE performed by EPs.

Percutaneous closure of ventricular septal rupture after myocardial infarction: A retrospective study of 81 cases.

To investigate the efficacy and safety of percutaneous closure of ventricular septal rupture (VSR) after acute myocardial infarction (AMI). This retrospective study included 81 patients who underwent transcatheter closure for postinfarction VSR. We analyzed clinical data from hospitalization and the 30-day follow-up, compared clinical data from the survival and death groups, and explored the best closure time and the safety and efficacy of occlusion. The risk factors for death at 30 days were analyzed by logistic regression. C-reactive protein (CRP), white blood cell counts, N-terminal pro brain natriuretic peptide (NT-ProBNP), and aspartate aminotransferase were higher in the death group than in the survival group (p < .01), with a higher rate of application of vasoactive drugs, and a shorter time from AMI to operation (p < .05). At 30 days postocclusion, 19 patients (23.5%) had died. The mortality rate was significantly lower for operation performed 3 weeks after AMI than for operation performed within 3 weeks of AMI (12.5% vs. 48%, p < .001). Devices were successfully implanted in 76 patients, with 16 (21.1%) operation-related complications and 12 (15.8%) valve injuries. Cardiac function improved significantly (p < .001) at discharge (N = 66) and 30 days after procedure (N = 62). Qp/Qs and pulmonary artery systolic pressure decreased significantly, while aortic systolic pressure increased significantly (p < .001). Additionally, EF and LVDd improved (p < .05) after occlusion. Increases in CRP and NT-ProBNP were risk factors for death at 30 days after closure (p < .05). Percutaneous VSR closure can be a valuable treatment option for suitable patients with VSR.