Treatment Of Ventricular Septal Rupture Research Articles

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.

Surgical Treatment of Ventricular Septal Rupture Based on Infarct-Related Vessel in Patients with Acute Myocardial Infarction: A Single-Center Comparative Outcome Study

Surgical Treatment of Ventricular Septal Rupture Based on Infarct-Related Vessel in Patients with Acute Myocardial Infarction: A Single-Center Comparative Outcome Study

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.

Percutaneous Closure of Post-infarction and Iatrogenic Ventricular Septal Ruptures Using Amplatzer Occluder®: A Systematic Review.

Ventricular septal rupture (VSR) is a rare complication of myocardial infarction (MI), open heart surgery, and cardiac-based procedures, such as septal myectomy and valve replacement. VSR is associated with high mortality rates and the reported 30-day survival rate is less than 10% without any interventional therapy. Hence, prompt diagnosis and aggressive medical treatment with appropriate surgical intervention are necessary to improve survival. Immediate surgical intervention which is the standard treatment of VSR has a mortality rate of 19-60%. Due to persistent high mortality rate and challenging management of VSR, alternatives to surgical repair has been proposed; transcatheter approach as a new alternative method has been used for the closure of post-surgery residual defects or as a bridge to surgery and in some cases as a definitive therapy instead of surgical repair. Amplatzer Occluder® (AO), a type of transcatheter closure devices, is an approved method of repairing congenital atrial septal defects and it is being used as an alternative method of treatment in VSR. In this systemic review, we assessed the cases of VSR who underwent septal repair by using AO. The study shows that the total mortality rate of percutaneous VSR repair with AO is 20% which is comparable to 19-60% rate of death in patients who undergo surgery. While early intervention is necessary to prevent biventricular dysfunction, immediate surgical intervention on soft and friable tissue surrounding the infarction increases the risk of residual shunt and reoperation. However, this study reveals that the mortality rate of primary percutaneous VSR closure within 7 days of VSR detection was 37 % which is significantly lower than 60% in surgical repair in the same period. In conclusion, given that the prevalence of residual leak in both interventions are similar and close to 20%, percutaneous VSR closure with AO device could be superior to the surgical repair as a primary intervention in unstable or high-risk surgical patients.

Profile and Outcomes of Surgical Treatment for Ventricular Septal Rupture in Patients With Shock

The outcomes of surgical treatment of ventricular septal rupture (VSR) complicating acute myocardial infarction are worse in patients with cardiogenic shock. This study aimed to identify clinical characteristics and outcomes in patients with VSR presenting with cardiogenic shock. A retrospective analysis was performed in 105 consecutive VSR patients, 71 with cardiogenic shock (67.6%) and 34 without cardiogenic shock (32.4%), who underwent surgical treatment in the Department of Adult Cardiac Surgery of Fuwai Hospital between January 2002 and December 2017. Baseline characteristics and outcomes in patients with VSR with and without cardiogenic shock were assessed. There were no differences in hypertension, diabetes, history of myocardial infarction, body mass index, or location of VSR between patients with and without cardiogenic shock. The size of VSR was larger in patients with cardiogenic shock than in those without (18.2 ± 8.1 mm vs 14.0 ± 7.8 mm; P= .013). Intraaortic balloon pump was required more in patients with cardiogenic shock before operation (39 [68.4%] vs 1 [5.0%]; P < .001]. More emergency surgeries were performed in the cardiogenic shock group (21 [29.6%] vs 3 [8.8%]; P= .018). There were 3 in-hospital deaths among patients with VSR with cardiogenic shock. After 76.56 ± 47.78 months of follow-up, only 2 noncardiac deaths were documented. The larger the ventricular septal rupture is, the more prone patients are to develop cardiogenic shock. Surgical treatment outcomes for VSR with cardiogenic shock are satisfactory.

Successful Medical Treatment Using Tolvaptan of Ventricular Septal Rupture Following Myocardial Infarction

Although improved treatments for acute myocardial infarction (AMI) have considerably reduced the mortality of AMI in the past two decades, the treatment for ventricular septal rupture (VSR)-a rare but life-threatening mechanical complication of AMI-still remains quite challenging. We herein describe the case of a high-surgical-risk patient with VSR after AMI who was successfully treated using tolvaptan (a novel V2-receptor antagonist) without any mechanical support.

A Novel Treatment Using an Intraventricular Stent Graft for Postinfarction Ventricular Septal Rupture in a Porcine Model.

Ventricular septal rupture (VSR) is a severe complication of acute myocardial infarction, and the conventional technique for repair is associated with high operative mortality. A novel intraventricular stent graft (IVSG) device was tested as a less invasive treatment for VSR; it does not require cardiopulmonary bypass, cardiac arrest, or left ventricular incision. Its effectiveness was assessed using animal experiments. Six pigs were placed on cardiopulmonary bypass. The VSR model was created by making a hole in the interventricular septum via the right ventricle. Animals were weaned off the bypass. The sheath encasing the device was advanced over the guidewire, and the IVSG was placed in the left ventricle. Before and after rupture creation and after device deployment, left ventriculography was performed, hemodynamic data were collected, and Qp/Qs values were measured. All procedures were completed safely. The left-to-right shunt seen after rupture creation disappeared after device deployment. The pulmonary-to-systemic blood flow ratio after rupture was 3.35 ± 1.00, decreasing significantly to 1.09 ± 0.10 after device deployment (P = 0.007). Hemodynamic instability after rupture creation improved dramatically after deployment. The use of our new IVSG in this VSR animal experiment model significantly decreased the left-to-right shunt. The new device was able to control the acute heart failure associated with VSR with a minimally invasive procedure during the hyperacute phase of heart failure. Potential improvements in VSR treatment outcomes are expected with its clinical application.

Treatment of ventricular septal rupture as a complication of acute myocardial infarction

The ventricular septal rupture is a potentially fatal complication of acute myocardial infarction. The key to management is an aggressive approach to hemodynamic stabilization and surgical closure of the rupture. If a patient with a small rupture is in hemodynamicaly stable condition, surgery can be delayed to achieve better perioperative results. In unstable patients either urgent surgery or extracorporeal membranous oxygenation support and delayed surgery is indicated. In some patients transcatheter closure can be considered as an alternative to surgery

Ventricular septal rupture after blunt chest trauma

Ventricular septal rupture (VSR) is a rare complication of blunt chest trauma. The commonest effect of this non-penetrating injury of the thorax is pulmonary and myocardial contusion. We present the case of a 30-year-old man with post-traumatic ventricular septal rupture. Two days earlier he fell from a roof (about 4 m high) and was admitted to the emergency department of the regional hospital. On admission, he was fully conscious and by virtue of his left forearm being broken he was referred to the surgical department, where his left radius bone was attended to. Several hours later, the patient’s general clinical condition started gradually worsening. Symptoms of progressive pulmonary failure were observed, and eventually he was intubated and mechanically ventilated. Moreover, due to cardiac status deterioration, an echocardiographic examination was performed urgently and muscular VSR with left-to-right flow was visualised (Fig. 1). After this diagnosis was established, the patient was referred emergently to our Cardiosurgical Department. On admission he was mechanically ventilated and deeply unconscious with no reaction to pain. At that time no sedation was employed. Moreover, he required marked doses of positive inotropic agents (dobutamine and dopamine). By virtue of serious neurological status, he was disqualified from salvage cardiac surgical procedure. In transthoracic echocardiographic examination, a rupture in the middle, muscular part of the ventricular septum, about 10–12 mm in diameter, 40 mm from the mitral annulus and 30 mm from the apex, with accompanying left-right flow velocity of approximately 2.0 m/s was visualised. In the meantime, computed tomo graphy (CT) angiography was performed, which revealed normal thoracic aorta. Abdomen ultrasonography did not reveal serious abnormalities. Hypotonia (RR 70/40 mm Hg) was observed from the beginning and it was accompanied by high fever (up to 40°C). Several laboratory cardiac necrosis marker tests, such as cardiac troponin I, and creatinine kinase MB isoenzyme confirmed cardiac injury. Soon after admission, an intra-aortic balloon pump (IABP) was inserted through the puncture of the right femoral artery and continuous veno-venous haemofiltration (CVVH) was initiated due to renal failure with oliguria. In spite of the aggressive treatment with IABP and CVVH, the patient developed multi-organ failure including liver (alanine aminotransferase activity increased up to 8,328 IU/L and asparagine aminotransferase to 2,406 IU/L). A head CT (Fig. 2) revealed diffuse axonal injury, extensive post-traumatic changes in the form of significant swelling of the brain, overall tightening of the subarachnoid space in the third and fourth ventricles and also in the lateral ventricles. Disseminated air zones were found in the subcortical white matter. Small haemorrhagic changes were revealed in the right cerebellar hemisphere and single small (4 mm) changes were present in the frontal lobes. On the basis of the patient’s general status, and the results of imaging studies, the patient was disqualified from invasive treatment of VSR. On the seventh day of hospitalisation in the Department, the patient’s general condition rapidly worsened, hypotension non-responsive to increased doses of catecholamines appeared, and the patient developed coagulopathy. One day later, the patient developed progressive bradycardia and hypotension. Eventually, in spite of pharmacological resuscitation, he did not respond and he died.

Early and Late Results of Surgical Treatment for Ventricular Septal Rupture With and Without Use of the Infarction Exclusion Technique-Experience With Two- and Three-Sheet Modification

Ventricular septal rupture (VSR) is an infrequent but life-threatening situation. Although outcomes have improved with the introduction of infarction exclusion, we have experienced difficulty in determining the optimal patch size and shape for obtaining good outcomes. Therefore, we modified the infarction exclusion technique. Herein, we review our experience on the basis of early closure of VSR with and without use of the infarction exclusion technique. We retrospectively analyzed the hospital records of 33 patients who underwent surgical treatment for VSR. We employed Dagget's method from 1982 to 1995, and then introduced the infarction exclusion technique in 1995. We have developed two modifications: the two-sheet single-patch technique and the three-sheet double-patch technique. Overall hospital mortality was 41.9% and that of the infarction exclusion group was significantly lower than the hospital mortality rate of the noninfarction exclusion group (21% and 63%, respectively, p = 0.0266). Late mortality of survivors was low in all groups during the observation period. The three-sheet double-patch group showed no residual shunt. This difference in outcomes between the single-patch and double-patch groups was statistically significant (p = 0.0174). The two-sheet method facilitates the restoration of ventricular geometry. A double-patch using the three-sheet method may be useful for reducing residual shunt.

The early and middle-long term clinical results of surgical treatment for ventricular septal rupture

To explore the way of promoting the efficacy of surgical treatment for ventricular septal rupture (VSR) after acute myocardium infarction in terms of perioperative and long term survival. The clinic data of 37 VSR cases underwent surgical treatment from October 1994 to October 2007 were analyzed retrospectively. There were 24 male and 13 female, and the age was (63.4 +/- 7.6) years old. The whole group was divided into the VSR repair plus revascularization group (group A, 26 cases) and simple VSR repair group (group B, 11 cases). There were 4 operative deaths in group A (15.4%), 7 deaths in group B (63.6%), P = 0.006. With the follow-up of (34.0 +/- 29.8) months ranged from 2 to 103 months of the 26 operational survivors, there were 5 late deaths, of which 2 deaths in group A and 3 deaths in group B. According to the Kaplan-Meier survival curve, the actuarial survival rate at 6 to 8 year was (64.3 +/- 21.0)% for group A and the actuarial survival rate at 4 year was (25.0 +/- 21.7)% for group B, P = 0.011. Of the 21 mid-long term survivors, 17 cases were in NYHA class I to II and 4 cases in NYHA class III to IV. There were 4 cases suffered from VSR recurrence. According to Logistic regression, the risk factors for the early death were not adoptive of revascularization, cardiogenic shock and emergency surgical procedure, while the risk factors for late death were not adoptive of revascularization and low cardiac output after the procedures. VSR repair plus revascularization could improve the perioperative and mid-long term survival for the surgical treatment of VSR. The appropriate timing and procedures of the surgical operation are very important to promote perioperative survival and to prevent VSR recurrence.

Image-guided surgical repair of ventricular septal rupture using self-expanding device

The purpose of this study was to determine the possibility of a new surgical technique for the treatment of ventricular septal rupture after acute myocardial infarction. The operations were conducted under the guidance of real-time three-dimensional echocardiography (RT3DE) (iE33, Philips Medical Systems, Andover, MA). Six pigs were anesthetized, and after median sternotomy, the echo probe was applied directly to the surface of the heart. A ventricular septal defect (VSD) was created in all the six porcine hearts. The VSDs were closed with an Amplatzer septal occluder (AGA Medical Corp, Golden Valley, MN) through the right ventricular free wall under RT3DE monitoring. The procedure was successful in all the six pigs. The VSDs were precisely closed with the septal occluder under RT3DE guidance. Both left ventriculography and color-Doppler echocardiography showed no residual shunt in any of the six pigs. The use of the Amplatzer septal occluder under the guidance of real-time three-dimensional echocardiography made it possible to close the ventricular septal defect safely and successfully without the need to resort to cardiopulmonary bypass. Our results strongly suggest that the application of this new technique is feasible for the treatment of ventricular septal rupture after acute myocardial infarction.

Surgical treatment of ventricular septal rupture complicating myocardial infarction

A review of postinfarction ventricular septal defects repaired surgically at Providence Hospital over the past 6 years is presented. Although this complication of myocardial infarction carries a high mortality rate, a lower rate can be achieved with early operative intervention. Preoperative pharmacologic reduction of preload, afterload, and intra-aortic balloon pumping are only temporizing measures to allow delineation of concomitant lesions. Operative mortality does not appear to be influenced by posterior location of the ventricular septal defects.