Ventricular Septal Rupture - Mortality

5/24/00 (Del Rio)

Group: Wednesday Residents

RE: A 69 year old male with dry cough and shortness of breath for 5 days. 

Question: What is the mortality and outcome for patients undergoing repair for ventricular septal rupture from myocardial infarction?

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Link Directly to Fulltext article in Ovid

Unique Identifier: 20086776

Authors: Crenshaw BS. Granger CB. Birnbaum Y. Pieper KS. Morris DC. Kleiman NS. Vahanian A. Califf RM. Topol EJ.

Institution: Duke Clinical Research Institute, Durham, NC 27715, USA.

Abstract: BACKGROUND: Ventricular septal defect (VSD) complicating acute myocardial infarction has been studied: primarily in small, prethrombolytic-era trials. Our goal was to determine clinical predictors and angiographic and clinical: outcomes of this complication in the thrombolytic era. METHODS AND RESULTS: We compared enrollment: characteristics, angiographic patterns, and outcomes (30-day and 1-year mortality) of patients enrolled in the Global: Utilization of Streptokinase and TPA for Occluded Coronary Arteries (GUSTO-I) trial with and without a confirmed: diagnosis of VSD. Univariable and multivariable analyses were used to assess relations between enrollment factors and: the development of VSD. In all, 84 of the 41 021 patients (0.2%) developed VSD, a smaller percentage than reported: in the prethrombolytic era. The median time from symptom onset to VSD diagnosis was 1 day. Enrollment factors most: associated with this complication were advanced age, anterior infarction, female sex, and no previous smoking. The: infarct artery was more often the left anterior descending and more likely to be totally occluded in patients who: developed VSD. Mortality at 30 days was higher in patients with VSDs than in those without this complication (73.8%: versus 6.8%, P<0.001). Patients with VSDs selected for surgical repair (n=34) had better outcomes than patients: treated medically (n=35; 30-day mortality, 47% versus 94%). CONCLUSIONS: Compared with historical control: subjects, patients who undergo thrombolysis within 6 hours of infarction onset may have a reduced risk of later VSD. If: patients develop this mechanical complication, however, it typically occurs sooner than described in the prethrombolytic: era. Despite improvements in medical therapy and percutaneous and surgical techniques, mortality with this: complication remains extremely high.

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Unique Identifier: 99161718

Authors: Bouchart F. Bessou JP. Tabley A. Redonnet M. Mouton-Schleifer D. Haas-Hubscher C. Soyer R.

Institution: Department of Thoracic and Cardiovascular Surgery, University Hospital, Rouen, France.

Abstract: AIM: This retrospective analysis focuses on predictive factors of operative mortality and long-term survival after: surgical repair of postinfarction ventricular septal rupture (VSR). METHODS: Sixty-seven patients (43 males, 24: females) with VSR underwent surgical repair between December 1977 and December 1995. The site of the rupture was: anterior in 44 patients and posterior in 23. The mean interval between myocardial infarction (MI) and VSR was: 3.6+/-4.1 days. Clinical condition on admission was critical in 63 patients (49 in cardiogenic shock). An intra-aortic: balloon pump was inserted preoperatively in 54 patients. RESULTS: Operative mortality was 25% (17 patients). The: main cause of death was cardiac failure. Factors influencing early deaths in univariate analysis were preoperative: hemodynamic status (cardiogenic shock present in 30%; absent in 8%; p = 0.001), the location of the MI (anterior in: 11.6%, posterior in 45.4%), the interval between infarction and surgery (<1 week was 33%, >1 week was 6.2%), and: the response to initial active therapy. All patients were available for follow-up. The actuarial survival rates at 1 and 5: years are 74.6%+/-5.3% and 66.2%+/-6.2%, respectively. There were 12 late deaths and 40% were cardiac related.: Two patients presented residual VSD (one reoperation). The left ventricular ejection fraction (LVEF) was mildly: impaired in 9 patients. Three patients had moderate mitral insufficiency and two had moderate tricuspid insufficiency.: CONCLUSION: Repair of the postinfarction VSR remains a challenge. Improvement should be rendered possible by: optimizing techniques. Postoperative morbidity is high, and these patients require intensive hospital resources. The late: results have been satisfactory.

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Unique Identifier: 98121161

Authors: Di Summa M. Actis Dato GM. Centofanti P. Fortunato G. Patane F. Di Rosa E. Forsennati PG. La Torre M.

Institution: Division of Cardiac Surgery, University of Turin, Italy.

Abstract: BACKGROUND: Ventricular septal defect (VSD) represents a serious complication after acute myocardial: infarction (AMI) with an incidence of 1-2%. Surgical treatment is often mandatory in the early period after AMI because: of the worsening of the hemodynamic and clinical conditions. METHODS: We reviewed 34 patients complicating AMI: who underwent surgical treatment at our Institution from January 1988 to December 1994 (23 males, 11 females, mean: age 64.2+/-7.96, range 45-78). The localization of the AMI was anterior in 47.05% but inferior in 52.95% of the: patients (p=NS). The mean time between AMI and VSD was 5.24+/-9.31 days. The preoperative NYHA functional: class was III-IV in 93% of the patients. QP/QS ratio was 2.7+/-0.65 and the diameter of VSD ranged from 1 to 8: (mean 2.5+/-0.35). In 26 patients (76.4%) an intraortic balloon pump (IABP) was inserted before surgery. Surgical: treatment was done after 10+/-17.7 days after VSD appearance through a left ventriculotomy. Ten patients received a: concomitant myocardial revascularization. RESULTS: Overall surgical mortality was significantly higher (p<0.05) in: patients operated on in the early period after AMI (1+/-1.4 days) and with VSD complicating an inferior AMI. A: complete follow-up was possible in all the survivors with a cumulative FU of 1453 month/patients. Two patients received: a redo procedure after 30 and 40 days after the first correction because of a residual shunt. We observed 3 late deaths: for re-AMI and one for complications after bronchial pneumonia. The actuarial survival rate is 70% at 1 year, 68% at 2: years and 65% at 7 years. NYHA functional class after operation is 1-11 in 91% of the patients. CONCLUSIONS:: The major determinant of hospital survival in VSD after AMI in our patient population was the anatomical localization: and the early timing of the operation. We believe that a prompt diagnosis and immediate cardiac support (IABP or: ventricular assist device) is recommended to obtain a hemodynamic stabilization and to achieve the shaping of stronger: cicatricial tissue before surgery. Nevertheless surgical repair of VSD is mandatory when clinical and hemodynamic: condition becomes unacceptable. The results in the long term assessment are very satisfying.