How Should We Treat VSDs and Acute MR Post MI?

Ventricular septal defect (VSD) complicating AMI is a relatively rare event associated with high mortality. The incidence of infarct related VSD without reperfusion ranged from 1-2%,1,2 with a decrease to 0.2% in the era of reperfusion.3 In patients with cardiogenic shock, VSD is the underlying cause in 3.9%, and mortality can be as high as 87.3%, as was seen in the SHOCK trial registry.4 Without surgical repair of postinfarction VSD 90% of patients die within 2 months.5

Surgical VSD correction was first described in 1957.6 The current mortality of surgical postinfarction VSD closure is as high as 50%, with a lower mortality seen when surgery is delayed (Slide 1).7 However, the lower mortality from delayed surgery may relate more to selection bias, with survival of the fittest. In two prospective registries, the mortality rates were as high as 81-100% for patients with VSD and shock.3,8 Current guidelines recommend immediate surgical VSD closure irrespective of the patient's hemodynamic status.9,10 Nevertheless, a subgroup of patients with VSD exists for whom surgery is futile, because mortality approaches 100%; this includes the very elderly and patients with poor right ventricular function.

As a result of the high mortality and suboptimal surgical results with a postoperative residual shunt found in up to 20% of the treated patients,3,11,12 the technique of percutaneous VSD device closure has been developed.13 Currently, data are limited for postinfarction VSD interventional closure. The largest single-center experience reported was in 29 patients, which found a survival rate at 30 days of 35%. Mortality was much higher in cardiogenic shock as opposed to non-shock patients (88% versus 38%, p<0.001).13 Procedure related complications were not infrequent, which demonstrates the requirement of additional technical improvement. An overview on outcomes of interventional VSD repair can be found in Slide 2, showing similar mortality rates as compared to surgical repair.

In patients with cardiogenic shock, acute ischemic mitral regurgitation was the underlying cause in 6.9%. In acute ischemic mitral regurgitation, only papillary muscle rupture needs immediate repair. Other causes, such as left ventricular global or regional remodelling, or ischemic papillary muscle dysfunction, may resolve after revascularization and recovery of left ventricular function. Accordingly, only 46% of the patients in the SHOCK trial registry underwent mitral valve surgery.14 In contrast to VSD repair, surgery of papillary muscle rupture does not involve necrotic myocardium in suture lines. Therefore, mortality associated with this repair is lower, although is still high with an overall mortality of 55%.4,14 Nevertheless, the unpredictability and potential for rapid deterioration and death with papillary muscle rupture makes early surgery necessary. There are few case reports with interventional edge-to-edge repair in acute ischemic mitral regurgitation; however, no larger series have been published. A treatment algorithm with the underlying guideline recommendations for the assessment and treatment of patients with cardiogenic shock and potential mechanical complications has recently been published and may be a helpful tool in clinical practice.15

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References

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  8. Menon V, Webb JG, Hillis LD, Sleeper LA, Abboud R, Dzavik V, Slater JN, Forman R, Monrad ES, Talley JD, Hochman JS. Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK? J Am Coll Cardiol 2000; 36:1110-1116.
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Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and CHD & Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Congenital Heart Disease, CHD & Pediatrics and Interventions, CHD & Pediatrics and Quality Improvement, Acute Heart Failure, Interventions and ACS, Interventions and Structural Heart Disease, Mitral Regurgitation

Keywords: Aged, Algorithms, Cardiac Surgical Procedures, Heart Septal Defects, Ventricular, Hemodynamics, Incidence, Mitral Valve, Mitral Valve Insufficiency, Myocardial Infarction, Papillary Muscles, Prospective Studies, Registries, Selection Bias, Shock, Shock, Cardiogenic, Survival Rate, Sutures, Ventricular Function, Left, Ventricular Function, Right, Acute Coronary Syndrome


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