Postinfarction ventricular septal defect: patch repair with infarct exclusion

Postinfarction rupture of the interventricular septum is usually fatal without prompt surgical intervention. Repair of postinfarction ventricular septal rupture by an endocardial patch technique with infarct exclusion is associated with less morbidity and mortality. The results of this repair in 22 consecutive patients were analyzed retrospectively. After myocardial infarction, 16 patients were operated on within 7 days, 3 at 8-21 days, and 3 at 3-6 weeks. 2D-echocardiography, color Doppler studies and coronary angiography were performed in all patients prior to surgery. The mean age of the patients was 57.46 +/- 5.31 years and 20 were male; 15 were in cardiogenic shock or congestive heart failure at the time of operation. There were 5 (22.7%) operative deaths. Postoperative complications included low cardiac output, renal failure and respiratory failure. Preoperative cardiogenic shock, severe right ventricular dysfunction, residual ventricular septal defect, and preoperative renal failure were predictors of operative mortality. There were 2 late deaths. A rapid diagnosis, aggressive medical management and prompt surgical intervention are required to optimize survival and recovery in patients who present with septal rupture complicating myocardial infarction.     

Post-infarction septal rupture. Surgical management and evolution

BACKGROUND: The occurrence of a ventricular septal rupture abruptly worsens the prognosis of the patients who initially survived a myocardial infarction and imposes a surgical correction to reverse the evolving hemodynamic shock. This study reports our experience in the management of post-infarction septal defects. PATIENTS: 54 consecutive patients with a post-infarct ventricular septal defect were reviewed. The rupture was located in the antero-apical septum in 24 patients and in the postero-basal septum in 30. 26 patients presented with a one-vessel disease (the infarct-related artery), 19 with a two- and 9 with a three-vessel disease. 25 patients were in shock preoperatively. The septal rupture was approached through a left ventriculotomy in 53 patients and through a right atriotomy in 1 patient and was closed with a patch of pericardium or synthetic tissue. Aorto-coronary bypasses using vein grafts were performed on the coronary arteries that presented significant stenosis. RESULTS: 14 patients died peroperatively (2 pts) or postoperatively (12 pts) (mortality rate: 26%) mostly due to cardiac failure or cardiac complications: 25 patients among the 40 survivors suffered significant morbidity post-operatively. During follow-up (median time: 48 months), 19 patients died, again mostly from cardiac causes. Survival rate at 5 and 10 years was 70 and 40 percent, respectively. The necessity to operate within a short delay (less than 36 hours after occurrence of septal rupture) turned to be a significant predictor for increased post-operative mortality (p = 0.03). Pre-operative shock showed only a trend for an increased post-operative mortality (p = 0.13). CONCLUSION: The mortality and morbidity after surgical correction of post-infarction ventricular septal rupture remains significant. Early closure of the septal rupture seems, however, indicated in view of the gravity and evolution of the underlying disorder.     

Papillary muscle rupture in fatal acute myocardial infarction: a potentially treatable form of cardiogenic shock.

Although cardiogenic shock in acute myocardial infarction is usually associated with a critical loss of myocardium, this may not be the case in papillary muscle rupture. During the past 21 years, 13 patients came to autopsy (11 died in cardiogenic shock) with a papillary muscle rupture complicating myocardial infarction. Rupture occurred from 2 to 7 (mean, 4) days after the infarct, and survival after rupture was usually brief (median, 3 days). The infarct involved between 1% and 50% (mean, 19%) of the left ventricle, and in 10 it was less than 25%. In all instances myocardium around the mitral annulus was not infarcted. Because papillary muscle rupture occurred mostly with first infarcts (eight), involved relatively small areas of necrosis, and spared the myocardium surrounding the annulus, early mitral valve replacement should make this cause of fatal acute myocardial infarction one of the most treatable forms of cardiogenic shock.     

Post-infarction rupture of the interventricular septum. Evaluation of the main clinical parameters and postoperative survival

We reviewed 16 patients with ventricular septal rupture complicating myocardial infarction who underwent surgical repair between January 1984 and August 1987. Nine of them had anterior acute myocardial infarction (56%) and 7 inferior acute myocardial infarction (44%). The overall surgical mortality was 43.8%; in the group of patients with early treatment (less than 15 days after acute myocardial infarction) the mortality was 55%, while in the group with later treatment (16-30 days) the mortality was 28% (p-NS). Survival was unrelated to preoperative evidence of shock, magnitude of the shunt or the extent of coronary artery disease. We found a better in-hospital survival in the group of patients with ventricular septal rupture complicating anterior acute myocardial infarction (77%) vs inferior acute myocardial infarction (28%) with statistical significance (p less than 0.05). After a follow-up ranging from 1 to 40 months (mean: 17 months), 78% of the in-hospital survivors were alive and they were all in NYHA class II-III. We conclude that the major determinant of in-hospital survival in our patients was the anatomical site of acute myocardial infarction. Furthermore, we believe that the surgical repair of the ventricular septal defect is helpful in modifying the negative outcome of such an acute myocardial infarction complication.     

Ventricular septal rupture and cardiogenic shock complicating STEMI during COVID-19 pandemic: An old foe re-emerges

The COVID 19 pandemic resulted in a total reduction in the number of hospitalizations for acute coronary syndromes. A consequence of the delay in coronary revascularization has been the resurgence of structural complications of myocardial infarctions. Ventricular septal rupture (VSR) complicating late presenting acute myocardial infarction (AMI) is associated with high mortality despite advances in both surgical repair and perioperative management. Current data suggests a declining mortality with delay in VSR repair; however, these patients may develop cardiogenic shock while waiting for surgery. Available options are limited for patients with VSR who develop right ventricular failure and cardiogenic shock. The survival rate is very low in patients with cardiogenic shock undergoing surgical or percutaneous VSR repair. In this study we present two late presenting ST elevation MI patients who were complicated by rapidly declining hemodynamics and impending organ failure. Both patients were bridged with venoarterial extracorporeal membrane oxygenation (ECMO) to cardiac transplant.     

Quantitative analysis of right and left ventricular infarction in the presence of postinfarction ventricular septal defect

To quantitate the amount of right and left ventricular infarction in patients dying with postinfarction ventricular septal defect (PIVSD), hearts from 54 patients with anterior or inferior myocardial infarction were studied at autopsy. Fifteen hearts had myocardial infarction with PIVSD and 39 hearts had infarction without PIVSD and were used as a comparison group. All infarcts were sized histologically and the percent of each ventricle infarcted was quantitated by computer-assisted planimetry. The pathologic substrate for PIVSD was diffuse coronary artery disease with acute thrombosis resulting in transmural confluent infarction. Within the PIVSD group, there was significantly more left ventricle involved in anterior infarctions than in inferior infarctions (p less than .04). Conversely, there was more right ventricular infarction in inferiorly located myocardial infarctions with resulting PIVSD (p = .059). When infarctions resulting in PIVSD were compared with infarctions not resulting in PIVSD, the PIVSD group was characterized by larger left and right ventricular infarcts irrespective of infarct location (p less than .003). The incidence of right ventricular infarction was 100% in the PIVSD group (p less than .0001). Twelve of the 15 patients with PIVSD (80%) developed cardiogenic shock within 48 hr of septal rupture. The high incidence of shock and the rapid deterioration may have been secondary to right ventricular infarction in these patients. Therefore, infarcts resulting in PIVSD and subsequent death are characterized by a high incidence of right ventricular infarction. Significantly more infarction of the right ventricle is seen in either anterior or inferior infarctions resulting in PIVSD compared with infarctions not resulting in PIVSD. PIVSD complicating inferior infarctions is associated with the greatest amount of right ventricular infarction.     

Long-term course of septal rupture operated on during the acute phase of a myocardial infarct

Between 1970 and 1979, 28 patients (18 men and 10 women, aged 46 to 76 years, average 62 years) with acute myocardial infarction complicated by septal rupture survived surgery performed during the acute phase. In the same period 62 patients were admitted to the Cardiology Department and were operated early for septal rupture complicating myocardial infarction. The site of infarction was the anterior wall in 22 cases and the posterior wall in 6 cases; septal rupture occurred on average after 4.2 days (range 1 to 10 days); 15 patients including 13 with cardiogenic shock underwent intraaortic balloon pumping for an average of 3:7 (range 1 to 11 days) before surgery; the operation performed after an average interval of 11 days consisted in direct suture of the defect in 3 cases and a patch repair in the other 25 cases, associated in all cases with infarctectomy and LAD coronary bypass grafting in 1 case. The immediate postoperative course was simple; three patients with residual shunts were not reoperated. Five to 14 years later, in 1984, 4 patients had been lost to follow-up; 4 patients had died, 2 of cardiac causes (LVF after 1 year and an arrhythmia after 4 years). Of the 20 survivors, 2 were successfully reoperated (1 coronary bypass after 10 years and 1 false aneurysm after 5 years). Only one patient had recurrent myocardial infarction. The quality and longevity of long-term survival encourage early surgery. The factors affecting long-term survival are discussed: correction of associated valvular defects, resifual shunts, conservation of left ventricular function and evaluation of the coronary circulation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiac pseudoaneurysm coupled with a rupture of the papillary muscle complicating myocardial infarction

As a complication of myocardial infarction, dual rupture of the left ventricular myocardium and the papillary muscle is a rare condition. In such a case, the heart is predisposed to reduced output because of unloading of the ventricle during systole, resulting in the patient being in danger of deteriorating into a severe state or dying suddenly from cardiogenic shock. We report a rescued case of a 65-year-old woman, who had cardiogenic shock due to left ventricular pseudoaneurysm, coupled with partial rupture of the posteromedial papillary muscle three weeks after posterior myocardial infarction. Emergent left ventriculography revealed a large aneurysmal cavity and regurgitation towards the left atrium. The patient underwent emergent aneurysmectomy with mitral valve replacement.     

Silent myocardial infarction complicated by asymptomatic ventricular septal defect and deferred rupture of left ventricular pseudoaneurysm

Patients with a postinfarction ventricular septal defect or ruptured left ventricular pseudoaneurysm usually present with sudden cardiogenic shock or cardiac tamponade, respectively. We report the case of a 59-year-old man who had a silent myocardial infarction followed by an asymptomatic ventricular septal defect, both of which remained undiagnosed until the patient experienced a 2nd myocardial event 1 month later. This 2nd event was possibly a new infarction accompanied by left ventricular pseudoaneurysmal development and exsanguination, but not by tamponade. On admission, an electrocardiogram showed changes suggesting the presence of an old anterior myocardial infarction. Echocardiography revealed a ventricular septal defect and moderate pericardial perfusion, while left ventriculography disclosed a large extraventricular sac protruding from the anterior wall. The patient also had severe 2-vessel coronary artery disease, as indicated by angiography. Surgery confirmed a postinfarction ventricular septal defect and an exsanguinating pseudoaneurysm, highly circumscribed and well apart from the septal defect, involving the anterior wall of the left ventricle. The patient made good recovery following resection of the aneurysm, repair of the septal defect, and placement of 2 bypass grafts.     

Surgical repair of remediable postinfarction cardiogenic shock in the elderly. Early and long-term results

The in-hospital mortality associated with acute myocardial infarction rises markedly with advancing age. It is not established whether the elderly may benefit from early surgical repair of postinfarction cardiogenic shock due to ventricular septal defect (VSD), acute severe mitral regurgitation (MR), or left ventricular power failure. Eighteen consecutive patients between the ages of 66 and 79 (mean, 72 years) and in cardiogenic shock underwent surgical repair, most with counterpulsation support, within one week of developing VSD, MR, or left ventricular power failure. Of ten patients with VSD, five (50%) survived. Three of seven patients with MR (43%) and the only patient with power failure survived for an overall survival of 50%. The nine long-term survivors were followed up for six months to five years (mean 31 months) by personal interviews with the patient or referring physician. There was one late death, due to congestive heart failure, ten months after the operation. Of the remaining eight patients, seven are categorized as New York Heart Association class I, and one as class II. These patients have all been able to live and function independently after cardiac operation. The authors conclude that older patients with postinfarction cardiogenic shock may benefit from early operation and that advanced age does not preclude successful surgical outcome. Furthermore, operation may result in excellent long-term quality of life.     

Hybrid approach to postmyocardial infarction ventricular septal defect repair

Postinfarction ventricular septal rupture is a rare and devastating complication of myocardial infarction. Despite attempts at acute surgical and percutaneous defect closure, morbidity and mortality remain high. Herein, we describe a hybrid surgical and catheter-based approach to defect closure in a 63-year-old woman with postinfarction ventricular septal rupture and cardiogenic shock.     

Hemodynamic complications of ventricular septal rupture after acute myocardial infarction.

Ventricular septal rupture (VSR) is a rare but serious complication following acute myocardial infarction (MI). Patients may present with a new murmur associated with a thrill. Right heart catheterization will demonstrate elevated right atrial and pulmonary artery pressures as well as an oxygen step-up at the right ventricular level. Patients with a right ventricular infarction or cardiogenic shock and a ventricular septal rupture have high in-hospital mortality rates. Prompt diagnosis followed by surgical repair is essential for patients with VSR following MI.     

Evaluation of 2 years' experience with assisted circulation by diastolic counterpulsation]

The authors report their two years' experience of circulatory assistance by diastolic counter-pulsation with an intra-aortic balloon. This technique was used in 23 patients: 9 cases of cardiogenic shock due to acute myocardial infarction, 9 septal ruptures, 1 rupture of the papillary muscle of the mitral valve, 1 acute ventricular aneurysm, 2 high risk coronary arteriographies and 1 case of early post-infarction recurrent ischemia. It confirms the gravity of cardiogenic shock as, in spite of the frequent improvement in hemodynamic parameters under counter-pulsation, there was only one survivor. The efficacy is greater in cases of septal rupture, where the author obtained 3 survivors out of 6 operated cases. The security of the method and its innocuity permit one to carry out high risk coronary arteriography and extend the indications for circulatory assistance, to certain cases of unstable angina or early recurrent anginal following acute infarction.     

急性心肌梗死并发室间隔穿孔六例介入治疗

目的 评价Amplatzer肌部室间隔封堵器封堵室间隔穿孔(VSR)和同期经皮腔内冠状动脉成形术(PTCA)及冠脉支架术联合介入方法治疗急性心肌梗死(AMI)并发VSR的可行性及安全性.方法 6例患者术前均经超声心动图检查诊断为AMI并发心尖部VSR,出现心原性休克后均予主动脉球囊反搏(IABP)、机械通气支持.于3周后行室间隔封堵术,同期完成PTCA及支架术.结果 6例子Amplatzer肌部室间隔封堵器成功封堵VSR,2例有少量残余漏;同期冠状动脉造影3例患者为前降支中段及回旋支局限性狭窄,分别予植入1～2枚支架,另外3例患者为多支多段狭窄,未予以植入支架;3例并行支架的患者存活出院.结论 应用Amplatzer肌部室间隔封堵器封堵VSR同期行PTCA及冠状动脉支架术治疗AMI并发VSR是安全可行的.     

Prognosis in rupture of the ventricular septum after acute myocardial infarction and role of early surgical intervention.

Since 1944, 91 patients (50 men and 41 women, mean age 68 years [range 39 to 86]) with ventricular septal rupture after acute myocardial infarction were seen at the Mayo Clinic. Patients were divided into 4 groups according to therapy and timing of surgical intervention. Fourteen patients seen before 1965, when surgery was not performed for such a complication or not readily available, were excluded from the analysis. Group 1 (n = 22) had surgery within 48 hours of septal rupture, group 2 (n = 6) underwent operation between 2 and 14 days, group 3 (n = 24) had surgery after 14 days, and group 4 (n = 25) only received medical treatment. Short-term (30 days) survivors (45%, 35 of 77 patients) were compared with nonsurvivors. Using logistic regression, by univariate analysis, 3 variables were significantly associated with outcome: age (p less than 0.01), cardiogenic shock (p less than 0.00001), and long delay between ventricular septal rupture and surgical intervention (p less than 0.004). By multivariate analysis, however, only cardiogenic shock (p less than 0.00001) and age (p less than 0.007) correlated with an adverse outcome. In patients with cardiogenic shock after septal rupture, the prognosis was uniformly fatal unless patients undergo early surgery. None of the 23 patients in groups 2, 3 or 4 survived, whereas 5 of 13 patients (38%) who had surgery within 48 hours of septal rupture survived.(ABSTRACT TRUNCATED AT 250 WORDS)     

Short and long term predictive value of admission wall motion score in acute myocardial infarction. A cross sectional echocardiographic study of 345 patients.

A score of left ventricular segmental wall motion was used as a convenient rapid way to assess overall left ventricular function in acute myocardial infarction. Its success in risk stratification at admission was assessed by a blind review of cross sectional echocardiographic tape recordings from multiple acoustic windows. Sixty nine (20%) of the 345 patients died during hospital stay or within a one year follow up. The mean (SD) wall motion score in those who died was significantly higher than in those who survived (16.2 (5.9) vs 5.7 (3.9)). There were no differences between the group that died in hospital within three months of discharge and the group that died between three months and one year after discharge. Among the 31 patients who died in hospital, however, wall motion score was highest in 15 patients dying of cardiogenic shock (19.2 (4.2)). In 16 patients with lethal ruptures it was 13.5 (6.1). The nine patients with free wall ruptures had higher wall motion scores than those with ventricular septal rupture or papillary muscle rupture (15.7 (6.9) vs 8.5 (5.3)). Eight (3.3%) of 245 patients with a score less than 10 died, compared with 61 (61%) of 100 scoring greater than or equal to 10. The sensitivity of a score of greater than or equal to 10 in predicting death within one year was 88%, the specificity was 86%, the positive predictive value was 61%, and the negative predictive value was 97%.     

Short and long term predictive value of admission wall motion score in acute myocardial infarction. A cross sectional echocardiographic study of 345 patients

A score of left ventricular segmental wall motion was used as a convenient rapid way to assess overall left ventricular function in acute myocardial infarction. Its success in risk stratification at admission was assessed by a blind review of cross sectional echocardiographic tape recordings from multiple acoustic windows. Sixty nine (20%) of the 345 patients died during hospital stay or within a one year follow up. The mean (SD) wall motion score in those who died was significantly higher than in those who survived (16.2 (5.9) vs 5.7 (3.9)). There were no differences between the group that died in hospital within three months of discharge and the group that died between three months and one year after discharge. Among the 31 patients who died in hospital, however, wall motion score was highest in 15 patients dying of cardiogenic shock (19.2 (4.2)). In 16 patients with lethal ruptures it was 13.5 (6.1). The nine patients with free wall ruptures had higher wall motion scores than those with ventricular septal rupture or papillary muscle rupture (15.7 (6.9) vs 8.5 (5.3)). Eight (3.3%) of 245 patients with a score less than 10 died, compared with 61 (61%) of 100 scoring greater than or equal to 10. The sensitivity of a score of greater than or equal to 10 in predicting death within one year was 88%, the specificity was 86%, the positive predictive value was 61%, and the negative predictive value was 97%.     

Surgical treatment of post-infarction left ventricular pseudoaneurysm: a two-decade experience

Herein, we present a retrospective analysis of our experience with acquired pseudoaneurysms of the left ventricle over a 20-year period.From February 1985 through September 2004, 14 patients underwent operation for left ventricular pseudoaneurysm in our clinic. All pseudoaneurysms (12 chronic, 2 acute) were caused by myocardial infarction. The mean interval between myocardial infarction and diagnosis of pseudoaneurysm was 7 months (range, 1-11 mo). The pseudoaneurysm was located in the inferior or posterolateral wall in 11 of 14 patients (78.6%). In all patients, the pseudoaneurysm was resected and the ventricular wall defect was closed with direct suture (6 patients) or a patch (8 patients). Most patients had 3-vessel coronary artery disease. Coronary artery bypass grafting was performed in all patients.Five patients died (postoperative mortality rate, 35.7%) after repair of a pseudoaneurysm (post-infarction, 2 patients; chronic, 3 patients). Two patients died during follow-up (median, 42 mo), due to cancer in 1 patient and sudden death in the other.Although repair of left ventricular pseudoaneurysm is still a surgical challenge, it can be performed with acceptable results in most patients. Surgical repair is warranted particularly in cases of large or expanding pseudoaneurysms because of the propensity for fatal rupture.     

Cardiogenic shock due to myocardial infarction: surgical revascularization with centrifugal left ventricular assistance. Report of 2 cases treated successfully

Cardiogenic shock in the acute phase of myocardial infarction still carries a high mortality. In young patients who cannot be revascularised by angioplasty, when medical therapy is failing, some workers recommend an energetic approach, even cardiac transplantation, often with the bridge of mechanical cardiac assistance. This is not possible everywhere, thus preventing possible myocardial salvage and resulting in fairly high mortality. The authors report two cases in which endoluminal revascularisation was not possible and so complete surgical revascularisation with left ventricular assistance was chosen. The two patients survived and one was successfully transplanted electively. This management may be proposed in young patients with multiple occlusions of large coronary arteries in post-infarction cardiogenic shock when medical management is failing despite intra-aortic balloon pumping.