Rotura del septum interventricular post infarto agudo al miocardio: una complicación potencialmente letal Revisión de la literatura a propósito de un caso clínico / Ventricular septal rupture after acute myocardial infarction: a potentially lethal complication Case report and literature review

Rupture of the ventricular septum with the appearance of an interventricular communication is an infrequent and life-threatening mechanical complication after acute myocardial infarction. The advent of coronary reperfusion therapies has reduced the incidence of this complication, but mortality remains high. The clinical presentation varies from mild compromise with exertional dyspnea to severe compromise with cardiogenic shock. In this pathology, early diagnosis is fundamental and surgical repair is the treatment of choice. In this article we report an interesting clinical case about a 77-year-old woman who was belatedly referred to our hospital and diagnosed with postinfarction rupture of the ventricular septum with an unfortunately fatal evolution. Relevance of this case lies in its atypical clinical presentation which led to a delay in diagnosis and a missed opportunity for early reperfusion therapy. An updated literature review about rupture of the ventricular septum complicating acute myocardial infarction was carried out.

Efficacy and safety of percutaneous closure of ventricular septal rupture after acute myocardial infarction: a clinical study of 69 cases / 中华心血管病杂志

Objective: To investigate the efficacy and safety of percutaneous closure of ventricular septal rupture (VSR) after acute myocardial infarction (AMI) and the risk factors of all-cause mortality at 30 days after operation. Methods: This is a retrospective case series study. A total of 69 patients with post-AMI VSR, underwent percutaneous closure of VSR from October 2013 to May 2020 in Department of Cardiology of Henan Provincial People's Hospital and Department of Cardiology of Central China Fuwai Hospital, were included. Patients were divided into survival group (53 cases) and non-survival group (16 cases) according to the status at 30 days after operation. Clinical data were collected and analyzed during hospitalization. Telephone follow-up was performed 30 days after operation. The primary safety endpoint was occlusion failure and all-cause mortality at 30 days post operation. The secondary safety endpoint was the operation related or non-operation related complications. Efficacy endpoint included NYHA classification of cardiac function, index measured by right heart catheterization and echocardiography. Multivariate logistic regression was performed to analyze the risk factors of all-cause mortality at 30 days after operation. Results: A total of 69 patients, aged 67 (64, 71) years, including 42 women (60.9%), were enrolled in this study. All-cause death occurred in 16 patients (23.2%), including 13 in-hospital death and 3 death during follow-up. There were 4 cases of closure failure (5.8%). Among the 65 patients with successful closure, 12 (18.5%) experienced operation-related complications, among which 8 (12.3%) experienced valve injury. The mortality was significantly higher in patients with operation-related complications than that in patients without operation-related complications (41.7% (5/12) vs. 13.2% (7/53), P = 0.022). One case received percutaneous closure of VSR and PCI, this patient experienced new-onset AMI immediately post procedure and died thereafter (1.5%). One case (1.5%) developed multiple organ failure and 2 cases (3.1%) developed gastrointestinal bleeding post operation. All of the 65 patients with successful occlusion completed postoperative echocardiography, 56 patients completed cardiac function assessment at discharge, and 53 patients who survived up to 30 days post discharge completed clinical follow up by telephone. The NYHA cardiac function at discharge and 30 days after operation were significantly improved as compared to that before operation (P<0.001), the ratio of NYHA Ⅰ and Ⅱ patients was significantly higher post operation at these two time points as compared to baseline level (76.8% (43/56) vs. 23.1% (15/65), P<0.001, 77.4% (41/53) vs. 23.1% (15/65), P<0.001). The pulmonary circulation/systemic circulation blood flow ratio (Qp/Qs), pulmonary artery systolic pressure (PASP) and left ventricular end-diastolic diameter (LVDd) were decreased, aortic systolic pressure (ASP) and left ventricular ejection fraction (LVEF) were increased post operation (P<0.05). Multivariate logistic regression analysis showed that WBC>9.8×109/L (OR=20.94, 95%CI 1.21-362.93, P=0.037) and NT-ProBNP>6 000 ng/L (OR=869.11, 95%CI 2.93-258 058.34, P=0.020) were the independent risk factors of mortality at 30 days. Conclusions: Percutaneous closure in VSR after AMI is safe and effective. The increase of WBC and NT-ProBNP are the independent risk factors of all-cause mortality at 30 days after operation.

A risk score model for predicting cardiac rupture after acute myocardial infarction / 中华医学杂志(英文版)

BACKGROUND@#Cardiac rupture (CR) is a major lethal complication of acute myocardial infarction (AMI). However, no valid risk score model was found to predict CR after AMI in previous researches. This study aimed to establish a simple model to assess risk of CR after AMI, which could be easily used in a clinical environment.@*METHODS@#This was a retrospective case-control study that included 53 consecutive patients with CR after AMI during a period from January 1, 2010 to December 31, 2017. The controls included 524 patients who were selected randomly from 7932 AMI patients without CR at a 1:10 ratio. Risk factors for CR were identified using univariate analysis and multivariate logistic regression. Risk score model was developed based on multiple regression coefficients. Performance of risk model was evaluated using receiver-operating characteristic (ROC) curves and internal validity was explored using bootstrap analysis.@*RESULTS@#Among all 7985 AMI patients, 53 (0.67%) had CR (free wall rupture, n = 39; ventricular septal rupture, n = 14). Hospital mortalities were 92.5% and 4.01% in patients with and without CR (P < 0.001). Independent variables associated with CR included: older age, female gender, higher heart rate at admission, body mass index (BMI) <25 kg/m, lower left ventricular ejection fraction (LVEF) and no primary percutaneous coronary intervention (pPCI) treatment. In ROC analysis, our CR risk assess model demonstrated a very good discriminate power (area under the curve [AUC] = 0.895, 95% confidence interval: 0.845-0.944, optimism-corrected AUC = 0.821, P < 0.001).@*CONCLUSION@#This study developed a novel risk score model to help predict CR after AMI, which had high accuracy and was very simple to use.

Clinical results after surgical treatment for non-selective case with postinfarction ventricular septal rupture / 北京大学学报(医学版)

OBJECTIVE@#To observe the clinical prognosis and surgical treatment results in patients with postinfarction ventricular septal rupture, and to discuss the risk factors, methods & timing of treatment.@*METHODS@#From January 2006 to February 2019, 23 patients with postinfarction ventricular septal rupture were admitted to the department of cardiac surgery, Peking University People's Hospital, including 12 males (52.2%) and 11 females (47.8%), aged (64.26 ±11.09) years. Among them, 18 cases underwent operation, and 5 cases did not receive surgical treatment. The clinical data and follow-up data were summarized retrospectively.@*RESULTS@#Among the patients treated with operation, the average time from perforation to operation was (19.39 ±13.67) d, including 6 cases (33.3%) of perforation within 1 week, 6 cases (33.3%) within 2 to 4 weeks and 6 cases (33.3%) more than 4 weeks. Emergency surgery was performed in 11 cases (61.1%) because of hemodynamic instability, and selective operation in 7 cases (38.9%). Direct enlarged patch was used in 13 cases (72.2%), and some infarct exclusion techniques were used in 5 patients (27.8%). In 18 cases, coronary artery bypass grafting was performed in 12 cases (66.7%). Of all the surgical patients, 7 (38.9%) died during hospitalization. Compared with the survival patients, the perioperative death patients had earlier perforation [(1.83±0.75) d vs. (5.22 ±4.66) d, P=0.019] and higher emergency operation rate (100% vs. 36.4%, P=0.009) and lower simultaneous bypass grafting rate (28.6% vs. 90.1%, P=0.008). The median follow-up time was 2 years (3 months to 10 years). 2 patients died of heart failure in 2 months after operation, and 9 cases (50.0%) survived for a long time. Of the 5 patients who had not been treated, 2 died while waiting for operation, and 3 patients who refused surgery died within 1 week after discharge.@*CONCLUSION@#Surgery is an effective treatment for patients with acute myocardial infarction complicated with ventricular septum perforation. The best time for operation should be determined by real-time evaluation and monitoring, combined with the situation of patients. Concomitant coronary artery bypass grafting may be beneficial to these patients.

Surgical repair of post-infarction ventricular septal rupture: determinants of operative mortality and survival outcome analysis

Background and Objective: Ventricular septal rupture [VSR] is one of the fatal complications of myocardial infarction [MI]. Surgery provides the maximum survival benefit. Our objective was to investigate the risk factors of surgical mortality and to do the survival analysis in the past six years at our hospital

Methods: All the patients operated at CPE Institute of Cardiology Multan Pakistan, between 2009 and 2015 for repair of post MI VSR were analysed retrospectively for demographics, comorbidities, operative and post operative outcomes. The primary outcome was 30 days mortality. The follow up was done till April 2017 and the follow up data was obtained from hospital records and by telephoning the patients. SPSS was used for statistical analysis. P value < 0.05 was considered significant

Results: A total of 31 patients were operated for VSR repair with a mean age of 57.19 +/- 7.73 years. Eighteen patients also had a concomitant coronary artery bypass grafting [CABG]. The operative mortality in this series was 25.8% Univariate analysis showed that pre-operative ejection fraction [E.F] [p value 0.010] and cardiogenic shock [p value 0.031] were a significant risk factors for operative mortality while on logistic regression analysis only the cardiogenic shock was found to be an independent risk factor for operative mortality with the odds ratio of 2.17. Low ejection fraction only acted as a confounding variable. The mean survival at six years was 34 months with a survival rate of 28.6%. The additional CABG did not confer any survival benefit

Conclusion: The patients in cardiogenic shock pre-operatively have a high operative mortality. Low ejection fraction [E.F] acts as a confounding factor. Concomitant CABG does not confer any survival benefit

Techniques, timing & prognosis of post infarct ventricular septal repair: a re-look at old dogmas

Abstract Objective: The study aimed to identify the factors affecting the prognosis of post myocardial infarction (MI) ventricular septal rupture (VSR) and to develop a protocol for its management. Methods: This was a single center, retrospective-prospective study (2009-2014), involving 55 patients with post MI VSR. The strengths of association between risk factors and prognosis were assessed using multivariate logistic regression analysis. The UNM Post MI VSR management and prognosis scoring systems (UPMS & UPPS) were developed. Results: Thirty-day mortality was 52.5% (35% in the last 3 years). Twenty-eight (70%) patients underwent concomitant coronary artery bypass grafting. Residual ventricular septal defect was found in 3 (7.5%) patients. The multivariate analysis showed low mean blood pressure with intra-aortic balloon pump (OR 11.43, P=0.001), higher EuroSCORE II (OR 7.47, P=0.006), higher Killip class (OR 27.95, P=0.00), and shorter intervals between MI and VSR (OR 7.90, P=0.005) as well as VSR and Surgery (OR 5.76, P=0.016) to be strong predictors of mortality. Concomitant coronary artery bypass grafting (P=0.17) and location (P=0.25) of VSR did not affect the outcome. Mean follow-up was 635.8±472.5 days and 17 out of 19 discharged patients were in NYHA class I-II. Conclusion: The UNM Post-MI VSR Scoring Systems (UPMS & UPPS) help in management and prognosis, respectively. They divide patients into 3 groups: 1) Immediate Surgery - Patients with scores of <25 require immediate surgery, preferably with extracorporeal membrane oxygenation support, and have poor prognosis; 2) Those with scores of 25-75 should be managed with "Optimal Delay" and they have intermediate outcomes; 3) Patients with scores of >75 can undergo Elective Repair and they are likely to have good outcomes.

Delayed Repair of Ventricular Septal Rupture Following Preoperative Awake Extracorporeal Membrane Oxygenation Support

Outcomes of ventricular septal rupture (VSR) as a complication of acute myocardial infarction are extremely poor, with an in-hospital mortality rate of 45% in surgically treated patients and 90% in patients managed with medication. Delaying surgery for VSR is a strategy for reducing mortality. However, hemodynamic instability is the main problem with this strategy. In the present case, venoarterial extracorporeal membrane oxygenation (ECMO) was used to provide stable hemodynamic support before the delayed surgery. Awake ECMO was also used to avoiding the complications of sedatives and mechanical ventilation. Here, we describe a successful operation using awake ECMO as a bridge to surgery.

Rupture of Right Ventricular Free Wall Following Ventricular Septal Rupture in Takotsubo Cardiomyopathy with Right Ventricular Involvement

Most patients diagnosed with takotsubo cardiomyopathies are expected to almost completely recover, and their prognosis is excellent. However, complications can occur in the acute phase. We present a case of a woman with takotsubo cardiomyopathy with right ventricular involvement who developed a rupture of the right ventricular free wall following ventricular septal rupture, as a consequence of an acute increase in right ventricular afterload by left-to-right shunt. Our case report illustrates that takotsubo cardiomyopathy can be life threatening in the acute phase. Ventricular septal rupture in biventricular takotsubo cardiomyopathy may be a harbinger of cardiac tamponade by right ventricular rupture.

A Case of Ventricular Septal Rupture in Stress Cardiomyopathy

Stress cardiomyopathy (SCMP) is a reversible heart disease, commonly accompanied by emotional or physical stress. Early clinical features are similar to those of acute myocardial infarction, such as acute chest symptoms, ST-segment elevation on electrocardiography, and cardiac biomarkers elevation. However, there is usually no evidence of significant coronary obstruction on a coronary angiogram. Moreover, ventricular dysfunction with regional wall motion abnormalities does not correlate with a single vascular territory. The typical type of SCMP is apical wall motion abnormality with an apical ballooning pattern, and various types of SCMP have recently been reported. Generally, cardiac dysfunction or abnormal wall motion is improved within several weeks, and the prognosis of SCMP is generally good. Thus, the mainstay of the treatment is largely conservative. However, there are some serious complications during the acute phase. In particular, cardiac rupture is a rare but serious structural complication associated with high mortality. In this manner, SCMP could potentially be life threatening during the acute phase, despite it generally being a benign disease in most cases. Early recognition of this complication, appropriate medical therapy, and surgical intervention are required to improve recovery and survival. Here, I report a case of an 83-year-old female patient with SCMP complicated by ventricular septal rupture.

Transatrial Approach for the Repair of the Posterior Post-Infarct Ventricular Septal Rupture

Ventricular septal rupture (VSR) is a disastrous mechanical complication of myocardial infarction. Although several surgical interventions have been developed, mortality due to surgical management remains high, especially in the case of posterior VSR. We report a successful case of repair of posterior VSR using an alternative transatrial approach to avoid the complications related to ventricular incision.

Transatrial Approach for the Repair of the Posterior Post-Infarct Ventricular Septal Rupture

Ventricular septal rupture (VSR) is a disastrous mechanical complication of myocardial infarction. Although several surgical interventions have been developed, mortality due to surgical management remains high, especially in the case of posterior VSR. We report a successful case of repair of posterior VSR using an alternative transatrial approach to avoid the complications related to ventricular incision.

Spontaneous perforation and dissection of the sinus of Valsalva and interventricular septum with intracardiac thrombus in a patient with Behcet's disease

No abstract available.

Ventricular Septal Rupture in a Case Suspected as Stress Induced Cardiomyopathy

An 87-year-old woman with continuous chest discomfort was referred to our hospital. ST-segment elevation in lead V1-4 was detected on electrocardiography and ventricular septal rupture (VSR) was observed on echocardiography. Post-acute myocardial infarction (AMI) VSR was suspected and she underwent emergency cardiac catheterization. However, coronary angiography showed normal coronary artery. On the fourth day after admission, the patient died. We suspect that VSR was developed by stress induced cardiomyopathy, not by AMI.

Management of patients with acute myocardial infarction complicated by ventricular septal rupture - AFIC study

The aim of this study was to report management; peri-procedural and short term results of patients hospitalized with acute myocardial infarction [MI]complicated by ventricular septal rupture [VSR] considered high risk or unfit for surgical repair at AFIC-NIHD. Quasi experimental study Adult and paediatric cardiology departments of Armed Forces Institute of Cardiology / National Institute of Heart Diseases [AFIC/NIHD] from 1[st] January 2012 to 31[st] August 2013. We included 12 patients with post myocardial infarction VSR with mean age of 59 years [41-85 years], who underwent elective transcatheter closure. The entry criteria for trans-catheter closure after initial medical stabilization was 1] patients with ventricular septal rupture up to 20 mm size with significant left to right shunting [Qp/Qs >1.5] 2] defect anatomy and location thought to be suitable for device closure or otherwise considered high risk or unfit for surgical closure. The time from the onset of infarction to the index procedure ranged between 4 to 20 days [mean 10.83 days]. There were ten patients in acute phase [2 weeks or less] and two presented in sub-acute phase [> 2 weeks]. Ten patients were in NYHA class III and one each in class II and IV. A successful device implantation occurred in all patients except in one in whom second attempt failed. The defect size ranged 4-18 mm [mean 9.25 mm] and the devices ranging from 8-22 mm [mean 13.3 mm] were implanted. The procedure time ranged from 90-140 min [mean 105 min]. In all patients Qp/Qs was more than 2 and decreased to less than two after the procedure. Six surviving patients are in NYHA class II and doing well. One patient died one hour after the procedure whereas one patient died twelve hour after the closure because of re-infarction. One patient developed another VSR leak 3 days after the procedure and device closure was attempted again but the device could not be deployed. He subsequently died awaiting surgery. Primary trans-catheter closure of post-infarction ventricular septal rupture may be an alternative to surgery in patients with suitable anatomy and high risk or unfit for surgery

Cirugía de la comunicación interventricular post infarto: análisis de los últimos 22 años / Surgery for post infarction ventricular septal defect: a 22-year experience

Introducción: El desarrollo de una comunicación interventricular en la evolución de un infarto miocárdico es una complicación muy grave, aunque infrecuente. Objetivo: Comunicar nuestros resultados con el tratamiento quirúrgico de pacientes con comunicación interventricular post infarto (CIVPI) intervenidos en los últimos 22 años. Método: Analizamos en forma retrospectiva los antecedentes de los pacientes intervenidos entre Enero de 1991 y Diciembre de 2012. Revisamos fichas clínicas, protocolos operatorios y certificamos la mortalidad con el Registro Civil e Identificación de Chile. Resultados: Operamos 43 pacientes, edad promedio de 66,6 +/- 10,2 años. El 58 por ciento eran hombres, de menor edad que las mujeres (63,1 +/- 10,8 vs 71,5 +/- 6,9 años, p=0,006). El tiempo promedio entre el diagnóstico de infarto y de CIVPI fue 10 +/- 15 días. El 74 por ciento fueron intervenidos de urgencia. La CIVPI fue anterior en 58 por ciento. Se realizó revascularización miocárdica concomitante en el 58 por ciento. Trece pacientes fallecieron (30 por ciento) en el posoperatorio. Factores de riesgo de mortalidad operatoria fueron: cirugía de urgencia ( p = 0,019]) y uso de balón intra aórtico (p = 0,006). La cirugía realizada después de las 24 horas del diagnóstico tuvo una mortalidad significativamente menor (7,7 por ciento, p=0,033). El seguimiento promedio fue de 8,36 +/- 5,3 años. La supervivencia alejada, excluida la mortalidad operatoria, a 5 y 10 años, fue 93 por ciento y 71 por ciento, respectivamente. Conclusión: La CIVPI tiene elevada mortalidad operatoria, especialmente en pacientes intervenidos de urgencia y en los que requirieron balón de contra pulsación, pero la supervivencia alejada de los sobrevivientes es muy satisfactoria.

Background: The development of a ventricular septal defect (VSD) after myocardial infarction is a rare but very serious complication for which the treatment of choice is surgical repair. Aim: To report our results with patients operated on for post-infarction VSD in the last 22 years. Methods: This is a retrospective review of all patients operated for post infarction VSD between january 1991 and december 2012. We reviewed all clinical charts and operative notes. Longterm mortality was certified by the "Registro Civil e Identificación de Chile". Results: Fourty three patients with a mean age of 66.6 +/- 10.2 years underwent surgical repair. Fifty eight percent were males. The average time between myocardial infarction and the diagnosis of vsd was 10 +/- 15.2 days. Seventy four percent of patients were operated on as an emergency. In 58 percent of cases the VSD was located in the anterior septum. Myocardial revascularization was performed in 58 percent. Thirteen patients died for an operative mortality of 30 percent. Risk factors for operative mortality were emergency surgery (p = 0,04) and the use of intraaortic balloon pump (p = 0,004). Non emergency surgery had a much lower mortality rate ( 7,7 percent, p = 0,033). Survival excluding operative mortality at 5 and 10 years was 90 percent and 71 percent, respectively. Conclusions: Operative mortality for repair of post infarction VSD remains high, mainly in patients undergoing an emergency operation. Surgical survivors have a very good life expectancy.

Died immediately after corrective surgery for right ventricular acute myocardial infarction and ventricular septal rupture / 영남의대학술지

Postinfarction ventricular septal rupture (VSR) is a rare but fatal complication of acute myocardial infarction. In many cases, postinfarction VSR leads to hemodynamic instability and urgent surgical treatment is necessary. Here we describe a case of a patient with right ventricular (RV) dysfunction caused by acute RV infarction and with cardiogenic shock, whose condition improved after development of postinfarction VSR, but the patient died after corrective surgery.

Ruptura de parede septal e corda tendínea de valva tricúspide após infarto audo do miocárdio / Ventricular septal perforation and rupture of the chordae tendineae of the tricuspid valve after acute myocardial infarction

Ruptura de parede septal (RPS) no infarto agudo do miocárdio (IAM) é uma complicação com alta mortalidade, com incidência de 0,2% na era de reperfusão miocárdica. Relata-se um caso de paciente com IAM associado à RPS, e possível rotura de cordas tendinosas da valva tricúspide.

Postinfarction ventricular septal perforation (VSP) is high-mortality complication with an incedence of 0,2%. This paper presents a case report on a patient presenting VSP in association with a possible rupture of the chordae tendineae of the tricuspide valve.

Anesthetic management for reentry sternotomy in a patient with a full stomach and pericardial tamponade from left ventricular rupture.

A 57-year-old man presented with chest pain and shortness of breath 1 month after left ventricular aneurysmectomy and ventricular septal defect closure for post-infarct left ventricular aneurysm and ventricular septal defect. Echocardiography revealed a large recurrent ruptured inferior left ventricular aneurysm with high-velocity flow into a 5 cm posterolateral pericardial effusion. Thirty minutes earlier, the patient had eaten a full meal. Rapid sequence induction was performed with midazolam, ketamine, and succinylcholine. Moderate hypotension was treated effectively and the patient tolerated controlled transition to cardiopulmonary bypass. The ventricular defect was oversewn and reinforced with bovine pericardium. The patient had a difficult but ultimately successful recovery. Options for anesthetic management in the setting of tamponade and a full stomach are discussed, with a brief review of the evidence relating to this clinical problem.