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.

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.

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.

Perfil clínico-cirúrgico de pacientes operados por ruptura do septo interventricular pós-infarto do miocárdio / Clinical and surgical profile of patients operated for postinfarction interventricular septal rupture

OBJETIVOS: Estudar características clínicas, complicações e desfechos intra-hospitalares de pacientes operados por ruptura do septo interventricular pós-infarto. MÉTODOS: Estudo retrospectivo envolvendo 21 pacientes entre janeiro/1996 e junho/2009. Todas as operações foram realizadas na Divisão de Cirurgia Cardiovascular do Complexo Hospitalar HUOC/PROCAPE. RESULTADOS: Idade média dos pacientes foi de 62,81 anos (± 8,21), sendo 61,9 por cento (n=13) do sexo masculino. Ruptura ocorreu, em média, 4,8 dias após o infarto. Foi observado choque cardiogênico em 57,1 por cento (n=12) dos casos, sendo este fator de risco para óbito (100 por cento com choque vs. 22,2 por cento sem choque; P<0,001). Sobreviventes apresentaram média de fração de ejeção maior em comparação aos óbitos (66,29 por cento ± 4,61 por cento versus 42,71 por cento ± 4,79 por cento; P<0,001). Todos pacientes foram classificados em alto risco pelo EuroSCORE, tendo os sobreviventes média de pontuação menor em comparação aos óbitos (6,57 ± 0,53 versus 10,93 ± 2,23; P<0,001). A maioria (76,2 por cento; n=16) dos pacientes teve necessidade de uso de drogas vasoativas e 57,1 por cento (n=12) foram considerados instáveis hemodinamicamente. Necessidade de drogas vasoativas foi fator de risco para óbito (81,3 por cento no grupo com drogas vasoativas versus 20 por cento no grupo sem drogas vasoativas, P=0,025). Instabilidade hemodinâmica também foi fator de risco para óbito (100 por cento no grupo instável versus 22,2 por cento no grupo estável; P<0,001). A taxa de mortalidade intra-hospitalar foi de 66,7 por cento (n=14). CONCLUSÕES: Necessidade de drogas vasoativas, instabilidade hemodinâmica e choque cardiogênico se associaram com maiores taxas de mortalidade. Pacientes que evoluem com desfecho adverso apresentam menor função ventricular e maior pontuação no EuroSCORE. A taxa de mortalidade permanece alta.

OBJECTIVES: To study clinical features, complications and in-hospital outcomes of patients operated for postinfarction ventricular septal rupture. METHODS: A retrospective study involving 21 patients between January/1996 and June/2009. All operations were performed at the Division of Cardiovascular Surgery of Complexo Hospitalar HUOC/PROCAPE. RESULTS: Mean age of patients was 62.81 years (± 8.21), 61.9 percent (n = 13) were male. Rupture occurred on average 4.8 days after infarction. Cardiogenic shock was observed in 57.1 percent (n = 12), being risk factor for death (100 percent with shock vs. 22.2 percent without shock; P<0.001). Survivors had a higher mean ejection fraction compared to deaths (66.29 percent ± 4.61 percent versus 42.71 percent ± 4.79 percent, P <0.001). All were classified as high risk by the EuroSCORE, and the survivors had lower average score compared to deaths (6.57 ± 0.53 versus 10.93 ± 2.23; P <0.001). The majority (76.2 percent, n = 16) of the patients needed to use vasoactive drugs and 57.1 percent (n = 12) considered hemodynamically unstable. Need for vasoactive drugs was a risk factor for death (81.3 percent with vasoactive drugs versus 20 percent without vasoactive drugs, P = 0.025). Hemodynamic instability was also a risk factor for death (100 percent in the unstable group versus 22.2 percent in the stable group; P <0.001). The rate of in-hospital mortality was 66.7 percent (n = 14). CONCLUSIONS: The need for vasoactive drugs, hemodynamic instability and cardiogenic shock were associated with higher rates of mortality. Patients who had adverse outcomes had less ventricular function and higher score in the EuroSCORE. Mortality remains high.

Successful treatment of early postinfarction massive ventricular septal rupture and cardiogenic shock

A 65 years old woman presented to the ER with vomiting and severe retro-sternal chest pain for twelve hours. She was extremely dyspneic with a respiratory rate of 32/min, heart rate of 120/min, blood pressure of 70/50 mmHg and 02 saturations of 91% on 15 liters by face mask. She had bilateral crepitations upto mid lung zones bilaterally and had pan systolic murmur and had cool extremities with no pedal pulses. ECG showed massive anterior ST elevation myocardial infarction. An emergent echocardiography showed dilated right ventricle, and a large ventricular septal rupture anteriorly with severely reduced LV function. Patient was intubated, taken to the cardiac catheterization lab. An IABP was placed and on angiography large ventricular septal rupture was identified along with complete LAD occlusion. Median sternotomy was performed and patient was placed on cardiopulmonary bypass. The anterior infracted portion was excised and large anterior VSD was identified. The edges were debrided and then a large 7.5 cm defect in the anterior interventricular septum was identified. A Dacron patch was sewn along the edges of the VSD with interrupted plegeteted ethibond sutures and then the free wall of the LV and RV were brought together with plegeted prolene sutures; thus sandwitching the patch and closing the ventricular free wall also. LAD was grafted with a vein graft. IABP was removed after 48 hours and the patient was extubated. The rest of the hospital stay was unremarkable and patient was discharged home in 10 days

Ruptura do septo interventricular após trauma torácico fechado / Ventricular septal rupture following blunt chest trauma

Relatamos a seguir um caso de ruptura do septo interventricular após trauma torácico automobilístico com evolução relativamente benigna a despeito da extensão da lesão anatômica.

We report a case of ventricular septal rupture following chest trauma resulting from a car accident. The outcome was relatively favorable despite the extension of the anatomic lesion.

Pronostic des ruptures septales interventriculaires dans l'infarctus du myocarde: a propos de 13 cas

The authors report the experience about 13 cases of postinfarction ventricular septal rupture. Patients [9 men and 4 women] aged 60 to 76 years average 68 years. The site of necrosis was the anterior wall in 8 cases and the posterior wall in 5 cases. The diagnosis of septal rupture was confirmed by echocardiography and /or angiography. 6 patients died after averages: 7 days. Surgical intervention was performed in 7 cases after a mean of 51 days following the date of the myocardial infarction after an intensive care. We emphasize to demonstrate the help of intensive care and the role of early surgery for a good prognosis

Oclusión de ruptura septal interventricular en dos pacientes con infarto / Occlusion of interventricular septal rupture in two myocardic patients

Se describen dos casos de ruptura del séptum interventricula, secundaria a infarto miocárdico anteroseptal causado por la obstrucción total de la arteria coronaria descendente anterior. Con objeto de estabilizar hemodinámicamente a las pacientes, antes del cierre quirúrgico de la ruptura, se coluyó temporalmente el orificio septal por medio de un catéter con globo, introducido al ventrículo izquierdo desde la arteria femoral e inflado en el ventrículo derecho, frente a la ruptura, después de hacer pasar el globo por el defecto septal. Se observaron cambios hemodinámicos inmediatos a la oclusión de la ruptura: disminución en la relación entre el flujo sanguíneo pulmonar y el aórtico (6 por ciento en una paciente y 26 en la otra), reducción en el desvío arteriovenoso del flujo sanguíneo (8 y 31 por ciento) y elevación del flujo sanguíneo aórtico (10 por ciento) en una de las pacientes. Al disminuir el flujo pulmonar sin modificarse la presión arterial pulmonar, las resistencias arteriales pulmonares se elevaron inmediatamente después de la oclusión pero no se modificaron significativamente las presiones arteriales pulmonares y aórtica. Posteriormente las diferencias de O2 entre la arteria pulmonar y la aurícula derecha mostraron tendencias a mantenerse por debajo de los valores previos a la oclusión, favoreciendo la disminución del gasto y presión arteriales pulmonares. Una de las enfermas murió 14 días después del cierre quirúrgico de la ruptura septal; la otra murió antes de cirugía, siete días después de la colusión. Presentamos la evolución de las variables fisiológicas de las pacientes

Tratamento cirúrgico da comunicaçäo interventricular e rotura da parede livre do ventrículo esquerdo após infarto agudo do miocárdio e da disjunçäo atrioventricular após troca da valva mitral, empregando o dispositivo de isolamento ventricular (DIV): estudo experimental / Surgical treatment of postinfarction ventricular septal rupture, free wall rupture and rupture of the posterior wall of the left ventricle after mitral valve replacement, using ventricular isolation device (VID): experimental study

A rotura de parede livre do ventrículo esquerdo (VE) e a comunicaçäo interventricular (CIV) por rotura de septo säo dois eventos catastróficos que podem complicar a evoluçäo do infarto agudo do miocárdio (IAM). A oportunidade do tratamento cirúrgico, o acesso à CIV e a técnica cirúrgica ideal para o tratamento desta complicaçäo säo muito discutidos da literatura (1-5). Os resultados, porém, säo quase unânimes: alta taxa de mortalidade. A rotura da parede posterior do ventrículo esquerdo pós troca da valva mitral (disjunçäo atrioventricular) näo é uma complicaçäo rara, sendo quase sempre fatal (6,7). O objetivo de nosso trabalho é discutir a alternativa de tratamento cirúrgico destas graves lesöes, sem o manuseio direto do músculo cardíaco friável, necrozado. Desenvolvemos e testamos em animais (carneiros) o dispositivo de isolamento ventricular (DIV). No período de 12/7/95 a 10/1/96, operamos 12 carneiros adultos para o implante do DIV. No primeiro período de aprendizado da técnica de implante e de desenvolvimento da prótese, operamos 7 animais, sem sucesso, No segundo período operamos 5 animais, já com o DIV completamente desenvolvido e com a técnica cirúrgica já padronizada; obtivemos sucesso com todos os animais, sobrevivendo com bom débito cardíaco, constatado ao ecocardiograma e à ventriculografia. Após 20 dias de sobrevida, os animais foram submetidos a ventriculografia e ecocardiografia. Observamos o completo isolamento da cavidade ventricular com o emprego do DIV, obtendo o tratamento provisório destas graves lesöes.

Resultados quirúrgicos de la miomectomía septal ventricular

Este trabajo tiene por objetivo analizar los resultados a corto y mediano plazo de la miomectomía septal ventricular. Fueron revisados 6 pacientes sometidos a miotomía/miomectomía en un período comprendido entre noviembre de 1986 y diciembre de 1993 para estenosis subaórtica hipertrófica idiopática aislada o asociada a otras patologías. Se trata de 3 mujeres y 3 hombres con edades comprendidas entre 2 y 54 años (promedio 35). El diagnóstico se realizó con base en cuadro clínico, radiografía torácica, ecocardiografía bidimensional y cateterismo cardíaco. Cinco pacientes estaban en clase funcional III de la NYHA y 1 en clase II. El gradiente sistólico del tracto de salida del ventrículo izquierdo en el preoperatorio era de 66,8 mmHg en promedio. Los diagnósticos asociados fueron: estenosis valvular aórtica, insuficiencia mitral severa y bloqueo atrio-ventricular total. Las cirugías asociadas fueron valvuloplastia aórtica 1 caso (16.6 por ciento), prótesis aórtir cientoca 1 caso (16.6 por ciento), prótesis mitral 1 caso (16.6 por ciento), marcapaso epicárdico 1 caso .(16.6 por ciento). Hubo una complicación trasope (16ratoria: laceración de valvs aórticas. Las complic 1aciones postoperatorias incluyeron: infección respiratoria 2 (33.3 por ciento), fibrilación atrial aguda 1 (16.6 por ciento), accidente vascular cerebral 1 (16.6 por ciento), y mediastinitis 1 (16.6 por ciento). La mortalidad postoperatoria fue de 1 caso como uconsecuencia de sepsis y falla multiorgánica. El seguimiento fue de 2 a 53 meses (promedio 23.6) y demostró una mejoría en la clase funcional: clase I (NYHA) 4 casos 66.6 por ciento y clase II 1 caso (16.6 por ciento). El gradiente postoperatorio mejoró en todos los pacientes (promedio 17 mmHg). La miomectomía septal ventricular es un procedimiento que presenta bajo riesgo quirúrgico; la mayoría de los pacientes mostró un resultado favorable a mediano plazo

Desenvolvimento tardio de insuficiência cardíaca congestiva em comunicaçäo interventricular por ferimento penetrante, com resoluçäo da hipertensäo pulmonar após correçäo cirúrgica / Late Development of Congestive Heart Failure After a Stab Wound Ventricular Septal Defect with Regression of Wound Ventricular Septal Defect with Regression of Pulmonary Hypertension After Surgical Intervention

Male, 33 years-old, with onset of heart failure and edema; he used to be completely asymptomatic but mentioned he underwent previously a pleural drainage, after a hemothorax provoked by a stab wound. His physical examination confirmed he was in heart failure and showed a harsh holosystolic murmur between mitral and tricuspid areas. Cardiac catheterization demonstrated a large apical ventricular septal defect (VSD) and systemic pulmonary arterial pressures. With oxygen there was an increase in the left to right shunt and normal pulmonary vascular resistance. The clinical diagnosis was that of a traumatic VSD provoking pulmonary hypertension although a congenital etiology could not be completely ruled out. At surgery there was a sharp cut at the pericardium and an apical epicardial lesion; the VSD was patch sutured and the patient did well with control of his heart failure. A control hemodynamic study performed within the first postoperative month showed no residual shunt and complete normalization of the pulmonary pressures and resistance