Outcome Analysis After Surgical Management of Ventricular Septal Defect Complicating Acute Myocardial Infarction

ABSTRACT

Introduction: Surgical approaches to closure of postmyocardial infarction ventricular septal defect (PIVSD) areassociated with high morbidity and mortality. Timing ofintervention for its closure remains controversial. Severalstudies advocate early operative intervention, after diagnosisof PIVSD but these are associated with high mortality.However, the strategy of delayed closure around 14 to20 days or higher has been advocated in certain subsets ofpatients who can be stabilized from cardiogenic shock (CS)with pharmacological means with or without temporarymechanical circulatory support (tMCS). This helps to allowtissue fibrosis around PIVSD which increases the chance ofoperative success. Results of 5 such patients in whom surgerywas moderately delayed, and 2 in whom early operation wereperformed are reported in this paper.Material and methods: Between May 2012 to April 2016,7 consecutive patients of PIVSD had operative closure undercardio pulmonary bypass in our hospital. 5 patients had diureticand inotrope responsive CS and had delayed closure of PIVSDwithin 12 to 20 days, while 2 with severe CS, who weresupported preoperatively with tMCS like intra aortic balloonpump (IABP), had early closure within 72 hours. Patient dataof these seven subjects were retrospectively collected, and thecurrent status of the survivors was ascertained by out patientfollow up.Results: 4 of 5 patients from delayed surgery group withsmall PIVSD survived while 1 patient had early mortalitydue to severe right ventricular dysfunction post operativelyresulting in LCOS. 1 patient out of the 2 early surgery groupwith a large PIVSD survived while the other patient with asmall PIVSD and an extensive MI had early post operativemortality. 1 had from late surgery group had delayed mortalityafter 3 years. 4 patients are living at present.Conclusion: We advocate delayed elective repair of PIVSD,in patients with CS who responded to aggressive conservativemanagement maintaining hemodynamic stability, to allowinflammatory state to subside. In those patients with severeCS, additional rescue therapy with temporary mechanicalcirculatory support is needed to prevent further deteriorationof systemic perfusion. If the severe CS is due to high left toright shunt rather than infarct size, prognosis after repair ofPIVSD is better than in patients with CS due to extensivemyocardial damage.