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. 2021 Oct 1;4(10):e2128309.
doi: 10.1001/jamanetworkopen.2021.28309.

Surgical Treatment of Postinfarction Ventricular Septal Rupture

Daniele Ronco  1   2 , Matteo Matteucci  1   2 , Mariusz Kowalewski  1   3 , Michele De Bonis  4 , Francesco Formica  5   6 , Federica Jiritano  1   7 , Dario Fina  1   8 , Thierry Folliguet  9 , Nikolaos Bonaros  10 , Claudio Francesco Russo  11 , Sandro Sponga  12 , Igor Vendramin  12 , Carlo De Vincentiis  13 , Marco Ranucci  8 , Piotr Suwalski  3 , Giosuè Falcetta  14 , Theodor Fischlein  15 , Giovanni Troise  16 , Emmanuel Villa  16 , Guglielmo Actis Dato  17 , Massimiliano Carrozzini  11 , Giuseppe Filiberto Serraino  7 , Shabir Hussain Shah  18 , Roberto Scrofani  19 , Antonio Fiore  9 , Jurij Matija Kalisnik  15 , Stefano D'Alessandro  5 , Vittoria Lodo  17 , Adam R Kowalówka  20   21 , Marek A Deja  20   21 , Salman Almobayedh  1 , Giulio Massimi  1 , Matthias Thielmann  22 , Bart Meyns  23 , Fareed A Khouqeer  24 , Nawwar Al-Attar  25 , Matteo Pozzi  26 , Jean-François Obadia  26 , Udo Boeken  27 , Nikolaos Kalampokas  27 , Carlo Fino  28 , Caterina Simon  28 , Shiho Naito  29 , Cesare Beghi  2 , Roberto Lorusso  1   30
Affiliations

Surgical Treatment of Postinfarction Ventricular Septal Rupture

Daniele Ronco et al. JAMA Netw Open. .

Abstract

Importance: Ventricular septal rupture (VSR) is a rare but life-threatening mechanical complication of acute myocardial infarction associated with high mortality despite prompt treatment. Surgery represents the standard of care; however, only small single-center series or national registries are usually available in literature, whereas international multicenter investigations have been poorly carried out, therefore limiting the evidence on this topic.

Objectives: To assess the clinical characteristics and early outcomes for patients who received surgery for postinfarction VSR and to identify factors independently associated with mortality.

Design, setting, and participants: The Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort (CAUTION) Study is a retrospective multicenter international cohort study that includes patients who were treated surgically for mechanical complications of acute myocardial infarction. The study was conducted from January 2001 to December 2019 at 26 different centers worldwide among 475 consecutive patients who underwent surgery for postinfarction VSR.

Exposures: Surgical treatment of postinfarction VSR, independent of the technique, alone or combined with other procedures (eg, coronary artery bypass grafting).

Main outcomes and measures: The primary outcome was early mortality; secondary outcomes were postoperative complications.

Results: Of the 475 patients included in the study, 290 (61.1%) were men, with a mean (SD) age of 68.5 (10.1) years. Cardiogenic shock was present in 213 patients (44.8%). Emergent or salvage surgery was performed in 212 cases (44.6%). The early mortality rate was 40.4% (192 patients), and it did not improve during the nearly 20 years considered for the study (median [IQR] yearly mortality, 41.7% [32.6%-50.0%]). Low cardiac output syndrome and multiorgan failure were the most common causes of death (low cardiac output syndrome, 70 [36.5%]; multiorgan failure, 53 [27.6%]). Recurrent VSR occurred in 59 participants (12.4%) but was not associated with mortality. Cardiogenic shock (survived: 95 [33.6%]; died, 118 [61.5%]; P < .001) and early surgery (time to surgery ≥7 days, survived: 105 [57.4%]; died, 47 [35.1%]; P < .001) were associated with lower survival. At multivariate analysis, older age (odds ratio [OR], 1.05; 95% CI, 1.02-1.08; P = .001), preoperative cardiac arrest (OR, 2.71; 95% CI, 1.18-6.27; P = .02) and percutaneous revascularization (OR, 1.63; 95% CI, 1.003-2.65; P = .048), and postoperative need for intra-aortic balloon pump (OR, 2.98; 95% CI, 1.46-6.09; P = .003) and extracorporeal membrane oxygenation (OR, 3.19; 95% CI, 1.30-7.38; P = .01) were independently associated with mortality.

Conclusions and relevance: In this study, surgical repair of postinfarction VSR was associated with a high risk of early mortality; this risk has remained unchanged during the last 2 decades. Delayed surgery seemed associated with better survival. Age, preoperative cardiac arrest and percutaneous revascularization, and postoperative need for intra-aortic balloon pump and extracorporeal membrane oxygenation were independently associated with early mortality. Further prospective studies addressing preoperative and perioperative patient management are warranted to hopefully improve the currently suboptimal outcome.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr De Bonis reported consulting for Abbott and Medtronic until 2020. Dr Folliguet reported consulting for LivaNova outside the submitted work. Dr Bonaros reported receiving grants and personal fees from Edwards Lifesciences, personal fees from Medtronic, and grants from LivaNova outside the submitted work. Dr Ranucci reported consulting for LivaNova and Medtronic outside the submitted work. Dr Suwalski reported receiving speakers’ fees from Atricure outside the submitted work. Dr Fischlein reported consulting for LivaNova and BioStable outside the submitted work. Dr Meyns reported receiving grants from Abiomed outside the submitted work. Dr Al-Attar reported serving as a member of the advisory board of Medtronic outside the submitted work. Dr Obadia reported receiving grants from Abbott and Carmat and receiving personal fees from Delacroix Chevalier, Landanger, and Medtronic during the conduct of the study. Dr Lorusso reported being the principal investigator of the Perceval Sutureless Implant versus Standard Aortic Valve Replacement (PERSIST-AVR) Study, sponsored by LivaNova, and consulting for Medtronic, LivaNova, and Eurosets with all honoraria paid to the University. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Mean Timing of Ventricular Septal Rupture (VSR) Occurrence and Repair
AMI indicates acute myocardial infarction. Dots represent individual cases, and the whiskers mark the SD.
Figure 2.
Figure 2.. Association of Patient and Clinical Characteristics With Early Mortality
ECMO indicates extracorporeal membrane oxygenation; IABP, intra-aortic balloon pump; VSR, ventricular septal rupture.
See this image and copyright information in PMC

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