Little Change in Prognosis for Ventricular Septal Rupture

Ventricular septal rupture following myocardial infarction is a rare but potentially catastrophic complication.  Current ACC and AHA guidelines recommend immediate operative intervention in patients with postinfarction ruptures, regardless of their clinical status, but surgical repair remains very challenging with reported in-hospital mortality being reported in the range of 20-60%.
In this single-centre, retrospective study the authors identified a total of 68 patients undergoing repair between 1988 and 2007 out of a total of 37,177 cardiac surgical procedures during this time.  The majority (85%) were operated on within 48 hours of diagnosis and 96% had preceding coronary angiography and 71% subsequent surgical revascularisation with an average of 1.7 grafts per case.  A total of 14 surgeons were responsible for the operations and approaches and techniques differed but 99% had repair using a patch either of artificial material (74%), bovine pericardium (22%) or autologous pericardium (3%).  A minority of patients also underwent a variety of other procedures including LV aneurysmectomy (6%) and mitral valve surgery (1%). The mean follow-up period was 9.2 +/- 4.9 years.
Thirty-day mortality for the whole group was 35%, with previous myocardial infarction, previous cardiac surgery, preoperative left ventricular ejection fraction less than 40%, and urgent surgery being independent risk factors for death.  However in the group who presented with cardiogenic shock (12%) 30-day mortality was 100% and this is clearly a sub-group with a very poor prognosis.  On the other hand, in those who survived 30 days, prognosis was good with an actuarial survival of 88% at 5 years, 73% at 10 years, and 51% at 15 years.  Actuarial freedom from congestive cardiac failure and ventricular tachyarrhythmia was also good at 70% and 85% at 5 years, 54% and 71% at 10 years, and 28% and 61% at 15 years, respectively.
Interestingly, despite the long period of the study and the evolution in surgical techniques and technology over time, there was no significant difference in early mortality between those operated on in the period 1988-1992 (38%) and those operated on in the period 2003-2007 (40%) but there did appear to be a trend towards fewer presentations over time, with 32 in the initial period and only 10 in the latter, perhaps due to more timely and effective reperfusion strategies.

Conclusion:

Aggressive surgical management of ventricular rupture leads to benefits in both early and late mortality and the prognosis for survivors is generally favourable.  However, there appears however to have been little progress in bringing down early surgical mortality rates.
Figure

• Fukushima S, Tesar PJ, Jalali H, Clarke AJ, Sharma H, Choudhary J, Bartlett H and Pohlner PG. Determinants of in-hospital and long-term surgical outcomes after repair of postinfarction ventricular septal rupture. J Thorac Cardiovasc Surg. 2009 Nov 16. 140(1) 59-65

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