Surgical repair of postinfarction VSR tied to high early mortality risk: Study

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-centre series or national registries are usually available in the literature, whereas international multicenter investigations have been poorly carried out, therefore limiting the evidence on this topic.

A team of researchers conducted a study to assess the clinical characteristics and early outcomes for patients who received surgery for postinfarction Ventricular septal rupture (VSR) and to identify factors independently associated with mortality.

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 centres worldwide among 475 consecutive patients who underwent surgery for postinfarction Ventricular septal rupture (VSR).

The primary outcome was early mortality; secondary outcomes were postoperative complications.

The results of the study are as follows:

• 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
• Low cardiac output syndrome and multiorgan failure were the most common causes of death
• Recurrent Ventricular septal rupture (VSR) occurred in 59 participants (12.4%) but was not associated with mortality.
• Cardiogenic and early surgery were associated with lower survival.
• At multivariate analysis, older age, preoperative cardiac arrest and percutaneous revascularization and postoperative need for intra-aortic balloon pump and extracorporeal membrane oxygenation were independently associated with mortality.

Thus, the researchers concluded that 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.

Reference:

Surgical Treatment of Postinfarction Ventricular Septal Rupture by Daniele Ronco, et al. published in the JAMA Network Open.

doi:10.1001/jamanetworkopen.2021.28309