Current Status of Surgical Intervention in Post Infarction Ventricular Septal Defect

Abstract

Post infarction ventricular septal defect (VSD) is an opening in the ventricular septum resulting from rupture of acutely infarcted myocardium Classification of VSDs still remains a matter for debate. However, the most widely accepted classification which is useful both clinically and surgically describes VSDs based on their location in the ventricular septum. It could be diagnosed depending on clinical symptoms, chest X-ray, electrocardiogram (ECG), echocardiogram (echo) and cardiac catheterization. The incidence of ventricular septal rupture after acute myocardial infarction is declining as interventional and thrombolytic coronary revascularization techniques have become readily available for a large number of patients. However, morbidity and mortality rates associated with this severe complication remain high, particularly when patients arrive in cardiogenic shock despite established surgical and transcatheter-based rescue efforts. Medically managed patients with postinfarct VSDs have 30-day mortality rates as high as 94%. Given this high mortality rate, surgical closure has traditionally been advocated as the preferred treatment strategy. In ventricular septal defect (VSD) surgery the alternatives of early surgical repair to avert hemodynamic instability, and surgical delay to allow for the tissue surrounding the infarcted myocardium to solidify, must be carefully weighed against one another. With advances in cardiovascular surgery and peri-operative management of the cardiac surgery patient, there were increasing reports of survival in what was previously felt to be a lethal problem Percutaneous treatment strategies can represent a reasonable alternative to surgery. However, mortality rates after interventional treatment are reported to be within the range of emergency surgery and residual or recurring shunt formation is a frequent phenomenon. A novel strategy in the surgical management of postinfarction ventricular septal rupture may be a staged approach of initial biventricular mechanical support followed by secondary surgical repair to avoid surgery on freshly infracted myocardium. Also, mechanical circulatory support following surgical repair of post infarction VSD should be considered for reducing the mortality rate after surgery. Complications of VSDs may lead to high mortality rates, congestive heart failure, pulmonary vascular disease, infective endocarditis and aortic regurgitation.