Ventricular Septal Rupture

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J Am Coll Cardiol. 2000 Sep;36(3 Suppl A):1110-6.
Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?
Menon V, Webb JG, Hillis LD, Sleeper LA, Abboud R, Dzavik V, Slater JN, Forman R, Monrad ES, Talley JD, Hochman JS.
Division of Cardiology, St. Luke's-Roosevelt Hospital Center, Columbia University, New York, New York 10025, USA.

OBJECTIVES: We wished to assess the profile and outcomes of patients with ventricular septal rupture (VSR) in the setting of cardiogenic shock (CS) complicating acute myocardial infarction (MI). BACKGROUND: Cardiogenic shock is often seen with VSR complic ating acute MI. Despite surgical therapy, mortality in such patients is high. METHODS: We analyzed 939 patients enrolled in the SHOCK Trial Registry of CS in acute infarction, comparing 55 patients whose shock was associated with VSR with 884 patients who had predominant left ventricular failure. RESULTS: Rupture occurred a median 16 h after infarction. Patients with VSR tended to be older (p = 0.053), were more often female (p = 0.002) and less often had previous infarction (p < 0.001), diabetes mellitus (p = 0.015) or smoking history (p = 0.033). They also underwent right-heart catheterization, intra-aortic balloon pumping and bypass surgery significantly more often. Although patients with rupture had less severe coronary disease, their in-hospital mort ality was higher (87% vs. 61%, p < 0.001). Surgical repair was performed in 31 patients with rupture (21 had concomitant bypass surgery); 6 (19%) survived. Of the 24 patients managed medically, only 1 survived. CONCLUSIONS: There is a high in-hospital mor tality rate when CS develops as a result of VSR. Ventricular septal rupture may occur early after infarction, and women and the elderly may be more susceptible. Although the prognosis is poor, surgery remains the best therapeutic option in this setting.

Acta Cardiol. 2005 Apr;60(2):213-7.
Postinfarction ventricular septal rupture: surgical intervention and risk factors influencing hospital mortality.
Ozkara A, Cetin G, Mert M, Eray Yildiz C, Arat A, Akcevin A, Suzer K.
Department of Cardiovascular Surgery, Institute of Cardiology, Istanbul University, Turkey.

Postinfarction rupture of the interventricular septum is usually fatal without surgical intervention and requires urgent closure. Between 1989 and 2003 twenty consecutive patients (15 male, 5 female), underwent postinfarction ventricular septal rupture (V SR) repair. Mean age of the patients was 62.05 +/- 7.51 years. Fifteen patients were operated within 48 hours after myocardial infarction. Patch reconstruction was performed in all patients. Infarct locations were anterior in 65%, posterior in 35%. Corona ry artery surgery was performed in 14 patients (70%). Hospital mortality was 30% (6 patients). Four patients were presented for surgical therapy with frank cardiogenic shock or low cardiac output syndrome. A residual shunt was detected in 4 patients and t hree of these patients were reoperated. One of them, who has been reoperated on the first day of the postoperative period, did not survive. The statistical analysis of the patients' records demonstrated that time period between MI and surgery, applied add itional CABG procedure, the sex of the patients and the site of the rupture are significant factors influencing in-hospital mortality. Preoperative condition, age of the patients and the number of the affected coronary vessels do not have an important eff ect on the mortality. Postinfarction ventricular septal rupture is a fatal complication of the myocardial infarction and must be treated surgically. The time interval between septal rupture independent from the preoperative haemodynamic condition, the loc ation of the defect and additional myocardial revascularization procedure are the factors influencing the early outcome.

Kyobu Geka. 2005 Apr;58(4):278-83.
Risk factors for the surgical repair of ventricular septal perforation; an 8-year multiinstitutional analysis
Sugiki H, Murashita T, Kunihara T, Matsuzaki K, Shiiya N, Yasuda K.
Department of Cardiovascular Surgery, Hokkaido University School of Medicine, Sapporo, Japan.

OBJECTIVE: The purpose of this study was to determine the surgical outcomes and risk factors for surgical repair of the ventricular septal perforation (VSP). METHOD: From 1995 to 2003, 41 patients with VSP underwent surgical repair. There were 18 males an d 23 females, with the mean age of 71.7 +/- 9.2. Sixteen patients (39.0%) had the preoperative shock, while 30 patients received intraaortic balloon pumping (IABP) assistance and 1 of those required percutaneous cardiopulmonary support (PCPS). Mean durati ons from onset of myocardial infarction and VSP to operation were 5.8 +/- 9.4 and 2.4 +/- 8.1 days, respectively. Twenty-six patients underwent infarct exclusion technique, 11 underwent patch closure, and 4 Daggett operation. Mean cardiopulmonary and aort ic cross-clamp time were 211 +/- 85 and 105 +/- 43 minutes, respectively. RESULTS: Thirty days mortality was 11 (26.8%). Nine patients (22%) required PCPS after repair, however, 2 weaned off the support and only 1 discharged the hospital. Residual shunt w as found in 12 patients (29.3%), and 4 underwent the reclosure of the residual shunt 13 +/- 8.6 days after the initial operation, whereas none of patients with PCPS had residual shunt. Univariate analysis revealed the preoperative shock (p = 0.03), longer cardiopulmonary bypass time (p < 0.01), and the need for PCPS after repair (p < 0.01) were the risk factors for the early mortality. Multivariate analysis indicated the cardiopulmonary time over 210 minutes and the need for PCPS to be the significant ris k factors. CONCLUSION: The long cardiopulmonary bypass support after repair and the subsequent need for PCPS imply the poor left ventricular function. Since the residual shunt was not the cause of PCPS, the surgical outcome for VSP may be limited in patie nts with poor left ventricular function. In these patients, other therapeutic strategies may be required, such as ventricular assisting devices, transplantation, or regenerative therapy.

Am J Cardiol. 2005 May 15;95(10):1153-8.
Risk factors, echocardiographic patterns, and outcomes in patients with acute ventricular septal rupture during myocardial infarction.
Vargas-Barron J, Molina-Carrion M, Romero-Cardenas A, Roldan FJ, Medrano GA, Avila-Casado C, Martinez-Rios MA, Lupi-Herrera E, Zabalgoitia M.
Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico.

Ventricular septal rupture (VSR), which can complicate an acute myocardial infarction (MI), carries a high mortality rate. Because precordial and transesophageal echocardiography can identify the type of rupture and assess right ventricular (RV) function at the patient's bedside, we examined the prognostic significance of echocardiographic patterns in postinfarct VSR by postulating that complex rupture and RV involvement carry a worse prognosis. Seventeen patients (10 men; mean age 66 years) who had confi rmed postinfarct VSR underwent precordial and transesophageal echocardiography followed by coronary angiography. Serial 12-lead and right precordial leads were also available. Type of septal rupture was classified as simple or complex based on autopsy-pro ved echocardiographic criteria. Three patients had inferior wall MI and 14 had anterior wall MI. ST-segment elevation persisted >72 hours in all 3 patients who had inferior wall MI and in 12 who had anterior wall MI. Segmental wall motion abnormalities he lped in detecting the left ventricular entry site, and use of unconventional views superimposed with color flow Doppler provided the RV exit site. RV function was better appreciated with transesophageal echocardiography. Two patients who had inferior wall MI and 7 who had anterior wall MI had complex ruptures. All 3 patients who had inferior wall MI and 7 who had anterior wall MI had electrocardiographic and echocardiographic evidence of RV involvement. Mortality rate was higher in patients who had comple x rupture (78% vs 38%, p <0.001) and in those who had RV extension (71% vs 29%, p <0.001). In conclusion, persistent ST elevation is a common finding in patients who have postinfarct VSR. Complex VSR and RV involvement are significant determinants of clin ical outcome.

Ann Thorac Surg. 2004 Nov;78(5):e77-8.
Survival after simultaneous left ventricular free wall, papillary muscle, and ventricular septal rupture.
Walts PA, Gillinov AM.
Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.

Cardiac rupture is a catastrophic complication of acute myocardial infarction. The three potential sites of rupture are the left ventricular free wall, interventricular septum, and papillary muscle. Without rapid surgical correction, each of these complic ations typically leads to cardiogenic shock, multiorgan failure, and death. Postmortem analysis has identified a small number of cases in which myocardial infarction led to rupture at more than one of these sites; however, there are no reports of survival from such an event. We report a case involving rupture at all three sites in the same patient, emphasizing the importance of transesophageal echocardiography and surgical management.

Ann Thorac Surg. 2004 Nov;78(5):e77-8.
Survival after simultaneous left ventricular free wall, papillary muscle, and ventricular septal rupture.
Walts PA, Gillinov AM.
Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.

Cardiac rupture is a catastrophic complication of acute myocardial infarction. The three potential sites of rupture are the left ventricular free wall, interventricular septum, and papillary muscle. Without rapid surgical correction, each of these complic ations typically leads to cardiogenic shock, multiorgan failure, and death. Postmortem analysis has identified a small number of cases in which myocardial infarction led to rupture at more than one of these sites; however, there are no reports of survival from such an event. We report a case involving rupture at all three sites in the same patient, emphasizing the importance of transesophageal echocardiography and surgical management.

Catheter Cardiovasc Interv. 2003 Jun;59(2):230-3; discussion 234.
Comment in: Catheter Cardiovasc Interv. 2003 Jun;59(2):234.
Compassionate use of the amplatzer ASD closure device for residual postinfarction ventricular septal rupture following surgical repair.
Lowe HC, Jang IK, Yoerger DM, MacGillivray TE, de Moor M, Palacios IF.
Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02144, USA.

We report successful transcatheter closure of a post-MI ventricular septal rupture acutely following unsuccessful surgical repair. Catheter closure was accomplished by the use of a 26-mm Amplatzer atrial septal occluder. Initial attempts to close the defe ct with the use of 28-mm and 33-mm CARDIOSEAL were unsuccessful. Closure technique, immediate and long-term follow-up outcomes are reported.

J Chin Med Assoc. 2003 Dec;66(12):722-6.
Surgical techniques for emergent repair of post-infarction ventricular septal defect: compare endocardial patch and infarct exclusion method with traditional method.
Chang YL, Hsu- CP, Lai ST, Yu TJ, Weng ZC, Hwang JH, Shih CT, Yung MC, Chang SH, Wang JS.
Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taiwan, ROC.

BACKGROUND: The traditional surgical repair of post-infarction ventricular septal defect (VSD) includes excision of necrotic myocardium and approximation of the remaining of healthy ventricular wall and septal portion. The exclusion method emphasizes no e xcision of infarcted myocardium, preservation of the left ventricular geometry and exclusion of infarction area. We discuss our experiences in 13 patients and compared the results obtained from 2 different surgical methods. METHODS: From July 1996 to Dece mber 2001, 13 patients with post-infarction VSD received emergent repair. Seven patients were repaired in the traditional way and the other 6 with infarct exclusion method. There were 9 men and 4 women, ranging in age from 57 to 79. In the traditional gro up, all 7 patients were classified as NYHA IV and supported by intra-aortic balloon counter-pulsation (IABP) and 4 patients were for synchronous coronary bypass grafting. Patients using exclusion method were the 1 classified as NYHA III and 5 as IV with c ardiogenic shock and supported by IABP. Coronary bypass grafting was performed concomitantly in 2 patients. RESULTS: Five patients died within 30 days after the surgery. Four patients (mortality rate = 57.1%) had reconstruction in traditional way and 1 (m ortality rate = 16.6%) in exclusion way. The complication rate was higher in the traditional group (= 100%, n = 7, p = 0.005). In the traditional group, 1 patient received heart transplantation due to persistent severe pump failure and recovered well. Two received tracheostomy due to respiratory failure and 1 died 2 months later. In the group of exclusion method, 1 patient suffered recurrent VSD 2 days after the first surgery and died due to ventricular arrhythmia. CONCLUSIONS: The surgical mortality caus ed by acute post-infarction VSD has decreased with endocardial patch and infarction exclusion method. Rapid diagnosis, appropriate preoperative management and delicate surgical repair improve the overall results and help to attain long-term survival.

Catheter Cardiovasc Interv. 2003 Dec;60(4):509-14.
Hemodynamic complications of ventricular septal rupture after acute myocardial infarction.
Sasseen BM, Gigliotti OS, Lavine S, Gilmore PS, Percy R, Bass TA.
University of Florida Health Science Center, Jacksonville, Florida 32209, USA.

Ventricular septal rupture (VSR) is a rare but serious complication following acute myocardial infarction (MI). Patients may present with a new murmur associated with a thrill. Right heart catheterization will demonstrate elevated right atrial and pulmona ry artery pressures as well as an oxygen step-up at the right ventricular level. Patients with a right ventricular infarction or cardiogenic shock and a ventricular septal rupture have high in-hospital mortality rates. Prompt diagnosis followed by surgica l repair is essential for patients with VSR following MI.

Ann Thorac Cardiovasc Surg. 2001 Jun;7(3):180-2.
Transatrial repair of ventricular septal rupture under preoperative localization by transesophageal echocardiography.
Tokui T, Hatanaka K, Tani K, Miyamura K, Morimoto T.
Department of Thoracic and Cardiovascular Surgery, National Mie Chuo Hospital, 2158-5 Myojincho, Hisai, Mie 514-1101, Japan.

We report about a 71-year-old woman with postinfarction ventricular septal rupture who was successfully treated by the transatrial closure under preoperative localization by transesophageal echocardiography. In an attempt at transatrial repair of the vent ricular septal rupture, the most important thing is preoperative localization of the defect in the septum, which is located high and posterior, where it is smooth with relatively few trabeculations and can be readily exposed by retraction of the tricuspid valve.

Eur J Cardiothorac Surg. 2000 Aug;18(2):194-201.
Post infarction ventricular septal defect - can we do better?
Deja MA, Szostek J, Widenka K, Szafron B, Spyt TJ, Hickey MS, Sosnowski AW.
Department of Cardio-thoracic Surgery, Glenfield General Hospital, 1 Groby Road, LE3 9QP, Leicester, UK.

OBJECTIVE: To identify predictors of early and late outcome among 117 consecutive patients who underwent postinfarction ventricular septal defect (VSD) repair over a period of 12 years. METHODS: A retrospective analysis of clinical data was performed. Mea n age was 65.5+/-7.8. There were 43 females. Full data were obtained in 110 patients. Of these, 76 patients presented with anterior and 34 with posterior VSD. Thirty-three patients were operated in cardiogenic shock. Mean time between myocardial infarctio n (MI) and VSD development was 5.6+/-7.8 days (median 4) and from VSD to surgery 9. 0+/-28.1 (median 2). Sixty-six patients had intraaortic balloon pump (IABP) inserted, and 15 were ventilated preoperatively. Logistic regression and Cox regression were us ed for multivariate analysis. RESULTS: Thirty days mortality was 37%. Among 110 patients, in whom complete analysis was possible, 38 died within 30 days (35%). Mortality in the posterior VSD group was 35% and in the anterior VSD group 34% (NS). In 44 pati ents (40%) a residual shunt was found on postoperative echocardiography . This required reoperation in 13 patients (four deaths). Cardiogenic shock prior to surgery adversely influenced early survival - odds ratio (OR) 5.7 (confidence interval (CI ) 2.1-16.0) (P=0.0008). Deterioration of haemodynamic status in between admission and surgery was stronger predictor of mortality than shock on admission - OR 6.0 (CI 1.6-22.6) (P=0.008) vs. 3.1 (CI 1.0-9.3) (P=0.049). A longer time between MI and surgery favoured survival - OR 0.1 (CI 0.03-0.4) (P=0.002). The time period from the infarct to the septal rupture, but not from the rupture to surgery, appeared to be a significant predictor of survival - OR 0.2 (CI 0. 05-0.6) (P=0.008). Five years survival was 46+/-5%. Preoperative cardiogenic shock affected late survival - OR 2.7 (CI 1.5-4.9) (P=0. 001). Of 72 patients who survived 30 postoperative days, 12 (17%) were in New York Heart Association (NYHA) class III or IV and five (6.9%) in Canadian Cardiovascu lar Soceity (CCS) class III or IV at the last follow-up. CONCLUSIONS: Preoperative cardiogenic shock and early postinfarction septal rupture carry a grave prognosis. Achieving haemodynamic stability prior to surgery may be beneficial but prolonged attempt s to improve patients' cardiovascular state are hazardous.

Cardiol. 1996 Feb;27(2):77-83.
Pseudoaneurysm and ventricular septal rupture complicated with inferior myocardial infarction diagnosed by two-dimensional and Doppler echocardiography: case report.
Kawai J, Yoshikawa J, Yoshida K, Hozumi T, Akasaka T, Syakudo M, Takagi T, Tanaka N, Yagi T.
Division of Cardiology, Kobe General Hospital.

A 72-year-old woman with inferior myocardial infarction presented with both a pseudoaneurysm and a ventricular septal rupture detected by two-dimensional and Doppler echocardiography. The pseudoaneurysm originated from the junctional area between the infe rior portion of the ventricular septum and posterior left ventricular wall. The short-axis view of two-dimensional echocardiography revealed an abrupt discontinuity of the junctional area and an echo-free space behind the left ventricular cavity. The comm unication orifice was 5 mm wide. Color Doppler echocardiography showed a left-to-right shunt flow from the pseudoaneurysm to the right ventricle was visualized. Combined use of two-dimensional and color Doppler echocardiography was useful for detecting a pseudoaneurysm resulting in rupture of the ventricular septum.

Coron Artery Dis. 1993 Oct;4(10):911-7.
Transthoracic and transesophageal echocardiography to diagnose ventricular septal rupture: importance of right heart infarction.
Zotz RJ, Dohmen G, Genth S, Erbel R, Dieterich HA, Meyer J.
II. Medizinische Klinik, Johannes Gutenberg University, Mainz, Germany.

BACKGROUND: Rapid and accurate diagnosis of ventricular septal rupture (VSR) remains difficult, and the monitoring of hemodynamic deterioration is a prerequisite for the institution of adequate therapy. The timing of surgical repair is a matter of controv ersy. METHODS: Transthoracic, transesophageal, color Doppler, and contrast echocardiography were evaluated in 17 patients with VSR in whom the diagnosis was confirmed by catheterization, surgery, or necropsy. RESULTS: Routine transthoracic echocardiograph y visualized VSR in four out of 17 patients and, with additional views, in 12 out of 17 patients. Color Doppler echocardiography identified the rupture in 15 out of 16, and contrast echocardiography in 11 out of 11 patients. VSR was identified using trans esophageal echocardiography in six out of nine patients, and using color Doppler and contrast echocardiography in all patients. Eight out of 10 patients who developed right heart myocardial infarction (RMI) died, whereas all patients without RMI survived (P = 0.0070). Similarly, eight out of 10 patients with shock died, whereas all patients without survived (P = 0.0070). Shock occurred more often in patients with RMI (eight out of 10) than in patients without (two out of six). All patients with both RMI a nd shock died, whereas those without both conditions survived (P = 0.0002). CONCLUSION: Modern echocardiography is the method of choice in the diagnosis of VSR. Right ventricular function should be evaluated in patients with VSR because patients with RMI are at high risk of hemodynamic deterioration, with poor outcome. RMI, visible as abnormal wall motion, was identified better with transesophageal than with transthoracic echocardiography.

Circulation, 1986; Vol 74, 45-55 Postinfarction ventricular septal rupture: the importance of location of infarction and right ventricular function in determining survival CA Moore, TW Nygaard, DL Kaiser, AA Cooper and RS Gibson

Over a 5.5 year period, 1264 consecutive patients with acute myocardial infarction as confirmed by enzyme levels were prospectively identified. Of these, 25 (2%) suffered ventricular septal rupture (pulmonary/systemic flow range 1.5 to 6) 7 +/- 7 days aft er onset of myocardial infarction. Death occurred in 14 patients (56%) and was more common after inferior than anterior myocardial infarction (11 of 15 [73%] vs three of 10 [30%], p less than .05). Among 133 variables analyzed, survivors and nonsurvivors were similar with respect to all premorbid clinical characteristics, infarct size as assessed by peak creatine kinase values, shunt size, two-dimensional echocardiographic and hemodynamic indexes of left ventricular function, and extent of coronary diseas e. Compared with survivors, the nonsurvivors had greater impairment of right ventricular function as determined by a higher two- dimensional echocardiographically derived right ventricular wall motion index (RVWMI) (0.55 +/- 0.87 vs 1.70 +/- 0.45, p less than .001), greater elevation of right ventricular end-diastolic pressure (11 +/- 6 vs 17 +/- 6, p less than .02), and greater mean right atrial pressure (10 +/- 6 vs 16 +/- 3, p less than .01). Of interest, two of the three patients who presented with an terior myocardial infarction and who died had inferiorly extended infarcts and all had abnormal RVWMIs (greater than or equal to 1.0). As expected, cardiogenic shock shortly after onset of ventricular septal rupture was associated with a 91% mortality, bu t was more common after inferior than anterior myocardial infarction (60% vs 20%, p less than .05). The mean effective cardiac index was also higher in survivors than nonsurvivors (2.1 +/- 0.5 vs 1.2 +/- 0.5, p less than .001). Finally, multivariate analy sis indicated that all nonsurvivors could be identified based on: an effective cardiac index of 1.75 liters/min/m2 or less, the presence of extensive right ventricular and septal dysfunction on the two- dimensional echocardiogram, a mean right atrial pres sure of 12 mm Hg or more, and early onset of ventricular septal rupture. Thus, our data demonstrate that: mortality is higher when ventricular septal rupture complicates inferior than when it complicates anterior myocardial infarction, survivors can be di stinguished from nonsurvivors and the prediction of outcome is highly accurate, and combined right ventricular and septal dysfunction has a substantial impact on prognosis.

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