eMedicine Specialties > Thoracic Surgery > Cardiac

Ventricular Septal Rupture Following Myocardial Infarction: Follow-up

Author: Shabir Bhimji, MD, PhD, Locum Cardiothoracic and Vascular Surgeon, Saudi Arabia and Middle East Hospitals
Contributor Information and Disclosures

Updated: Nov 7, 2008

Outcome and Prognosis

Survival
The operative mortality rate is directly related to the interval between infarction and surgical repair. If repair is performed 3 weeks or more after an infarction, the rate is approximately 20%. If surgery is performed prior to this time, the mortality rate approaches 50%. The most obvious reason for this is the fact that the greater the myocardial damage and hemodynamic compromise, the more urgent the need for early intervention. With the use of an early operative approach, most studies show an overall mortality rate of less than 25%. Mortality rates tend to be lower for patients with anteriorly located ventricular septal ruptures (VSRs) and lowest for patients with apical VSRs. For anterior defects, mortality rates vary from 10-15%; for posterior defects, mortality rates vary from 30-35%.

More than half the deaths after surgery for postinfarction VSR are due to cardiac failure. Sudden death is rare, and intractable heart failure can also occur. Other causes of death include cerebral embolism. The functional status of most patients surviving the hospital period is good. Most are within New York Heart Association class I or II.6

Risk factors for death
The most important risk factors for death in the early phase are poor hemodynamics and associated right ventricular dysfunction prior to coming to the operating room. The amount and distribution of myocardial necrosis and scarring are responsible for both. Right ventricular dysfunction results from ischemic damage or frank infarction of the right ventricle and is present when stenosis occurs in the right coronary artery system. The higher mortality rate after repair of defects located inferiorly in the septum is probably related to the higher prevalence of important right coronary artery stenosis. The severity and distribution of coronary artery disease (CAD) are also risk factors. Similarly, advanced age at operation, diabetes, and preinfarction hypertension are risk factors for death in the early phase.

Risk factors for death in patients with postinfarction VSR are summarized as follows:

  • Posteriorly located septal ruptures are technically more difficult to repair and are associated with profound right ventricular dysfunction.
  • The presence of multiple organ failure is a poor prognostic factor.
  • The presence of cardiogenic shock does not bode well for the patient's survival.
  • A shortened interval between infarction and surgery usually indicates the patient is considered more ill, which imparts more risk for death.
Residual and recurrent VSR
Residual ventriculoseptal defects (VSDs) have been noted early or late postoperatively in 10-25% of patients. These residual defects are easily diagnosed with the aid of color-flow Doppler investigations. Residual VSDs may be attributable to the reopening of a closed defect, the presence of an overlooked VSD, or the development of a new septal perforation during the early postoperative period. Reoperation is required for closure of such residual defects when the Qp-to-Qs ratio is greater than 2. When these VSDs are small and asymptomatic, a conservative approach may be recommended because spontaneous closure can occur.

Percutaneous closure

Percutaneous techniques have been used successfully to close some congenital VSDs. Technical improvements in experimental devices to close intracardiac shunts are being made to treat postinfarction VSR or residual shunts after primary repair. A balloon catheter introduced percutaneously has been used to abolish the shunt in poor-risk patients.

Future and Controversies

Advances in the management of postinfarction ventricular septal rupture (VSR) have helped significantly decrease the operative mortality rate. In current practice, postinfarction VSR is recognized as a surgical emergency and the presence of cardiogenic shock is an indication for intervention.4

The addition of coronary artery bypass grafting has helped improve long-term survival. Surgery is performed using a transinfarction approach, and all reconstruction is performed with prosthetic materials to avoid tension. Technical improvements in myocardial preservation and cardioplegia have helped decrease postoperative bleeding and preserve ventricular function. In current practice, patients undergoing shunt repair tend to be older and are more likely to have received thrombolytic agents, which may complicate repair. After successful repair, survival and quality of life are excellent, even in patients older than 70 years.7

 


More on Ventricular Septal Rupture Following Myocardial Infarction

Overview: Ventricular Septal Rupture Following Myocardial Infarction
Workup: Ventricular Septal Rupture Following Myocardial Infarction
Treatment: Ventricular Septal Rupture Following Myocardial Infarction
Follow-up: Ventricular Septal Rupture Following Myocardial Infarction
References
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References

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Further Reading

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Keywords

VSR, ventricular rupture, ventricle rupture, post-MI VSR, post MI ventricular rupture, postinfarct ventricular septal rupture, postinfarct VSR, postinfarction VSR, anteroapical septal rupture, posterior septal rupture, transmural infarction, loud systolic murmur, left-to-right shunt, left heart catheterization, intraaortic balloon pump, intra-aortic balloon pump, IABP, intraaortic balloon counterpulsation, IABCP, intra-aortic balloon counterpulsation cardiogenic shock, ventriculotomy, aneurysmectomy, patch repair, coronary revascularization, recurrent ventricular septal defect, ventriculoseptal defect, VSD, ventricular septal defect, congestive heart failure, CHF, coronary heart disease, CAD, heart failure

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Contributor Information and Disclosures

Author

Shabir Bhimji, MD, PhD, Locum Cardiothoracic and Vascular Surgeon, Saudi Arabia and Middle East Hospitals
Shabir Bhimji, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Chest Physicians, American Lung Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey C Milliken, MD, Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California at Irvine School of Medicine
Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, Southwest Oncology Group, and Western Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Shreekanth V Karwande, MBBS, Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center
Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, and Western Thoracic Surgical Association
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Consulting Staff, Department of Medicine, Southwest Medical Consultants, SC, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD, Professor, Department of Surgery, Louisiana State University Health Sciences Center
Mary C Mancini, MD, PhD is a member of the following medical societies: American Heart Association, American Medical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, International College of Surgeons, International Society for Heart and Lung Transplantation, New York Academy of Sciences, Phi Beta Kappa, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

 
 
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