Techniques, timing & prognosis of post infarct ventricular septal repair: a re-look at old dogmas

Abstract Objective: The study aimed to identify the factors affecting the prognosis of post myocardial infarction (MI) ventricular septal rupture (VSR) and to develop a protocol for its management. Methods: This was a single center, retrospective-prospective study (2009-2014), involving 55 patients with post MI VSR. The strengths of association between risk factors and prognosis were assessed using multivariate logistic regression analysis. The UNM Post MI VSR management and prognosis scoring systems (UPMS & UPPS) were developed. Results: Thirty-day mortality was 52.5% (35% in the last 3 years). Twenty-eight (70%) patients underwent concomitant coronary artery bypass grafting. Residual ventricular septal defect was found in 3 (7.5%) patients. The multivariate analysis showed low mean blood pressure with intra-aortic balloon pump (OR 11.43, P=0.001), higher EuroSCORE II (OR 7.47, P=0.006), higher Killip class (OR 27.95, P=0.00), and shorter intervals between MI and VSR (OR 7.90, P=0.005) as well as VSR and Surgery (OR 5.76, P=0.016) to be strong predictors of mortality. Concomitant coronary artery bypass grafting (P=0.17) and location (P=0.25) of VSR did not affect the outcome. Mean follow-up was 635.8±472.5 days and 17 out of 19 discharged patients were in NYHA class I-II. Conclusion: The UNM Post-MI VSR Scoring Systems (UPMS & UPPS) help in management and prognosis, respectively. They divide patients into 3 groups: 1) Immediate Surgery - Patients with scores of <25 require immediate surgery, preferably with extracorporeal membrane oxygenation support, and have poor prognosis; 2) Those with scores of 25-75 should be managed with "Optimal Delay" and they have intermediate outcomes; 3) Patients with scores of >75 can undergo Elective Repair and they are likely to have good outcomes.

Perfil clínico-cirúrgico de pacientes operados por ruptura do septo interventricular pós-infarto do miocárdio / Clinical and surgical profile of patients operated for postinfarction interventricular septal rupture

OBJETIVOS: Estudar características clínicas, complicações e desfechos intra-hospitalares de pacientes operados por ruptura do septo interventricular pós-infarto. MÉTODOS: Estudo retrospectivo envolvendo 21 pacientes entre janeiro/1996 e junho/2009. Todas as operações foram realizadas na Divisão de Cirurgia Cardiovascular do Complexo Hospitalar HUOC/PROCAPE. RESULTADOS: Idade média dos pacientes foi de 62,81 anos (± 8,21), sendo 61,9 por cento (n=13) do sexo masculino. Ruptura ocorreu, em média, 4,8 dias após o infarto. Foi observado choque cardiogênico em 57,1 por cento (n=12) dos casos, sendo este fator de risco para óbito (100 por cento com choque vs. 22,2 por cento sem choque; P<0,001). Sobreviventes apresentaram média de fração de ejeção maior em comparação aos óbitos (66,29 por cento ± 4,61 por cento versus 42,71 por cento ± 4,79 por cento; P<0,001). Todos pacientes foram classificados em alto risco pelo EuroSCORE, tendo os sobreviventes média de pontuação menor em comparação aos óbitos (6,57 ± 0,53 versus 10,93 ± 2,23; P<0,001). A maioria (76,2 por cento; n=16) dos pacientes teve necessidade de uso de drogas vasoativas e 57,1 por cento (n=12) foram considerados instáveis hemodinamicamente. Necessidade de drogas vasoativas foi fator de risco para óbito (81,3 por cento no grupo com drogas vasoativas versus 20 por cento no grupo sem drogas vasoativas, P=0,025). Instabilidade hemodinâmica também foi fator de risco para óbito (100 por cento no grupo instável versus 22,2 por cento no grupo estável; P<0,001). A taxa de mortalidade intra-hospitalar foi de 66,7 por cento (n=14). CONCLUSÕES: Necessidade de drogas vasoativas, instabilidade hemodinâmica e choque cardiogênico se associaram com maiores taxas de mortalidade. Pacientes que evoluem com desfecho adverso apresentam menor função ventricular e maior pontuação no EuroSCORE. A taxa de mortalidade permanece alta.

OBJECTIVES: To study clinical features, complications and in-hospital outcomes of patients operated for postinfarction ventricular septal rupture. METHODS: A retrospective study involving 21 patients between January/1996 and June/2009. All operations were performed at the Division of Cardiovascular Surgery of Complexo Hospitalar HUOC/PROCAPE. RESULTS: Mean age of patients was 62.81 years (± 8.21), 61.9 percent (n = 13) were male. Rupture occurred on average 4.8 days after infarction. Cardiogenic shock was observed in 57.1 percent (n = 12), being risk factor for death (100 percent with shock vs. 22.2 percent without shock; P<0.001). Survivors had a higher mean ejection fraction compared to deaths (66.29 percent ± 4.61 percent versus 42.71 percent ± 4.79 percent, P <0.001). All were classified as high risk by the EuroSCORE, and the survivors had lower average score compared to deaths (6.57 ± 0.53 versus 10.93 ± 2.23; P <0.001). The majority (76.2 percent, n = 16) of the patients needed to use vasoactive drugs and 57.1 percent (n = 12) considered hemodynamically unstable. Need for vasoactive drugs was a risk factor for death (81.3 percent with vasoactive drugs versus 20 percent without vasoactive drugs, P = 0.025). Hemodynamic instability was also a risk factor for death (100 percent in the unstable group versus 22.2 percent in the stable group; P <0.001). The rate of in-hospital mortality was 66.7 percent (n = 14). CONCLUSIONS: The need for vasoactive drugs, hemodynamic instability and cardiogenic shock were associated with higher rates of mortality. Patients who had adverse outcomes had less ventricular function and higher score in the EuroSCORE. Mortality remains high.