TY - JOUR
T1 - Surgical Treatment of Postinfarction Ventricular Septal Rupture
AU - Ronco, D.
AU - Matteucci, M.
AU - Kowalewski, M.
AU - De Bonis, M.
AU - Formica, F.
AU - Jiritano, F.
AU - Fina, D.
AU - Folliguet, T.
AU - Bonaros, N.
AU - Russo, C.F.
AU - Sponga, S.
AU - Vendramin, I.
AU - De Vincentiis, C.
AU - Ranucci, M.
AU - Suwalski, P.
AU - Falcetta, G.
AU - Fischlein, T.
AU - Troise, G.
AU - Villa, E.
AU - Dato, G.A.
AU - Carrozzini, M.
AU - Serraino, G.F.
AU - Shah, S.H.
AU - Scrofani, R.
AU - Fiore, A.
AU - Kalisnik, J.M.
AU - D'Alessandro, S.
AU - Lodo, V.
AU - Kowalowka, A.R.
AU - Deja, M.A.
AU - Almobayedh, S.
AU - Massimi, G.
AU - Thielmann, M.
AU - Meyns, B.
AU - Khouqeer, F.A.
AU - Al-Attar, N.
AU - Pozzi, M.
AU - Obadia, J.F.
AU - Boeken, U.
AU - Kalampokas, N.
AU - Fino, C.
AU - Simon, C.
AU - Naito, S.
AU - Beghi, C.
AU - Lorusso, R.
N1 - Funding Information:
Conflict of Interest Disclosures: Dr De Bonis reported consulting for Abbott and Medtronic until 2020. Dr Folliguet reported consulting for LivaNova outside the submitted work. Dr Bonaros reported receiving grants and personal fees from Edwards Lifesciences, personal fees from Medtronic, and grants from LivaNova outside the submitted work. Dr Ranucci reported consulting for LivaNova and Medtronic outside the submitted work. Dr Suwalski reported receiving speakers’ fees from Atricure outside the submitted work. Dr Fischlein reported consulting for LivaNova and BioStable outside the submitted work. Dr Meyns reported receiving grants from Abiomed outside the submitted work. Dr Al-Attar reported serving as a member of the advisory board of Medtronic outside the submitted work. Dr Obadia reported receiving grants from Abbott and Carmat and receiving personal fees from Delacroix Chevalier, Landanger, and Medtronic during the conduct of the study. Dr Lorusso reported being the principal investigator of the Perceval Sutureless Implant versus Standard Aortic Valve Replacement (PERSIST-AVR) Study, sponsored by LivaNova, and consulting for Medtronic, LivaNova, and Eurosets with all honoraria paid to the University. No other disclosures were reported.
Publisher Copyright:
© 2021 American Medical Association. All rights reserved.
PY - 2021/10/20
Y1 - 2021/10/20
N2 - IMPORTANCE 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-center series or national registries are usually available in literature, whereas international multicenter investigations have been poorly carried out, therefore limiting the evidence on this topic.OBJECTIVES To assess the clinical characteristics and early outcomes for patients who received surgery for postinfarction VSR and to identify factors independently associated with mortality.DESIGN, SETTING, AND PARTICIPANTS 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 centers worldwide among 475 consecutive patients who underwent surgery for postinfarction VSR.EXPOSURES Surgical treatment of postinfarction VSR, independent of the technique, alone or combined with other procedures (eg, coronary artery bypass grafting).MAIN OUTCOMES AND MEASURES The primary outcome was early mortality; secondary outcomes were postoperative complications.RESULTS 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 (median [IQR] yearly mortality, 41.7% [32.6%-50.0%]). Low cardiac output syndrome and multiorgan failure were the most common causes of death (low cardiac output syndrome, 70 [36.5%]; multiorgan failure, 53 [27.6%]). Recurrent VSR occurred in 59 participants (12.4%) but was not associated with mortality. Cardiogenic shock (survived: 95 [33.6%]; died, 118 [61.5%]; P < .001) and early surgery (time to surgery >= 7 days, survived: 105 [57.4%]; died, 47 [35.1%]; P < .001) were associated with lower survival. At multivariate analysis, older age (odds ratio [OR], 1.05; 95% CI, 1.02-1.08; P = .001), preoperative cardiac arrest (OR, 2.71; 95% CI, 1.18-6.27; P = .02) and percutaneous revascularization (OR, 1.63; 95% CI, 1.003-2.65; P = .048), and postoperative need for intra-aortic balloon pump (OR, 2.98; 95% CI, 1.46-6.09; P = .003) and extracorporeal membrane oxygenation (OR, 3.19; 95% CI, 1.30-7.38; P = .01) were independently associated with mortality.CONCLUSIONS AND RELEVANCE In this study, 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.
AB - IMPORTANCE 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-center series or national registries are usually available in literature, whereas international multicenter investigations have been poorly carried out, therefore limiting the evidence on this topic.OBJECTIVES To assess the clinical characteristics and early outcomes for patients who received surgery for postinfarction VSR and to identify factors independently associated with mortality.DESIGN, SETTING, AND PARTICIPANTS 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 centers worldwide among 475 consecutive patients who underwent surgery for postinfarction VSR.EXPOSURES Surgical treatment of postinfarction VSR, independent of the technique, alone or combined with other procedures (eg, coronary artery bypass grafting).MAIN OUTCOMES AND MEASURES The primary outcome was early mortality; secondary outcomes were postoperative complications.RESULTS 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 (median [IQR] yearly mortality, 41.7% [32.6%-50.0%]). Low cardiac output syndrome and multiorgan failure were the most common causes of death (low cardiac output syndrome, 70 [36.5%]; multiorgan failure, 53 [27.6%]). Recurrent VSR occurred in 59 participants (12.4%) but was not associated with mortality. Cardiogenic shock (survived: 95 [33.6%]; died, 118 [61.5%]; P < .001) and early surgery (time to surgery >= 7 days, survived: 105 [57.4%]; died, 47 [35.1%]; P < .001) were associated with lower survival. At multivariate analysis, older age (odds ratio [OR], 1.05; 95% CI, 1.02-1.08; P = .001), preoperative cardiac arrest (OR, 2.71; 95% CI, 1.18-6.27; P = .02) and percutaneous revascularization (OR, 1.63; 95% CI, 1.003-2.65; P = .048), and postoperative need for intra-aortic balloon pump (OR, 2.98; 95% CI, 1.46-6.09; P = .003) and extracorporeal membrane oxygenation (OR, 3.19; 95% CI, 1.30-7.38; P = .01) were independently associated with mortality.CONCLUSIONS AND RELEVANCE In this study, 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.
KW - MECHANICAL CIRCULATORY SUPPORT
KW - ELEVATION MYOCARDIAL-INFARCTION
KW - EXTRACORPOREAL MEMBRANE-OXYGENATION
KW - RISK-FACTORS
KW - MORTALITY-RATES
KW - CARDIAC RUPTURE
KW - TASK-FORCE
KW - REPAIR
KW - DEFECT
KW - OUTCOMES
U2 - 10.1001/jamanetworkopen.2021.28309
DO - 10.1001/jamanetworkopen.2021.28309
M3 - Article
C2 - 34668946
SN - 2574-3805
VL - 4
JO - Jama network open
JF - Jama network open
IS - 10
M1 - e2128309
ER -