title: Does the placement of an Amplatzer septal occluder device confer benefit in patients with a post-infarction ventricular septal defect?
abstract: A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Is the placement of an Amplatzer septal occluder device across a post-infarction ventricular septal defect a suitable alternative for patients not eligible for surgical repair?' Altogether, 31 papers were found using the reported search, of which 17 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that the insertion of an Amplatzer occluder device in patients with a post-infarction ventricular septal defect (VSD) not amenable to surgical repair can offer benefit in selected patients. Patients with cardiogenic shock frequently have an unfavourable outcome and closure should be considered cautiously. From the literature available, patients have a better outcome if the intervention is delayed by 2 weeks or more possibly due to the maturation of the VSD and recovery of myocardial function. In certain situations, device closure may be complicated by device dislocation or embolization, residual shunting or a tortuous course not amenable to device implantation. In such settings, surgical repair is the only option. In patients who proceed straight to surgical repair with no attempt at percutaneous closure, the overall mortality lies in the region of 43% and similar to percutaneous closure, there is an association observed between those operated within 7 days of the VSD occurrence and those greater than this time. Patients presenting in cardiogenic shock experienced an increased risk of death and if the timing of myocardial infarction to VSD closure could be delayed by 3 weeks, there was a statistically significant reduction in operative mortality. Percutaneous closure of a post-infarction VSD may avoid the requirement for surgical closure. However, in some cases, it provides time to allow the VSD to mature and the patient to stabilize and be optimized acting as a bridge to surgery to offer the best possible outcome for the patient.
authors.affiliation: Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen, UK alan.g.dawson.04@aberdeen.ac.uk.
authors.forename: Alan G
authors.initials: AG
authors.lastname: Dawson
authors.affiliation: Department of Anaesthetics, Aberdeen Royal Infirmary, Aberdeen, UK.
authors.forename: Stuart G
authors.initials: SG
authors.lastname: Williams
authors.affiliation: Aberdeen Medical School, University of Aberdeen, Foresterhill, Aberdeen, UK.
authors.forename: Daisy
authors.initials: D
authors.lastname: Cole
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019985:Benchmarking; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications* / Q000401:mortality; D018579:Patient Selection; D011474:Prosthesis Design; D012307:Risk Factors; D055989:Septal Occluder Device; D012770:Shock, Cardiogenic; D013997:Time Factors; D016896:Treatment Outcome; D018658:Ventricular Septal Rupture / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000628:therapy*
keywords: Amplatzer device; Myocardial infarction; Ventricular septal defect