Risk factors and outcome analysis after surgical management of ventricular septal rupture complicating acute myocardial infarction: a retrospective analysis.
BACKGROUND
Ventricular septal rupture (VSR) is an uncommon but well-recognized mechanical complication of acute myocardial infarction (AMI). The outcome of VSR remains poor even in the era of reperfusion therapy. We reviewed our experience with surgical repair of post-infarction VSR and analyzed outcomes in an attempt to identify prognostic factors.


METHODS
From October 1995 to December 2013, data from 47 consecutive patients (mean age, 68 ± 9.5 years) with post-infarction VSR who underwent surgical repair at our institute were retrospectively reviewed. The preoperative conditions, morbidity and surgical mortality were analyzed. Multivariate analysis was subsequently carried out by constructing a logistic regression model in order to identify independent predictors of postoperative mortality. Long term survival function were estimated using the Kaplan-Meier method and compared using the log-rank test.


RESULTS
Percutaneous coronary intervention was performed in 17 (36.2%) patients, intra-aortic balloon pump (IABP) was used in 34 (72.3%), and six (12.8%) were supported with extracorporeal membrane oxygenation (ECMO) preoperatively. Forty-one (87.2%) patients received emergent surgical treatment. Concomitant coronary artery bypass grafting was performed in 27 (57.4%) patients. Operative mortality was 36.2% (17 of 47). The survival rate was 59.3% with concomitant CABG and 70% without concomitant CABG (p = 14). Multivariate analysis revealed that the survivors had higher preoperative left ventricular ejection fractions (LVEFs) compared with those who died (51 ± 13.7% vs. 36.6 ± 6.4% , respectively; p < 0.001) and lower European system for cardiac operative risk evaluation II (EuroSCORE II) (22.9 ± 14.9 vs. 38.3 ± 13.9, respectively; p < 0.001). The patients receiving total revascularization has long term survival benefit (p = 0.028).


CONCLUSIONS
Post-infarction VSR remains a serious and challenging complication of AMI in the modern surgical era. The EuroSCORE II can be used for an approximate prediction of operative mortality. Preserved LVEF was associated with better prognosis, while the need for postoperative RRT was associated with higher early and late mortality. Besides, the strategy of total revascularization should be applied to ensure long-term survival benefit.
Departments of Surgery, Buddhist Tzu Chi General Hospital, Dalin Branch, Chiayi, Taiwan. wolfbaby@gmail.com.
Shih-Ming
SM
Huang
Departments of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan. cvshuang@gmail.com.
Shu-Chien
SC
Huang
Departments of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan. wchemail@ntu.edu.tw.
Chih-Hsien
CH
Wang
Departments of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan. aaronwu@ms6.hinet.net.
I-Hui
IH
Wu
Departments of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan. chinaihsin@gmail.com.
Nai-Hsin
NH
Chi
Departments of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan. hsiyuyu@gmail.com.
Hsi-Yu
HY
Yu
Departments of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan. ronbin@ntuh.gov.tw.
Ron-Bin
RB
Hsu
Departments of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan. joey@ntuh.gov.tw.
Chung-I
CI
Chang
Departments of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan. wangp@ntu.edu.tw.
Shoei-Shen
SS
Wang
Departments of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan. yschen1234@gmail.com.
Yih-Sharng
YS
Chen
D000368:Aged; D006348:Cardiac Surgical Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D009203:Myocardial Infarction / Q000150:complications*; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D013624:Taiwan / Q000453:epidemiology; D016896:Treatment Outcome; D016277:Ventricular Function, Left; D018658:Ventricular Septal Rupture / Q000453:epidemiology / Q000503:physiopathology / Q000601:surgery*