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Does the placement of an Amplatzer septal occluder device confer benefit in patients with a post-infarction
Alan G Dawson1, Stuart G Williams2, Daisy Cole3
1Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen, UK alan.g.dawson.04@aberdeen.ac.uk.
Insights
Percutaneous closure using an Amplatzer occluder device is a viable option for select patients with post-infarction ventricular septal defects (VSD) unsuitable for surgery. Delaying intervention may improve outcomes, but surgical repair remains necessary in complex cases.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
Background:
- Post-infarction ventricular septal defects (VSD) pose significant management challenges, particularly for patients ineligible for surgical repair.
- Percutaneous device closure offers a less invasive alternative, but its efficacy and safety require careful consideration.
Purpose of the Study:
- To evaluate the suitability of the Amplatzer septal occluder device for post-infarction VSD closure in patients not candidates for surgery.
- To review the best available evidence on percutaneous VSD closure versus surgical repair.
Main Methods:
- A structured literature search identified 31 relevant papers, with 17 selected as the best evidence.
- Data on patient groups, study types, outcomes, and results were tabulated for analysis.
Main Results:
- Amplatzer device closure can benefit selected patients with post-infarction VSDs not amenable to surgery.
- Outcomes are generally better when intervention is delayed by at least two weeks, allowing for VSD maturation and myocardial recovery.
- Patients presenting with cardiogenic shock have a poorer prognosis, necessitating cautious consideration of closure.
- Complications such as device dislocation, embolization, or residual shunting may require surgical intervention.
- Surgical repair, especially within 7 days of VSD occurrence, is associated with higher mortality (around 43%).
- Delaying surgical repair by three weeks significantly reduces operative mortality.
Conclusions:
- Percutaneous closure with the Amplatzer device is a beneficial option for specific patients with post-infarction VSDs unsuitable for surgery.
- Device closure can serve as a bridge to surgery, allowing for patient stabilization and optimization.
- Surgical repair remains the definitive option for complex cases or when percutaneous closure fails.
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.
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