Surgical repair for postinfarction left ventricular free-wall rupture: 25-year single-centre experience†

Postinfarction left ventricular free-wall rupture (LVFWR) is a rare, unpredictable and often fatal complication of acute myocardial infarction. We reviewed our surgical experience with postinfarction LVFWR over 25 years to identify risk factors for in-hospital mortality.

Seventy-two consecutive patients with LVFWR who underwent surgical repair between 1994 and 2023 were retrospectively analysed. The primary end point was in-hospital mortality. The mean follow-up period was 3.9 ± 5.4 years (maximum 25 years, 283 patient-years).

Thirty-five patients (49%) were directly transported to our centre, whereas 37 (51%) were initially taken to a local hospital. Prior to surgery, 30 (42%) developed out-of-hospital (n = 8, 11%) or in-hospital (n = 22, 31%) cardiac arrest. Upon entry to the operating room, 45 (63%) presented hypotensive shock, while 27 (38%) suffered cardiac arrest. LVFWR was oozing type in 42 patients (58%) and blow-out type in 30 patients (42%), for which sutureless repair (n = 27, 38%) or sutured repair (n = 45, 62%) was performed. The in-hospital mortality rate was 35%, in association with haemodynamic condition before surgery: 19% in patients without cardiac arrest, and 55% with in-hospital and 63% with out-of-hospital cardiac arrest. Patient age [adjusted odds ratio (OR) 2.2 per 10-year period, 95% confidence interval (CI) 1.0-4.9, P = 0.044], out-of-hospital cardiac arrest (adjusted OR 8.6, 95% CI 1.4-66, P = 0.020), in-hospital cardiac arrest (adjusted OR 6.6, 95% CI 1.6-33, P = 0.010) and initial ambulance transport to a local hospital (adjusted OR 4.2, 95% CI 1.2-17, P = 0.020) were identified as independent risk factors of in-hospital mortality. The overall 5-year survival rate was 50%, while that for in-hospital survivors was 77%. When the present study period is split into 2 eras (1994-2010 and 2011-2023), the in-hospital mortality rate was comparable between them (41% vs 31%, P = 0.408). Notably, the in-hospital mortality of patients with a blow-out type left ventricular rupture was significantly lower in that latter study period (86% vs 39%, P = 0.025).

In surgically treated patients with LVFWR, the early mortality rate was high, while the long-term prognosis for in-hospital survivors was acceptable. These findings highlight the need for early diagnosis and prompt management of haemodynamic instability at a tertiary centre to improve outcomes.