Changing patterns in the surgical management of ventricular septal rupture after myocardial infarction

Seventeen consecutive patients who underwent repair of postinfarction ventricular septal rupture between 1975 and 1980 at the Yale-New Haven Medical Center are reported on. The most important prognostic indicator of a favorable outcome was the patient's preoperative hemodynamic state. The mortality rate ranged from 83 percent for patients in shock to no mortality in patients with mild to moderate symptoms. There was a strong tendency for hemodynamic deterioration despite hemodynamic support with pharmacologic agents as well as intraaortic balloon pumping. Our review indicates that several patients might have been saved if operation had been performed earlier. Based on this experience and that of others, a management plan is formulated, and we recommend early surgical intervention in all operable patients with ventricular septal rupture. In patients with severe cardiogenic shock, we forego full cardiac catheterization, confirming the diagnosis by an oxygen step-up in the pulmonary artery only. These patients undergo operation on an urgent basis. No undue technical difficulties were related to early operation. At present, maximum survival of patients with postinfarction ventricular septal rupture may be accomplished by early surgical intervention in all operable cases.