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Postinfarction ventricular septal defect
A Chaux1, C Blanche, J M Matloff
1Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
Insights
Postinfarction ventricular septal perforation (VSD) is a challenging complication of coronary artery disease (CAD). While earlier medical therapy reduces VSD incidence, surgical outcomes remain poor, highlighting the need for improved treatment strategies.
Area of Science:
- Cardiology
- Cardiac Surgery
- Medical Complications
Background:
- Postinfarction ventricular septal perforation (VSD) remains a significant challenge despite advances in coronary artery disease (CAD) diagnosis and treatment.
- Earlier and more effective medical therapies for CAD appear to be reducing the annual incidence of VSD.
Purpose of the Study:
- To analyze trends and outcomes of postinfarction VSD.
- To evaluate the impact of evolving clinical presentation and treatment strategies on VSD outcomes.
Main Methods:
- Single-institutional retrospective review of patients with postinfarction VSD.
- Analysis of patient demographics, infarction patterns, and surgical repair outcomes.
Main Results:
- Surgical repair outcomes for VSD have not improved, even with aggressive strategies and technical advances.
- A shift in VSD presentation is observed, with an increase in female patients and posterior infarctions.
- The clinical spectrum of postinfarction VSD appears to be evolving.
Conclusions:
- Early surgical intervention and advanced cardiac support are indicated for postinfarction VSD.
- Improved earlier diagnosis and aggressive management of CAD, particularly in females, may reduce VSD occurrence.
- Further research is needed due to the small sample size and evolving nature of this complication.
Abstract:
Despite improved screening and diagnostic capabilities for the presence of coronary artery disease (CAD), with the promise of improved outcomes from earlier therapeutic interventions, postinfarction ventricular septal perforation (VSD) continues to be a very difficult therapeutic challenge. In our experience with VSD, the incidence of this complication per year has decreased, almost certainly related to earlier and more effective medical therapy in patients with CAD. By contrast, the outcomes of surgical repair have not improved, even with an aggressive strategy about bypassing involved coronary arteries. Furthermore, the earliest possible surgical approach and the incorporation of a number of technical advances, especially those relating to myocardial preservation, have not had an apparent effect. Because the number of patients who underwent operation is small, it is not possible from our single-institutional experience to define statistical significance to our continuing observations of this condition, suggesting that the clinical spectrum of postinfarction VSD is still evolving. Important changes appear to be associated with an increase in the number of female patients observed (60%), in contrast to their lesser frequency of uncomplicated coronary bypass (18%) and a change in the anatomic substrate, with posterior infarctions and rupture now accounting for 73% of cases at Cedars-Sinai. For the present, earliest possible surgical intervention to minimize the severity of multi-organ failure and use all of the advanced therapeutic modalities of cardiac support and surgical therapy that are available continues to be indicated. For the long term, continuing advances in the earlier diagnosis and more aggressive management of CAD, especially in females, may hold the best promise for a continued decrease in the occurrence of this very difficult-to-treat postinfarction complication.