RESUMEN
Left ventricular free wall rupture, ventricular pseudoaneurysm, papillary muscle rupture and ventricular septal rupture are life-threatening mechanical complications of acute myocardial infarction. Despite significant improvements over the last decades in overall mortality for patients with myocardial infarction, the outcome of subjects who develop post-infarction mechanical complications remains poor. Surgical treatment is considered the standard of care. However, percutaneous approaches (such as pericardial fibrin-glue injection for left ventricular free wall rupture, transcatheter edge-to-edge mitral repair for papillary muscle rupture and device closure for ventricular pseudoaneurysm or septal rupture) have been proposed in selected high-risk or inoperable patients, or in subjects with ideal characteristics for feasibility, as therapeutic alternatives to open surgery. The aim of the present review is to provide a comprehensive overview of the percutaneous strategies for the management of post-acute myocardial infarction mechanical complications.
Asunto(s)
Rotura Cardíaca Posinfarto , Infarto del Miocardio , Humanos , Infarto del Miocardio/terapia , Infarto del Miocardio/complicaciones , Rotura Cardíaca Posinfarto/terapia , Rotura Cardíaca Posinfarto/etiología , Aneurisma Falso/terapia , Aneurisma Falso/etiología , Rotura Septal Ventricular/etiología , Rotura Septal Ventricular/terapia , Músculos PapilaresRESUMEN
Ventricular septal rupture remains a dreadful complication of acute myocardial infarction. Although less commonly observed than during the prethrombolytic era, the condition remains complex and is often associated with refractory cardiogenic shock and death. Corrective surgery, although superior to medical treatment, has been associated with high perioperative morbidity and mortality. Transcatheter closure techniques are less invasive to surgery and offer a valuable alternative, particularly in patients with cardiogenic shock. In these patients, percutaneous mechanical circulatory support represents a novel opportunity for immediate stabilization and preserved end-organ function. Multimodality imaging can identify favorable septal anatomy for the most appropriate type of repair. The heart team approach will define optimal timing for surgery vs percutaneous repair. Emerging concepts are proposed for a deferred treatment approach, including orthotropic heart transplantation in ideal candidates. Finally, for futile situations, palliative care experts and a medical ethics team will provide the best options for end-of-life clinical decision making.
Asunto(s)
Infarto del Miocardio , Rotura Septal Ventricular , Humanos , Rotura Septal Ventricular/etiología , Rotura Septal Ventricular/terapia , Infarto del Miocardio/complicaciones , Infarto del Miocardio/terapia , Cateterismo Cardíaco/métodos , Procedimientos Quirúrgicos Cardíacos/métodosRESUMEN
BACKGROUND: Ventricular septal rupture (VSR) is a rare complication after acute myocardial infarction (AMI) especially in the reperfusion era but its associated mortality has remained high. This case series evaluated in-hospital and intermediate-term mortality in VSR patients. Additionally, we also analyzed risk factors, clinical presentation, intervention, and predictors of in-hospital mortality in VSR patients. METHODS: Data of 67 patients with echocardiography confirmed diagnosis of VSR from January 2011 to April 2020 was extracted from hospital medical records. Records were also reviewed to document 30 day and 1-year mortality, recurrent heart failure admission, repeat myocardial infarction, and revascularization. In addition, telephonic follow-up was done to assess health-related quality of life(HRQOL) assessed by KCCQ-12. SCAI shock classification was used to categorize severity of cardiogenic shock. Univariate and multivariable logistic regression was used to determine predictors of in-hospital mortality. Survival function was presented using the Kaplan-Meier survival curve. RESULTS: Mean age of patients was 62.7 ± 11.1 years, 62.7% were males. 65.7% of the patients presented more than 24 hours after MI and did not receive reperfusion therapy. Median time from AMI to VSR diagnosis was 2 (1-5) days. VSR closure was attempted in 53.7% patients. In-hospital mortality was 65.7%. At univariate level, predictors of in-hospital mortality were non-surgical management, basal VSR, right ventricular dysfunction, early VSR post-MI, and severe cardiogenic shock at admission (class C, D, or E). Adjusted predictors of in-hospital mortality included non-surgical management, basal VSR and advanced cardiogenic shock. There were 5 deaths during median followup of 44.1 months. HRQOL in patients available on followup was good (54.5%) or excellent (45.5%). CONCLUSION: High in-hospital mortality was seen in VSR patients. VSR closure is the preferred treatment to get long-term survival, however, timing of repair as well as severity of cardiogenic shock plays a significant role in determining prognosis.
Asunto(s)
Infarto del Miocardio , Rotura Septal Ventricular , Masculino , Humanos , Persona de Mediana Edad , Anciano , Femenino , Rotura Septal Ventricular/etiología , Rotura Septal Ventricular/terapia , Choque Cardiogénico , Calidad de Vida , Estudios Retrospectivos , Infarto del Miocardio/complicaciones , Infarto del Miocardio/terapia , Infarto del Miocardio/diagnóstico , Factores de Riesgo , Resultado del TratamientoRESUMEN
Ventricular septal rupture after acute myocardial infarction is a fatal complication with a very high in-hospital mortality. Herein, we describe a new repair technique using a first patch for exclusion of the infarcted myocardium and a second sutureless patch for rupture site closure with a novel tissue adhesive (Hydrofit, Terumo, Tokyo, Japan). Follow-up of over 2 years revealed a good clinical course and no residual interventricular shunt on echocardiography. This modified infarct exclusion technique with a second sutureless patch has a benefit of avoiding stitches to the fragile infarcted myocardium and might be effective in preventing interventricular shunt recurrence after ventricular septal rupture.
Asunto(s)
Procedimientos Quirúrgicos sin Sutura/métodos , Adhesivos Tisulares , Rotura Septal Ventricular/terapia , Anciano , Procedimientos Quirúrgicos Cardíacos/métodos , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND: Ventricular septal rupture (VSR) is a rare but severe complication of acute myocardial infarction (AMI). For such cases, surgical repair is recommended by major guidelines, but not always possible for such cases. CASE PRESENTATION: A 72-year-old man presented to the emergency room. ECG showed the ST-segment was elevated by 2-3 mm in lead II, III, and aVF, with Q-waves. Coronary angiography (CAG) showed multi-vessel disease with a total occlusion of the right coronary artery (RCA) and severe stenosis of the left anterior descending artery (LAD). A diagnosis of acute inferior myocardial infarction was made. VSR occurred immediately after percutaneous coronary intervention (a 2.5 × 20 mm drug-eluting stent implanted in RCA), and the patient developed cardiogenic shock. An intra-aortic balloon pump (IABP) was used to stabilize the hemodynamics. Transthoracic echocardiography (TTE) revealed an 11.4-mm left-to-right shunt in the interventricular septum. An attempt was made to reduce the IABP augmentation ratio for weaning on day 12 but failed. Transcatheter closure was conducted using a 24-mm double-umbrella occluder on day 28. The patient was weaned from IABP on day 31 and underwent secondary PCI for LAD lesions on day 35. The patient was discharged on day 41. Upon the last follow-up 6 years later, CAG and TTE revealed no in-stent restenosis, no left-to-right shunt, and 51% left ventricular ejection fraction. CONCLUSIONS: Prolonged implementation of IABP can be a viable option to allow deferred closure of VSR in AMI patients, and transcatheter closure may be considered as a second choice for the selected senior and vulnerable patients, but the risk is still high.
Asunto(s)
Cateterismo Cardíaco , Infarto de la Pared Inferior del Miocardio/terapia , Contrapulsador Intraaórtico/efectos adversos , Intervención Coronaria Percutánea , Choque Cardiogénico/terapia , Rotura Septal Ventricular/terapia , Anciano , Stents Liberadores de Fármacos , Humanos , Infarto de la Pared Inferior del Miocardio/complicaciones , Infarto de la Pared Inferior del Miocardio/diagnóstico por imagen , Infarto de la Pared Inferior del Miocardio/fisiopatología , Masculino , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Recuperación de la Función , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/etiología , Choque Cardiogénico/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Rotura Septal Ventricular/diagnóstico por imagen , Rotura Septal Ventricular/etiología , Rotura Septal Ventricular/fisiopatologíaRESUMEN
Rupture of the ventricular septum with the appearance of an interventricular communication is an infrequent and life-threatening mechanical complication after acute myocardial infarction. The advent of coronary reperfusion therapies has reduced the incidence of this complication, but mortality remains high. The clinical presentation varies from mild compromise with exertional dyspnea to severe compromise with cardiogenic shock. In this pathology, early diagnosis is fundamental and surgical repair is the treatment of choice. In this article we report an interesting clinical case about a 77-year-old woman who was belatedly referred to our hospital and diagnosed with postinfarction rupture of the ventricular septum with an unfortunately fatal evolution. Relevance of this case lies in its atypical clinical presentation which led to a delay in diagnosis and a missed opportunity for early reperfusion therapy. An updated literature review about rupture of the ventricular septum complicating acute myocardial infarction was carried out.
Asunto(s)
Humanos , Femenino , Anciano , Rotura Septal Ventricular/fisiopatología , Rotura Septal Ventricular/epidemiología , Choque Cardiogénico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Ecocardiografía , Factores de Riesgo , Rotura Septal Ventricular/diagnóstico , Rotura Septal Ventricular/terapia , Infarto del Miocardio/complicacionesRESUMEN
OBJECTIVE: To explore the clinical characteristics of acute myocardial infarction (AMI) with ventricular septal perforation (VSR), the prognosis comparison of different treatment methods, and analysis of related risk factors. METHODS: From January 2006 to February 2020, 29 patients with AMI and VSR diagnosed in the People's Hospital of Peking University were selected as the study group. Among them, 16 cases were male (55.2%), 13 cases were female (44.8%), and the average age was 64.69 ± 10.32 years old. They were divided into two groups: the survival group (N = 16) and non-survival group (N = 13), according to whether they survived within 30 days of surgical or drug conservative treatment. The clinical characteristics, coronary angiography, and treatment of the two groups were summarized, and the prognosis and related risk factors were analyzed. RESULTS: There was no significant difference in the basic clinical characteristics between the two groups (P > 0.05). Compared with the results of coronary angiography in the two groups, the proportion of the culprit vessel, which was a simple anterior descending branch in the non-survival group, was higher than that in the survival group. There was a statistical difference between the two groups (P < 0.05). The perioperative data of the two groups showed that the proportion of patients with complete revascularization, simultaneous bypass, and recanalization of culprit vessels in the survival group was significantly higher than that in the non-survival group (P < 0.05). However, the incidence of postoperative low cardiac output and mortality during hospitalization in the survival group were significantly lower than those in the non-survival group (P < 0.05). Logistic regression analysis showed that complete revascularization (OR = 0.021, 95% CI 0.001-0.374, P = 0.009) and recanalization of culprit vessels (OR = 0.045, 95% CI 0.004-0.548, P = 0.015) were independent risk factors for 30-day mortality. Kaplan-Meier survival curve showed that during the follow-up period, the long-term survival rate of patients with operation and complete revascularization was significantly higher than that of patients with drug conservative treatment and incomplete revascularization. There was a statistical difference between the two groups (P < 0.05). CONCLUSION: Complete revascularization and recanalization of culprit vessels are independent risk factors for 30-day mortality in patients with AMI and VSR. The long-term survival rate of patients after surgery and complete revascularization is significantly higher than that of patients with conservative medical treatment and incomplete revascularization. Surgery and complete revascularization are important factors affecting the long-term prognosis of patients with AMI and VSR.
Asunto(s)
Infarto del Miocardio/complicaciones , Rotura Septal Ventricular/etiología , Rotura Septal Ventricular/terapia , Anciano , Fármacos Cardiovasculares/uso terapéutico , Angiografía Coronaria , Puente de Arteria Coronaria , Femenino , Mortalidad Hospitalaria , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/cirugía , Revascularización Miocárdica , Pronóstico , Factores de Riesgo , Rotura Septal Ventricular/diagnóstico por imagenAsunto(s)
Técnicas de Imagen Cardíaca , Divertículo/diagnóstico por imagen , Aneurisma Cardíaco/diagnóstico por imagen , Cardiopatías Congénitas/diagnóstico por imagen , Rotura Septal Ventricular/diagnóstico por imagen , Adulto , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Diagnóstico Diferencial , Divertículo/terapia , Ecocardiografía , Femenino , Aneurisma Cardíaco/terapia , Cardiopatías Congénitas/terapia , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Imagen Multimodal , Valor Predictivo de las Pruebas , Rotura Septal Ventricular/terapiaAsunto(s)
Aneurisma Falso/etiología , Infarto de la Pared Anterior del Miocardio/complicaciones , Aneurisma Cardíaco/etiología , Rotura Septal Ventricular/etiología , Anciano , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/fisiopatología , Aneurisma Falso/terapia , Infarto de la Pared Anterior del Miocardio/diagnóstico por imagen , Cateterismo Cardíaco/instrumentación , Femenino , Aneurisma Cardíaco/diagnóstico por imagen , Aneurisma Cardíaco/fisiopatología , Aneurisma Cardíaco/terapia , Humanos , Resultado del Tratamiento , Rotura Septal Ventricular/diagnóstico por imagen , Rotura Septal Ventricular/fisiopatología , Rotura Septal Ventricular/terapiaRESUMEN
The associated mortality and morbidity of posterior ventricular septal rupture (VSR) is quite high increasing to almost 80% due to severe right ventricle dysfunction and pulmonary artery hypertension. Herein, we present a case of posterior VSR due to inferior wall myocardial infarction who underwent surgery. Premature removal of intra-aortic balloon pump (IABP) led to hemodynamic deterioration and he was salvaged with prolonged and prompt re-institution of IABP. This case also highlights the importance of IABP in right ventricle failure.
Asunto(s)
Hemodinámica/fisiología , Contrapulsador Intraaórtico/métodos , Disfunción Ventricular Derecha/complicaciones , Disfunción Ventricular Derecha/terapia , Rotura Septal Ventricular/complicaciones , Rotura Septal Ventricular/terapia , Humanos , Masculino , Persona de Mediana Edad , Disfunción Ventricular Derecha/fisiopatología , Rotura Septal Ventricular/fisiopatologíaAsunto(s)
Cateterismo Cardíaco , Infarto del Miocardio/complicaciones , Rotura Septal Ventricular/terapia , Anciano de 80 o más Años , Cateterismo Cardíaco/instrumentación , Femenino , Hemodinámica , Humanos , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/fisiopatología , Recuperación de la Función , Dispositivo Oclusor Septal , Resultado del Tratamiento , Rotura Septal Ventricular/diagnóstico por imagen , Rotura Septal Ventricular/etiología , Rotura Septal Ventricular/fisiopatologíaRESUMEN
BACKGROUND: Differences in the predictors between ventricular septal rupture (VSR) and free wall rupture (FWR) have not been fully studied. Data on the prevalence and clinical outcome of heart rupture are limited. HYPOTHESIS: This study aimed to investigate heart rupture incidence and clinical results in patients with acute myocardial infarction (AMI). METHODS: Of 9265 AMI patients in the MOODY registry between March 1999 and October 2016, a total of 146 were studied. The primary clinical endpoint was rupture prevalence and in-hospital mortality. Independent factors of heart rupture were analyzed using Cox proportional model and were compared between patients with VSR and those with FWR. RESULTS: Of 9265 AMI patients, 146 (1.58%) patients had a heart rupture (FWR, 94 (1.02%)) and VSR (52 (0.56%)). All patients with FWR died during hospitalization, and in-hospital mortality was recorded in 37 (71.2%) patients with VSR, who had an extremely longer time delay from AMI onset to the first medical contact (FMC) (~20â¯h). FWR usually occurred in patients with ST-elevation myocardial infarction (STEMI) patients with a FMCâ¯≥â¯3â¯h, for whom primary reperfusion was not performed. Percutaneous repair at 1-2â¯weeks following AMI was associated with less mortality, and 9 of 38 patients who underwent non-primary reperfusion died post procedure. CONCLUSION: This study demonstrated the importance of shortening FMC to prevent VSR and of early primary reperfusion in STEMI patients to reduce FWR. Urgent closure of rupture is necessary to reduce in-hospital and 1-year mortality. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.org, identifier: No. NCT03051048.
Asunto(s)
Rotura Cardíaca Posinfarto/epidemiología , Infarto del Miocardio/epidemiología , Rotura Septal Ventricular/epidemiología , Anciano , Anciano de 80 o más Años , Cateterismo Cardíaco/instrumentación , China/epidemiología , Femenino , Rotura Cardíaca Posinfarto/diagnóstico por imagen , Rotura Cardíaca Posinfarto/mortalidad , Rotura Cardíaca Posinfarto/terapia , Mortalidad Hospitalaria , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/mortalidad , Infarto del Miocardio/terapia , Intervención Coronaria Percutánea , Prevalencia , Estudios Prospectivos , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Dispositivo Oclusor Septal , Factores de Tiempo , Tiempo de Tratamiento , Resultado del Tratamiento , Rotura Septal Ventricular/diagnóstico por imagen , Rotura Septal Ventricular/mortalidad , Rotura Septal Ventricular/terapiaRESUMEN
Right ventricular (RV) wall dissection following ventricular septal rupture related to inferior myocardial infarction (MI) is an extremely rare complication with a high mortality rate. We report the case of a 61-year-old man who was admitted to our hospital because of syncope and intermittent chest pain with a precordial murmur. Transthoracic echocardiography showed a rupture at the basal infero-posterior septum and RV free-wall dissection forming an echolucent cavity that extended beyond the septum and subsequently re-entered into RV chamber. The patient's overall cardiac and renal functions deteriorated and he died 24 days after the diagnosis. We present a literature review of the published cases of complex dissecting tracts through the septum and RV wall in ischemic context.
Asunto(s)
Ecocardiografía/métodos , Infarto de la Pared Inferior del Miocardio/complicaciones , Infarto de la Pared Inferior del Miocardio/diagnóstico por imagen , Rotura Septal Ventricular/diagnóstico por imagen , Rotura Septal Ventricular/etiología , Enfermedad Aguda , Resultado Fatal , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Infarto de la Pared Inferior del Miocardio/terapia , Contrapulsador Intraaórtico , Masculino , Persona de Mediana Edad , Rotura Septal Ventricular/terapiaAsunto(s)
Oclusión Coronaria/diagnóstico por imagen , Infarto del Miocardio/diagnóstico , Rotura Septal Ventricular/diagnóstico por imagen , Anciano , Angioplastia Coronaria con Balón , Angiografía Coronaria , Oclusión Coronaria/complicaciones , Oclusión Coronaria/terapia , Ecocardiografía , Humanos , Contrapulsador Intraaórtico , Masculino , Infarto del Miocardio/complicaciones , Infarto del Miocardio/terapia , Dispositivo Oclusor Septal , Rotura Septal Ventricular/etiología , Rotura Septal Ventricular/terapiaAsunto(s)
Infarto de la Pared Anterior del Miocardio/complicaciones , Cateterismo Cardíaco/instrumentación , Dispositivo Oclusor Septal , Rotura Septal Ventricular/terapia , Infarto de la Pared Anterior del Miocardio/diagnóstico , Infarto de la Pared Anterior del Miocardio/fisiopatología , Ecocardiografía Doppler en Color , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Recuperación de la Función , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Rotura Septal Ventricular/diagnóstico por imagen , Rotura Septal Ventricular/etiología , Rotura Septal Ventricular/fisiopatologíaRESUMEN
OBJECTIVES: The present study was designed to assess whether the incidence and outcomes of VSR-AMI have changed in the era of timely primary PCI. BACKGROUND: Ventricular septal rupture (VSR) is a rare but frequently fatal complication of acute myocardial infarction (AMI). METHODS: We conducted a retrospective cohort study of all Medicare fee-for-service beneficiaries from 1999 to 2014 to examine trends in the incidence, surgical and percutaneous repair, and 30-day and 1-year mortality of VSR-AMI. RESULTS: The annual incidence of VSR-AMI hospitalization declined by 41.6% from 197 patients per 100,000 AMIs in 1999 to 115 patients per 100,000 AMIs in 2014 (P < 0.001). The 30-day VSR-AMI repair rate decreased from 49.9% in 1999 to 33.3% in 2014 (P < 0.001). In 2014, 82.9% of repairs were performed surgically and 17.1% percutaneously. VSR-AMI mortality rates were high (60.2% at 30 days; 68.5% at 1 year) and changed minimally over the study period with adjusted 30-day mortality per year Odds Ratio (OR) 0.99 (95% confidence interval [CI] 0.98-1.01) and adjusted 1-year mortality per year OR 0.98 (95% CI 0.97-1.00). Across the 16 years of data, unadjusted mortality rates were lower in patients undergoing repair than in unrepaired patients at 30 days (mean 51.7% and 65.7%, P ≤ 0.01) and 1 year (mean 62.0% and 72.8%, P < 0.01). CONCLUSIONS: In the era of increased timely primary PCI, the incidence of VSR-AMI hospitalization declined but its associated mortality rate remained high. Rates of VSR repair decreased from 1999 to 2014 despite increased use of percutaneous repair.
Asunto(s)
Cateterismo Cardíaco/tendencias , Procedimientos Quirúrgicos Cardíacos/tendencias , Infarto del Miocardio/epidemiología , Infarto del Miocardio/terapia , Intervención Coronaria Percutánea/tendencias , Rotura Septal Ventricular/epidemiología , Rotura Septal Ventricular/terapia , Anciano , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/mortalidad , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Femenino , Humanos , Incidencia , Masculino , Medicare , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/mortalidad , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Prevalencia , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiología , Rotura Septal Ventricular/diagnóstico por imagen , Rotura Septal Ventricular/mortalidadRESUMEN
Cardiac surgery performed on patients in cardiogenic shock is associated with a high mortality and morbidity. This review outlines the current role of preoperative veno-arterial extra corporeal membrane oxygenation to allow hemodynamic stability and organ recovery before definitive cardiac surgery.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Oxigenación por Membrana Extracorpórea , Cuidados Preoperatorios , Choque Cardiogénico/terapia , Hemodinámica , Humanos , Hipertensión Pulmonar/terapia , Infarto del Miocardio/complicaciones , Choque Cardiogénico/etiología , Rotura Septal Ventricular/etiología , Rotura Septal Ventricular/terapiaRESUMEN
Even in the modern era of percutaneous coronary intervention, postinfarction ventricular septal defect (VSD) remains a serious and often lethal complication. Whether or not immediate surgical repair or delaying surgery a few days aided by intra-aortic counterpulsation provides the optimal strategy remains a matter of debate. An interdisciplinary approach of intensivists and cardiac surgeons in this setting is mandatory. We report the use of veno-arterial extracorporeal membrane oxygenation and extracorporeal blood purification therapy (CytoSorb®) as bridging to surgical closure in a patient with an ischemic VSD leading to protracted cardiogenic shock after posterior myocardial infarction.
Asunto(s)
Citocinas/sangre , Oxigenación por Membrana Extracorpórea , Choque Cardiogénico/terapia , Rotura Septal Ventricular/terapia , Femenino , Hemodiafiltración , Humanos , Masculino , Persona de Mediana Edad , Choque Cardiogénico/etiología , Síndrome de Respuesta Inflamatoria Sistémica/terapiaRESUMEN
OBJECTIVES: The aim of this study was to define the dynamic in vivo morphology of post-infarct ventricular septal defect (PIVSD), which has not been previously described in living patients. BACKGROUND: PIVSD is a devastating complication of acute myocardial infarction. METHODS: The anatomic features of PIVSD, as demonstrated by computed tomography or magnetic resonance imaging, were retrospectively reviewed. RESULTS: Thirty-two PIVSDs were assessed, 16 left coronary artery and 16 right coronary artery PIVSDs. PIVSDs were large (mean maximum dimension 26.5 ± 11.5 mm, mean area 5.2 ± 4.2 cm2) and oval (mean eccentricity index 1.7 ± 0.5), with thin margins (diastolic mean thickness 5 mm from the edge of the PIVSD 6.4 ± 3.0mm), and only 22% of PIVSDs were entirely confined to the septum. The defects could be larger in diastole or systole. The stem of the largest available Amplatzer occluder stem (St. Jude Medical, St. Paul, Minnesota) filled only 50% of defects. Patients with small defects may survive without closure. Without closure, those with large defects die. If accepted for closure, PIVSD size and coronary territory did not predict survival >1 year (overall 60%). CONCLUSIONS: This is the first detailed anatomic description of PIVSD in living patients. Defects may be larger in systole or diastole, meaning that single-phase measurement is unsuitable. Its complex nature means that the most commonly available occluder device is frequently unsuitable. Successful closure leads to prolonged survival and should be attempted where possible. This study may lead to improved patient selection, closure techniques, and device design.