Original title: Percutaneous Closure of Postinfarction Ventricular Septal Defect: In-Hospital Outcomes and Long-Term Follow-Up of UK Experience. Reference: Circulation. 2014 Jun 10;129(23):2395-402.
As a mechanical post AMI complication, interventricular communication carries a grim prognosis. Surgery has achieved reasonable outcomes but only for those patients who survive the acute phase of healing. Percutaneous closure is a viable early alternative.
Between 1997 and 2012 percutaneous closure of postinfarction ventricular septal defect was attempted in 53 patients at 11 UK centers. 66% of MI were anterior and 34% inferior.
Time from MI to closure procedure was 13 days (5-54 range) and devices were successfully implanted in 89% of the population.
Immediate complications in this high risk population included periprocedural death in 3.8% and emergency cardiac surgery in 7.5% of the population.
Right to left shunt was partially occluded in most of patients (62%), completely occluded in 23% and failed despite device implantation in 15%.
58% of treated patients survived to discharge and were followed up to 395 days. During this period. four additional patients died (7.5%).
Factors more strongly associated to postinfarction mortality included age (HR 1.04; p=0.039), female sex (HR=2.33; p=0.043), NYHA functional class IV (HR=4.42; p=0.002), cardiogenic shock (HR=3.75; p=0.003), need for inotropes (HR=4.18; p=0.005) and the absence of revascularization for presenting MI (HR=3.28; p=0.009).
Prior surgical closure and immediate post implantation shunt reduction were associated with better survival.
Conclusion
Percutaneous closure is a reasonable alternative to treat post infarction percutaneous ventricular septal defect. Although mortality was high, patients who survived to discharge had a good long term prognosis.
Editorial Comment
This option should be considered especially for those patients that develop cardiogenic shock as a symptom of ventricular septal defect, since surgery at the acute phase is difficult due to the friable nature of septal tissue and waiting, in this context, is hardly a viable option.
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