Postinfarction Ventricular Septal Defect—Searching for the Optimal Solution

Background: Surgical treatment of postinfarction ventricular septal defect (VSD) carries a high mortality rate of up to 50% in larger studies. The aim of this study was to analyze our institutional outcome and mid-term mortality in treating postinfarction VSD during the past 10 years.

Methods: This was a retrospective, observational, single-center cohort study of data from a heterogeneous group of 46 patients with postinfarction VSD treated surgically at our institution between May 2012 and December 2022. Follow up was 100% complete. Primary endpoint of the study was 1-year survival.

Results: Mean age was 66.4 ± 11.2 years (range 37 to 85 years), 63% males. Median EuroScore II was 16 [IQR 8.2–29.2] %. Thirty six (78.3%) patients were in a critical preoperative state defined as any of the following: ventricular fibrillation, preoperative CPR, preoperative invasive ventilation, preoperative inotropic support, preoperative mechanical circulatory support or acute renal failure. Preoperatively, 26 (56.5%) of patients were supported with mechanical circulatory support. Anterior VSD was present in 19 (41.3%) patients and posterior VSD in 27 (58.7%). Surgical technique included the Dor-, Daggett- and “Butterfly” technique. VSD repair was performed using cardioplegic arrest in 28 (60.9%) patients and with an on-pump beating-heart strategy in 18 (39.1%) patients. Concomitant procedures were CABG in 14 (30.4%) patients, valve surgery in 8 (17.4%), LV aneurysmectomy in 24 (52.2%), ECMO implantation in 6 (13%) and IABP implantation in 7 (15.2%). Survival at one year was 50% for the whole group. In a binary logistic regression adjusted for posterior VSD repair, concomitant CABG, valve surgery, critical preoperative state, preoperative use of mechanical circulatory support and beating-heart VSD repair, there were no statistically significant variables that influenced one-year survival except whether VSD repair was performed on the beating-heart or not (OR 6.8 [CI 1.3–35.7] (p = 0.023)); survival at one year was 35.7% for the cardioplegic group and 72.2% for the beating-heart group (Fisher’s exact test; p = 0.033).

Conclusion: The mid-term mortality rate after postinfarction VSD repair remains high. Beating-heart techniques should be considered whenever feasible to avoid additional myocardial ischemia.

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Artikel online veröffentlicht:
13. Februar 2024