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Dr.Abhishek Gaikwad
DM Cardiology resident
PGIMER,Delhi
Latham
First described at autopsy in 1845
Cooley
First successful surgical repair in a
patient after 9 weeks post detectio...
Incidence
 1-3% without reperfusion therapy
 0.2-0.34% in fibrinolytic therapy From Antman EM ,Anbe DT,Armstrong PW etal...
Hyaline degeneration
↓
Fragmentation
↓
Enzymatic digestion
↓
Fissure formation
↓
Septal rupture
 Chest pain
 Shortness of breath
 Hypotension
 Harsh holosystolic murmur
 Thrill
 S3
 Loud 2nd heart sound
 Pulmonary edema
 RV/LV failure
 Cardiogenic shock
 No electrocardiographic (ECG) features are diagnostic
of postinfarction VSR, though ECG indeed provides
some useful info...
 RWMA
 Ventricular septal rupture
 LR shunt on color flow doppler
echo through vent.septum
 RA to RV step up
 Large v waves
 Pulmonary artery catheter monitoring  Class I recommendation in
suspected mechanical...
 Class I recommendation
if the patient is sufficiently stable before definitive
therapy of a mechanical complication of S...
 AWMI- apical
 IWMI- basal septum
worse prognosis than that of anterior location
 Type I - rupture shows an abrupt, slit-like tear, and is
associated with acute infarcts <24 h in age.
 Type II rupture ...
 Two types of VSD
◦ Simple: through and through defect
usually located anteriorly
◦ Complex: serpiginous dissection tract...
Predictors of VSD
◦ Advanced age,
◦ Anterior location of infarction,
◦ Female sex,
◦ CKD
Decreased likelihood
◦ h/o smokin...
High mortality despite various improvements in
therapy
◦ 30 day mortality- 74%
◦ 1 year mortality- 78%
GUSTO analysis, Cre...
 Incidence declining due to:
◦ Earlier restoration of flow by thrombolytics
and prim PCI preventing transmural MI
 Compared enrollment characteristics,angio findings,30d and
1yr mortality
 Total patients 84
Results
 Median time from symptom onset to VSD diagnosis was 1d
 Advanced age, awmi , female sex, and no previous smokin...
 29 patients were analysed; 15 received thrombolytic
therapy
 The median time to post-myocardial infarction VSD was
shor...
Am J Cardiol. 2010 Jan 1;105(1):59-63. doi: 10.1016/j.amjcard.2009.08.653.
Mechanical complications after percutaneous cor...
 Medical therapy
 Percutaneous device closure
 Surgical t/t
 To render the patient hemodynamically stable
 Vasodilators may be used in an attempt to decrease LR
associated with th...
Indications
 Too high risk for surgical repair due to their recent post-
AMI status, advanced age, severe coronary artery...
 ASD occluder
 Clamshell occluder (USCI Angiographics,Tewksbury, MA),
 CardioSeal (NMT Medical, Boston,MA) and
 Amplat...
 When VSD size is larger
 ASD occluders with larger
left-sided discs used
 Can lead to suboptimal
device deployment of ...
 Selfexpanding, single-unit nitinol
device with incorporated polyester
fabric
 Comprises two discs connected by a
7mm-lo...
 Specially designed for post-AMI
VSDs.
 larger disks ,longer waist (10
mm) to accommodate the
thicker adult IVS.
 avail...
 Antibiotic preprocedure
 Full heparinization
 Antiplatelet therapy for atleast 6months for device protection
but lifel...
Max. size of VSD
 Maltais etal- 15mm
 US registry – 24mm
 Thiele etal- 35mm ….device dislocation was relatively
high 17%
 130 patients in 11 series
 64 t/t in acute phase
 Remaining 66 procedure done atleast 14 days after index
event
 Over...
 Single centre retrospective cohort study from 1988 to 2008
boston children hospital
 Primary outcome mortality at 30day...
 Dec 1999 to feb 2005
 11 patients
 f/u done for 5yrs
Result –
 1patient device got displaced on 8th day so was subjec...
 Rigid sheath may traumatize and enlarge the VSD
 Devices come in a limited range of sizes
 Closure of the shunt in the...
Goal of Surgery
Exclusion or removal of infarcted myocardium
Elimination of Lt. to Rt. Shunt
Approach –mostly via right ...
 Daggett procedures
 David procedures
 Classical approach to antero-
septal rupture
◦ Infarctectomy, and
◦ Reconstruction of the ventricular
septum with Dacron...
 Classical approach to
infero-posterior rupture
◦ Infarctectomy, and
◦ Reconstruction of infroposterior
VSD,
◦ Reconstruc...
Balkanay et al.
Tex Heart Inst J 2005;32:43-6
◦ LV excluded from the infarcted muscle using a bovine
pericardial patch sutured to the healthy peri-infarct
endocardium
◦...
 2876 individuals aged ≥18 years underwent post-MI VSR repair
between 1999 and 2010.
 Overall operative mortality -- 42....
Controversial
Non-randomized studies showing:
Early repair, 40% - 50% mortality
Late repair (past 3 weeks), 10% mortality...
 Patients with less severe hemodynamic compromise, more
likely to survive the acute phase without need for prompt
surgery...
 A single-center, retrospective study January 1992 to December 2012.
 25 patients with 18 managed surgically and 7 manag...
Class I
 1. Patients with STEMI complicated by the development of a
VSR should be considered for urgent cardiac surgical ...
 Insertion of an IABP and prompt surgical referral are
recommended for almost every patient with an acute
VSR.
 Invasive...
 No change in The 2007 Focused Update of the
ACC/AHA 2004 Guidelines for the Management of
Patients with ST-Elevation Myo...
Ventricular septal rupture complicating acute myocardial infarction: a
contemporary review | European Heart Journal
 Post MI VSD bears a high mortality inspite of all the
advances
 Transcatheter device closure is an expanding technology...
 Large or multiple defects are best treated surgically
because the risk of device embolization
 A multidisciplinary team...
THANK
YOU
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  1. 1. Dr.Abhishek Gaikwad DM Cardiology resident PGIMER,Delhi
  2. 2. Latham First described at autopsy in 1845 Cooley First successful surgical repair in a patient after 9 weeks post detection of VSR in 1956 Heimbecker,Allen,Woodwark,Iben Surgery for acute phase in the late 1960s
  3. 3. Incidence  1-3% without reperfusion therapy  0.2-0.34% in fibrinolytic therapy From Antman EM ,Anbe DT,Armstrong PW etal  0.23 in prim PCI.Yip et al 0.17 (APEX-AMI)  3.9% in patients with cardiogenic shock  Male : Female = 3:2 crenshaw 2000  1 vessel (50%), 2 vessels (40%), 3 vessels (10%) gusto Time course  Bimodal peak Within 24 hrs and 3-5 days  Closer to 1 day in thrombolytic era ( Gusto trial ) 16 hrs (Shock trial)  Chronic VSR - : more than 4 ~ 6 weeks
  4. 4. Hyaline degeneration ↓ Fragmentation ↓ Enzymatic digestion ↓ Fissure formation ↓ Septal rupture
  5. 5.  Chest pain  Shortness of breath  Hypotension
  6. 6.  Harsh holosystolic murmur  Thrill  S3  Loud 2nd heart sound  Pulmonary edema  RV/LV failure  Cardiogenic shock
  7. 7.  No electrocardiographic (ECG) features are diagnostic of postinfarction VSR, though ECG indeed provides some useful information.  Persistent ST-segment elevation associated with ventricular aneurysm is common.
  8. 8.  RWMA  Ventricular septal rupture  LR shunt on color flow doppler echo through vent.septum
  9. 9.  RA to RV step up  Large v waves  Pulmonary artery catheter monitoring  Class I recommendation in suspected mechanical complications of STEMI, (ie, VSR, papillary muscle rupture, or free wall rupture with pericardial tamponade) if an echo has not been performed. (Level of Evidence: C)
  10. 10.  Class I recommendation if the patient is sufficiently stable before definitive therapy of a mechanical complication of STEMI, such as acute MR, VSR, pseudoaneurysm, or LV aneurysm. (Level of Evidence: B)
  11. 11.  AWMI- apical  IWMI- basal septum worse prognosis than that of anterior location
  12. 12.  Type I - rupture shows an abrupt, slit-like tear, and is associated with acute infarcts <24 h in age.  Type II rupture demonstrates erosion of the infarcted myocardium, and correlates clinically with a sub-acute presentation.  Type III rupture exhibits concomitant aneurysm formation with significant thinning of the septum and subsequent rupture, a process associated with older infarcts.
  13. 13.  Two types of VSD ◦ Simple: through and through defect usually located anteriorly ◦ Complex: serpiginous dissection tract remote from the primary septal defect- most commonly an inferior VSD
  14. 14. Predictors of VSD ◦ Advanced age, ◦ Anterior location of infarction, ◦ Female sex, ◦ CKD Decreased likelihood ◦ h/o smoking ◦ HTN ◦ DM ◦ Chronic angina ◦ Previous MI As Per GUSTO analysis
  15. 15. High mortality despite various improvements in therapy ◦ 30 day mortality- 74% ◦ 1 year mortality- 78% GUSTO analysis, Crenshaw et al, Circ. 1/2000
  16. 16.  Incidence declining due to: ◦ Earlier restoration of flow by thrombolytics and prim PCI preventing transmural MI
  17. 17.  Compared enrollment characteristics,angio findings,30d and 1yr mortality  Total patients 84
  18. 18. Results  Median time from symptom onset to VSD diagnosis was 1d  Advanced age, awmi , female sex, and no previous smoking proved to be high risk factors  30d mortality 74%  1yr mortality 78% Conclusion  Compared with historical control subjects, patients who undergo thrombolysis within 6 hours of infarction onset may have a reduced risk of later VSD  Despite improvements in medical therapy and percutaneous and sx techniques, mortality with this complication remains extremely high.  VSR occurs sooner in the thrombolytic era than prethrombolytic
  19. 19.  29 patients were analysed; 15 received thrombolytic therapy  The median time to post-myocardial infarction VSD was shorter with thrombolytic therapy .1 v 5.5 days (p=0.01). Conclusion: There appears to be an earlier presentation of post-myocardial infarction VSD when thrombolytic therapy has been used.
  20. 20. Am J Cardiol. 2010 Jan 1;105(1):59-63. doi: 10.1016/j.amjcard.2009.08.653. Mechanical complications after percutaneous coronary intervention in ST elevation myocardial infarction (from APEX-AMI). French JK , Hellkamp AS, Armstrong PW, Cohen E, Kleiman NS, O'Connor CM, Holmes DR, Hochman JS,Granger CB, Mahaffey KW.  Mechanical complications occurred in 52 of 5,745 patients  Freq of VSR -0.17%  90d survival rate was 20% in VSR  Factors associated with mechanical complications were older age, female gender, Q waves, presence of radiologic pulmonary edema, and increased prerandomization troponin levels Conclusion Rates of mechanical complications are lower with primary PCI than those previously reported after fibrinolytic therapy.
  21. 21.  Medical therapy  Percutaneous device closure  Surgical t/t
  22. 22.  To render the patient hemodynamically stable  Vasodilators may be used in an attempt to decrease LR associated with the mechanical defect and thereby increase CO  (IV) nitroglycerin can be used as a vasodilator and may provide improved myocardial blood flow in patients with significant ischemic cardiac disease.  When used alone, inotropic agents may increase CO; however, without changes in Qp-to-Qs ratio, they markedly increase left ventricular work and myocardial oxygen consumption
  23. 23. Indications  Too high risk for surgical repair due to their recent post- AMI status, advanced age, severe coronary artery disease, hemodynamic instability, and added comorbidity (such as renal failure and diabetes mellitus)  With residual leak after VSD repair surgery at excessive risk of a repeat surgical operation
  24. 24.  ASD occluder  Clamshell occluder (USCI Angiographics,Tewksbury, MA),  CardioSeal (NMT Medical, Boston,MA) and  Amplatzer septal occluder (AGA Medical Corporation)
  25. 25.  When VSD size is larger  ASD occluders with larger left-sided discs used  Can lead to suboptimal device deployment of the right ventricular disc due to the length of the waist  Often results in the so-called ‘cobra-phenomenon’ with persistent shunting
  26. 26.  Selfexpanding, single-unit nitinol device with incorporated polyester fabric  Comprises two discs connected by a 7mm-long waist portion, compared with a 4-mm waist in (ASD) device.  Sized between 4 and 18 mm by the diameter of the central waist, with the discs being 8 mm larger than this segment.  5- to 9-F diameter sheath.
  27. 27.  Specially designed for post-AMI VSDs.  larger disks ,longer waist (10 mm) to accommodate the thicker adult IVS.  available in sizes of 16 to 24 mm in 2-mm increments, as determined by the diameter of the waist section .  9- to 10-F sheath for delivery. newer sheaths include wire braiding that obviates the risk of kinking.
  28. 28.  Antibiotic preprocedure  Full heparinization  Antiplatelet therapy for atleast 6months for device protection but lifelong keeping in view of AMI  Echo guided sizing - device to be taken 2-8mm larger upto 50% larger than echo size  Balloon sizing - concerns due to friable defect Device Closure forVsd AfterMI By NIKOLAOS KAKOUROS, CARDIAC INTERVENTIONS TODAY
  29. 29. Max. size of VSD  Maltais etal- 15mm  US registry – 24mm  Thiele etal- 35mm ….device dislocation was relatively high 17%
  30. 30.  130 patients in 11 series  64 t/t in acute phase  Remaining 66 procedure done atleast 14 days after index event  Overall device implntn success rate 85%  30d survival 34% in acute phase 81% in chronic phase  Small residual shunt in 43%  Moderate residual shunt in 15% NOVEMBER 2009 I CARDIAC INTERVENTIONS TODAY
  31. 31.  Single centre retrospective cohort study from 1988 to 2008 boston children hospital  Primary outcome mortality at 30days  30 patients included Conclusion –  Transcatheter closure of post-AMI VSR using CardioSEAL or STARFlex devices is feasible and effective.  The MELD-XI score, a marker of multiorgan dysfunction, is a promising risk stratifier in this population of patients.  Early closure of post-AMI VSR is advisable before establishment of multiorgan failure.
  32. 32.  Dec 1999 to feb 2005  11 patients  f/u done for 5yrs Result –  1patient device got displaced on 8th day so was subjected to sx  2patients deviced in acute phase <3wks died 2 and 15days post procedure  8 patients who were deviced >3 wks improved significantly and doing well even after 5 yrs of f/u Conclusion:  Primary transcatheter closure of postinfarction ventricular septal defects may be an alternative to sx in patients with suitable anatomy and completed necrosis.  In our experience, primary transcatheter closure of ventricular septal defects in patients who are in the acute phase of infarction does not improve their survival.
  33. 33.  Rigid sheath may traumatize and enlarge the VSD  Devices come in a limited range of sizes  Closure of the shunt in the acute period may be suboptimal as the polyester fabric requires time to thrombose and endothelialize  Device migration  Transient complete AV block  T/t of basal defects – traping of mitral/tricuspid chordae interference with aortic valve--AR
  34. 34. Goal of Surgery Exclusion or removal of infarcted myocardium Elimination of Lt. to Rt. Shunt Approach –mostly via right ventriculotomy
  35. 35.  Daggett procedures  David procedures
  36. 36.  Classical approach to antero- septal rupture ◦ Infarctectomy, and ◦ Reconstruction of the ventricular septum with Dacron patches
  37. 37.  Classical approach to infero-posterior rupture ◦ Infarctectomy, and ◦ Reconstruction of infroposterior VSD, ◦ Reconstruction free wall with Dacron patches.
  38. 38. Balkanay et al. Tex Heart Inst J 2005;32:43-6
  39. 39. ◦ LV excluded from the infarcted muscle using a bovine pericardial patch sutured to the healthy peri-infarct endocardium ◦ No infarctectomy is performed ◦ RV is undisturbed  Better RV function preservation  May help support the posteromedial papillary muscle
  40. 40.  2876 individuals aged ≥18 years underwent post-MI VSR repair between 1999 and 2010.  Overall operative mortality -- 42.9% (highest mortality rate of any cardiac surgery. )  Patients who did not survive to 30 days tended to be older, female, higher serum creatinine levels and higher acuity of disease (cardiogenic shock, reduced LVEF, triple-vessel CAD, or requirement for pre-operative IABP).  Operative mortality was much lower for procedures considered elective (13.2% mortality) vs. emergent (56.0% mortality) vs. salvage (80.5% mortality). Annals of thoracic surgery 2012
  41. 41. Controversial Non-randomized studies showing: Early repair, 40% - 50% mortality Late repair (past 3 weeks), 10% mortality Retrospective studies Better results in those in whom Sx was delayed for 6 weeks compared to those in acute phase
  42. 42.  Patients with less severe hemodynamic compromise, more likely to survive the acute phase without need for prompt surgery: Lower pre-op risk =>Better outcome  Patients with greater hemodynamic compromise, and more severe insult: Higher pre-op risk =>Worse outcome
  43. 43.  A single-center, retrospective study January 1992 to December 2012.  25 patients with 18 managed surgically and 7 managed percutaneously  2patients with an initial surgical repair experienced patch dehiscence and were subsequently treated percutaneously, bringing the number in this group to 9.  Mortality rates were 44% and 75% for those with final percutaneous and surgical closure, respectively (P<.13).  Conclusion- Percutaneous closure may be a viable and non-inferior treatment strategy compared to traditional surgical closure
  44. 44. Class I  1. Patients with STEMI complicated by the development of a VSR should be considered for urgent cardiac surgical repair, unless further support is considered futile because of the patient’s wishes or contraindications /unsuitability for further invasive care. (Level of Evidence: B)  2. CABG should be undertaken at the same time as repair of the VSR. (Level of Evidence: B)
  45. 45.  Insertion of an IABP and prompt surgical referral are recommended for almost every patient with an acute VSR.  Invasive monitoring is recommended in all patients, together with judicious use of inotropes and a vasodilator to maintain optimal hemodynamics.  Surgical repair usually involves excision of all necrotic tissue and patch repair of the VSR, together with coronary artery grafting.
  46. 46.  No change in The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction and VSR
  47. 47. Ventricular septal rupture complicating acute myocardial infarction: a contemporary review | European Heart Journal
  48. 48.  Post MI VSD bears a high mortality inspite of all the advances  Transcatheter device closure is an expanding technology  Although Sx correction is gold std. a significant proportion of pts. are at too high risk for sx  Device also provide as alternative to repeat sx for patients with residual shunts and patch dehiscence
  49. 49.  Large or multiple defects are best treated surgically because the risk of device embolization  A multidisciplinary team, including interventional cardiologists and cardiac surgeons, should evaluate these high-risk patients to determine the optimal management strategy.  Large series are needed in the future to further compare percutaneous with surgical options, as well as different occlusion devices
  50. 50. THANK YOU

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