Temporary microaxial transvalvular left ventricular assist device for post-myocardial infarction ventricular septal rupture: Bridging a paradigm shift

Objective: To characterize the clinical courses and outcomes of patients presenting with post-myocardial infarction (MI) ventricular septal rupture (VSR) receiving temporary microaxial transvalvular left ventricular assist device (tVAD) support. Methods: Between December 2019 and July 2023, 10 consecutive patients presented with a post-MI VSR. All 10 patients received a tVAD. Patient characteristics, hemodynamics, intraoperative details, and postoperative outcomes were reviewed. Results: Eight patients underwent VSR repair (7 open, 1 percutaneous), and 2 patients died while on tVAD before being treated. Among the 7 patients who underwent open repair, 6 received preoperative tVAD support and 1 required intraoperative tVAD insertion during emergency right ventricular rupture repair. In the 6 patients receiving preoperative tVAD support, improvements from insertion to repair were observed in shunt fraction (from 2.6 [range, 2.3-3.3] to 1.8 (range, 1.5-3.3]), cardiac index (from 1.5 [range, 1.5-6.2] L$min(-1) m(-2 )to 3.1 [range, 2.2-6.9] L$min(-1)m(-2 )), pulmonary capillary wedge pressure (from 25 [range, 14-35] mm Hg to 16 [range, 14-18] mm Hg), central venous pressure (from 14 [range, 7-26] mm Hg to 12 [range, 1-26] mm Hg), creatinine (from 1.5 [range, 1.1-1.8] mg/dL to 1.2 [range, 0.9-1.5] mg/dL) and lactate (from 1.3 [1-1.7] mmol/L to 0.7 [range, 0.4-1.2] mmol/L). The median time from post-MI VSR diagnosis to repair was 15 (range, 13-18) days. Surgical repair was approached via right atriotomy in 4 patients, via left ventriculotomy in 2 patients, and via right ventricular defect in 1 patient, with no residual shunts or operative mortalities. Conclusions: Perioperative tVAD support for post-MI VSR acutely stabilizes hemodynamics and end-organ function, facilitating delayed intervention with reduced operative risk while also preventing futile interventions. This paradigm shift in management of post-MI VSR from emergency to urgent operations may be associated with improved outcomes.