Techniques, Timing & Prognosis of Post Infarct Ventricular Septal Repair: a Re-look at Old Dogmas

Objective: The study aimed to identify the factors affecting the prognosis of post myocardial infarction (Ml) ventricular septal rupture (VSR) and to develop a protocol for its management. Methods: This was a single center, retrospective-prospective study (2009-2014), involving 55 patients with post Ml VSR. The strengths of association between risk factors and prognosis were assessed using multivariate logistic regression analysis. The UNM Post Ml VSR management and prognosis scoring systems (UPMS & UPPS) were developed. Results: Thirty-day mortality was 52.5% (35% in the last 3 years). Twenty-eight (70%) patients underwent concomitant coronary artery bypass grafting. Residual ventricular septal defect was found in 3 (7.5%) patients. The multivariate analysis showed low mean blood pressure with intra-aortic balloon pump (OR 11.43, P=0.001), higher EuroSCORE II (OR 7.47, P=0.006), higher Killip class (OR 27.95, P=0.00), and shorter intervals between Ml and VSR (OR 7.90, P=0.005) as well as VSR and Surgery (OR 5.76, P=0.016) to be strong predictors of mortality. Concomitant coronary artery bypass grafting (P=0.17) and location (P=0.25) of VSR did not affect the outcome. Mean follow-up was 635.8 +/- 472.5 days and 17 out of 19 discharged patients were in NYHA class l-ll. Conclusion: The UNM Post-MI VSR Scoring Systems (UPMS & UPPS) help in management and prognosis, respectively. They divide patients into 3 groups: 1) Immediate Surgery-Patients with scores of<25 require immediate surgery, preferably with extracorporeal membrane oxygenation support, and have poor prognosis; 2) Those with scores of 25-75 should be managed with "Optimal Delay" and they have intermediate outcomes; 3) Patients with scores of >75 can undergo Elective Repair and they are likely to have good outcomes.