Introduction

Acute myocardial infarction (AMI), an abrupt and severe event of heart muscle damage due to reduced blood flow, is a prominent global health concern.¹ Despite advancements in diagnosis, risk stratification, and management, AMI remains a significant cause of morbidity and mortality, posing substantial societal and economic burdens worldwide. Further complicating this landscape is the occurrence of severe mechanical complications post-AMI, such as ventricular septal rupture (VSR).^2,3

Ventricular septal rupture represents an emergency clinical scenario.^4,5 It is a catastrophic event where a hole forms in the ventricular septum, the wall separating the heart’s left and right ventricles, secondary to an infarct.^6,7 The resultant left-to-right shunt leads to rapid hemodynamic compromise, placing patients at an exceedingly high risk of mortality. Even though the incidence of VSR has declined with the advent of reperfusion therapies, it still complicates 1%-2% of AMIs and carries a grim prognosis, with a mortality rate exceeding 40% even with surgical intervention.^8,9

The management of VSR post-AMI represents a significant clinical conundrum. Traditional medical management alone is typically insufficient due to the profound hemodynamic instability that accompanies VSR.¹⁰ Surgical repair, though considered the gold standard for managing VSR, is fraught with significant challenges due to the poor condition of the infarcted myocardium and the critically ill state of the patients.¹¹ More recently, the advent of percutaneous device closure techniques offers a less invasive alternative, yet its comparative efficacy and safety remain uncertain.^12,13

Given this backdrop, it is of utmost importance to deepen our understanding of AMI complicated by VSR to refine our management strategies further. The present study aims to explore the clinical characteristics of patients diagnosed with AMI complicated by VSR and to provide a comprehensive comparison of the prognostic outcomes following different therapeutic strategies. In particular, this study strive to delineate the survival outcomes associated with medical management, surgical repair, and percutaneous device closure.

Methods

Participants

Our retrospective cohort study comprised patients who presented to our hospital from January 2018 to December 2023, diagnosed with AMI and complicated by VSR. The local Institutional Review Board provided ethical clearance for the study, and this study adhered strictly to the principles laid out in the Declaration of Helsinki.

Study Population and Data Collection

A total of 205 patients with complete data were recruited. According to the consultation results, 5 of them were suspected to have congenital ventricular septal defects. Finally, this study included a total of 200 patients. The inclusion criteria consisted of adults over 18 years, diagnosed with AMI, and subsequent VSR confirmed by echocardiography. WePatients with a history of congenital ventricular septal defects, those who presented more than 24 hours after symptom onset, and those with missing data were excluded.

Demographic data, including age, sex, and comorbidities, were obtained from the hospital’s electronic health record system. Clinical presentation, AMI characteristics, echocardiographic findings, treatment details, and outcomes were systematically recorded.

Treatment Stratification

Clinical practice guideline recommendations for patients with VSR stem from the American College of Cardiology and American Heart Association Task Force on Practice Guidelines. (1) Patients were categorized into 3 groups according to the primary treatment for VSR. (2) Medical management (group A): consisting of patients who received only medical therapy, including inotropic support, afterload reduction, and intra-aortic balloon pump when required. (3) Surgical repair (group B): comprising patients who underwent surgical repair of VSR, either with a patch technique or direct suture closure. (4) Percutaneous device closure (group C): including patients where VSR was managed with a percutaneous septal occluder device.

Outcomes Assessment

The main focus of the study was the 1-year all-cause mortality rate. Secondary endpoints included in-hospital mortality, 30-day mortality, and major adverse cardiovascular events (MACEs) at 1 year, including recurrent MI, heart failure hospitalization, stroke, and the need for re-intervention.

Surgical Techniques

Median sternotomy was performed in all cases. The myocardium was protected by moderate hypothermia cardiopulmonary bypass and intermittent anterograde cold crystal arrest. If needed, coronary artery bypass grafting was performed first, followed by VSD repair. The bovine pericardial patch described by David et al¹⁴ was used to exclude infarction in all cases. According to the location of the ventricular septal defect, the left ventricle was incised in the infarct area. The bovine pericardial patch was large enough in size, typically 1.5 cm wider than the VSD edge, to provide sufficient support to hold the suture to healthy muscle without tearing. The patch was first sutured to healthy heart muscle 1.5 cm from the perforated edge using continuous 4-0 polypropylene sutures. Sutures maintained proper tension to avoid tearing the fragile heart muscle. The extra break 4-0 guaranteed that polypropylene sutures were used to enhance VSD repair. For patients with anterior ventricular septal defects, the ventricle incision was closed directly with long felt and 2-0 polypropylene sutures. In patients with posterior ventricular septal defects, a triangular bovine pericardial patch was used to close the incision to prevent tension on the fragile heart muscle.

Percutaneous Device Closure Procedure

The basic procedure refers to the common views of Chinese medical experts on interventional treatment of ventricular septal defect.¹⁵ Except for patients with acute ST segment elevation myocardial infarction combined with VSR and hemodynamic instability who required immediate surgery, surgery was generally delayed until 2-4 weeks after myocardial infarction. Procedure steps: A 6F pigtail catheter was delivered into the left ventricle near the apex of the heart, and left ventricle angiography was performed at the left anterior oblique position of 35°-50° and a cephalad position of 10° to evaluate the morphology, location, and diameter of the defect. A pigtail catheter at the cutting end or a JR 4.0 contrast catheter was used to help place the super-slip guidewire through the defect and establish an arteriovenous track. Digital subtraction angiography confirmed a smooth trajectory and avoided the annular tendon bundle. The delivery sheath was conveyed to the left cardiac system along the venous track side, and the occluder was released after being transported along the delivery sheath to the appropriate location. A left ventriculogram was performed again to confirm that the occluding device was fixed and well blocked, and then the occluding device was released. The closure device used here (A7B3H10) is from Shanghai Shape Memory Alloy Co., Ltd.

Statistical Analysis

Statistical analyses were conducted using SPSS software (version 24.0, IBM Corp., Armonk, NY, USA). Categorical variables were presented as percentages, while continuous variables were expressed as mean ± SD. The Kolmogorov–Smirnov test was used to determine the normality of distribution of the continuous variables. Group differences in outcomes were assessed using chi-square tests for categorical variables and 1-way ANOVA for continuous variables. Statistical significance was set at a P-value of less than .05.

Statement

The research and content presented in this manuscript were completed without the utilization of artificial intelligence.

Results

Baseline Characteristics and Clinical Presentation

A total of 200 patients diagnosed with AMI complicated by VSR were included in the study. The mean age of these patients was more than 60 years, with a majority being male. Several prevalent comorbidities of these patients were also observed, such as hypertension, diabetes, and a history of smoking. The weighted mean results were as follows: the time from AMI to VSR was 3.2 days and the time to VSR closure was 20.4 days.

Treatment Outcomes

These patients were categorized into 3 groups according to their primary treatment for VSR: group A (medical management, n = 51), group B (surgical repair, n = 63), and group C (percutaneous device closure, n = 86). They show a similar distribution in age, sex, percentage of hypertension, diabetes, smoking, VSR size, frequency of VSR location, number of coronaries involved, and the time from AMI to VSR (Table 1).

In-hospital mortality varied significantly across the groups: group A had the highest rate at 37.3%, compared to group B and group C, with mortality rates of 20.6% and 17.4%, respectively (Figure 1, Table 2).

The mortality rates observed during the in-hospital phase revealed a noticeable difference among the groups. This trend persisted during the 30-day follow-up, with group A’s mortality rate rapidly increasing to 56.9%. However, there was no change for group B and a slight upregulation for group C, with mortality rate of 20.6% for group B and 22.1% for group C (Figure 2, Table 2). By the end of the 1-year follow-up, group A’s mortality rate decreased to 31.4%, yet it remained the highest among the groups. Group B and group C’s 1-year mortality rates were observed at 28.6% and 25.6%, respectively (Figure 3, Table 2).

Major Adverse Cardiovascular Events

When evaluating the incidence of MACEs at the 1-year mark, group A again demonstrated the highest rate at 56.9%. Group C followed with an incidence rate of 32.6%, and group B reported the lowest incidence at 28.6% (Figure 4, Table 3). This further underscores the potential risks associated with group A, suggesting a more pronounced adverse cardiac event profile when compared to the other groups.

Association of the Clinical Factors with the Outcomes in Each Group

The factors having an association with the outcomes (in-hospital mortality, 30-day mortality, 1-year mortality, MACEs, hypertension, diabetes, smoking, and VSR size)in each group are described in Tables 4-6, respectively. Hypertension and smoking had a good association with 30-day mortality in group A. Besides, there was no significant correlation among them.

Discussion

The implications of VSR as a dire complication post-AMI have been long acknowledged in cardiological literature. Our study has further amplified this sentiment by providing a detailed, retrospective analysis of different treatment modalities for AMI patients experiencing VSR at a tertiary care center. The emphasis on outcomes not only enhances our understanding of these therapeutic strategies but also highlights critical areas of improvement in the management of these patients.

Our cohort of 200 patients echoed the age and gender trends often observed in the context of cardiovascular disease, with a slightly male-predominant presentation and a mean age in the mid-60s.¹⁶ Notably, the high prevalence of risk factors like hypertension, diabetes, and smoking history, as observed in our study, has been similarly reported in earlier studies, drawing attention to the critical role these factors play in AMI and its complications.^17-19

A striking observation was the considerable mortality disparity across different treatment groups. Medical management, a conservative approach, was associated with the highest rates of in-hospital, 30-day, and 1-year mortalities. This observation contrasts with the considerably more favorable outcomes in the surgical repair and percutaneous device closure groups. The underlying premise for this observation could be multifactorial. Medical management, in the face of such a severe mechanical complication, might only provide symptomatic relief without addressing the root cause, whereas both surgical and percutaneous interventions aim to repair the defect and restore hemodynamic stability.^20-22

The comparable efficacy of percutaneous device closure with the more traditional surgical repair route is a testament to the evolving landscape of interventional cardiology.^23,24 While surgical repair has been a trusted modality, the risks associated with surgery, especially in the backdrop of recent AMI, are significant. The similar outcomes observed with percutaneous device closure suggest its potential as a safer, less invasive alternative, particularly for patients deemed high-risk for surgical intervention.^25,26

Our study also indicated a significant rate of MACEs at the 1-year mark, particularly in the medically managed group. This observation underscores the chronic repercussions of VSR post-AMI and the overarching need for comprehensive, long-term follow-up, encompassing pharmacotherapy and lifestyle modifications.²⁷

There was no difference in the VSR size and location of VSR among the 3 groups in our study. Consistent with a previous study,²⁸ this study also observed no significant relation between VSR size and in-hospital mortality. A similar phenomenon was also detected between VSR size and 30-day mortality or 1-year mortality, respectively.

There were several limitations in our study. The retrospective design raises concerns regarding potential biases and a lack of causal interpretations. The lack of randomization in treatment modality selection might have introduced treatment selection bias. Additionally, the findings, based on a single tertiary center’s experience, could have limitations in generalizability.

Conclusion

Our study provides critical insights into the clinical outcomes associated with different therapeutic interventions for AMI complicated by VSR. Notably, both surgical repair and device closure were associated with significantly better survival outcomes compared to medical management alone, emphasizing the crucial role of timely and appropriate interventions. Moreover, our results underscore the importance of robust, long-term follow-up strategies to manage the high risk of MACEs in this patient population. While the primary focus should be on providing immediate and effective intervention for VSR, equal emphasis should be placed on long-term management to prevent future cardiovascular events.

Footnotes

Ethics Committee Approval: The study received approval from the Ethics Committee of Changsha First Hospital, approval number 2023LY150 (November 8, 2023).

Informed Consent: Written informed consent was obtained from the patients who agreed to take part in the study.

Peer-review: Externally peer-reviewed.

Author Contributions: Z.C.H. and Z.F.W. designed the study, conducted the experiments, and prepared the manuscript. B.D. and Q.X.L. collected and analyzed the data. All authors reviewed and approved the final manuscript.

Acknowledgments: We express our deepest gratitude to all medical staff, including doctors, nurses, and allied healthcare professionals, who provided care to the patients included in this study. We are also thankful to the patients for their participation.

Declaration of Interests: The authors have no conflicts of interest to declare.

References

1. Saleh M, Ambrose JA. Understanding myocardial infarction. F1000Res. 2018;7():F1000-.
2. Mahtta D, Mohammed I, Elgendy IY. Overview of prevalence, trends, and outcomes of post myocardial infarction mechanical complications. Ann Cardiothorac Surg. 2022;11(3):322-324.
3. Bruoha S, Yosefy C, Taha L. Mechanical circulatory support devices for the treatment of cardiogenic shock complicating acute myocardial infarction-A review. J Clin Med. 2022;11(17):-.
4. Carter AJ, Davis KA, Evans LV, Cone DC. Information loss in emergency medical services handover of trauma patients. Prehosp Emerg Care. 2009;13(3):280-285.
5. Wang D, Wan K, Ma W. Emergency decision-making model of environmental emergencies based on case-based reasoning method. J Environ Manage. 2020;262():110382-.
6. Iosifescu AG, Iosifescu TA, Timisescu AT, Antohi EL, Iliescu VA. Left ventricular pseudoaneurysms discovered early after acute myocardial infarction: the surgical timing Dilemma. Tex Heart Inst J. 2022;49(5):e207462-.
7. Zhong W, Liu Z, Fan W. Transcatheter closure for the treatment of pseudoventricular aneurysm after acute myocardial infarction: a case report. Ann Transl Med. 2020;8(22):1528-.
8. Dabrowska A, Telec W. [New guidelines of Basic and Advanced Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (ECC) American Heart Association (AHA)]. Wiad Lek. 2011;64(2):127-131.
9. Long B, Koyfman A, Gottlieb M. Diagnosis of acute heart failure in the emergency department: an evidence-based review. West J Emerg Med. 2019;20(6):875-884.
10. Samsky MD, Morrow DA, Proudfoot AG, Hochman JS, Thiele H, Rao SV. Cardiogenic shock after acute myocardial infarction: a review. JAMA. 2021;326(18):1840-1850.
11. Porter TR, Mulvagh SL, Abdelmoneim SS. Clinical applications of ultrasonic enhancing agents in echocardiography: 2018 American Society of Echocardiography guidelines update. J Am Soc Echocardiogr. 2018;31(3):241-274.
12. Stark AM, van de Bergh J, Hedderich J, Mehdorn HM, Nabavi A. Glioblastoma: clinical characteristics, prognostic factors and survival in 492 patients. Clin Neurol Neurosurg. 2012;114(7):840-845.
13. Formigari R, Di Donato RM, Mazzera E. Minimally invasive or interventional repair of atrial septal defects in children: experience in 171 cases and comparison with conventional strategies. J Am Coll Cardiol. 2001;37(6):1707-1712.
14. David TE, Dale L, Sun Z. Postinfarction ventricular septal rupture: repair by endocardial patch with infarct exclusion. J Thorac Cardiovasc Surg. 1995;110(5):1315-1322.
15. Chen T, Liu Y, Zhang J, Sun Z, Han Y, Gao C. Percutaneous closure of ventricular septal rupture after myocardial infarction: a retrospective study of 81 cases. Clin Cardiol. 2023;46(7):737-744.
16. McGurnaghan SJ, McKeigue PM, Read SH. Development and validation of a cardiovascular risk prediction model in type 1 diabetes. Diabetologia. 2021;64(9):2001-2011.
17. Wu H, Wu J, Zhang Z. Prevalence and associated risk factors of hypertension in adults with disabilities: a cross-sectional study in Shanghai, China. Clin Epidemiol. 2021;13():769-777.
18. Selvin E, Burnett AL, Platz EA. Prevalence and risk factors for erectile dysfunction in the US. Am J Med. 2007;120(2):151-157.
19. Colhoun HM, McKnight J. Diabetes in Scotland: a rising tide. Lancet Diabetes Endocrinol. 2020;8(5):375-376.
20. Mancini R. Nonsurgical considerations for addressing periocular aesthetics: a conceptual dimensional approach. JAMA Facial Plast Surg. 2014;16(6):451-456.
21. Murphy A, Goldberg S. Mechanical complications of myocardial infarction. Am J Med. 2022;135(12):1401-1409.
22. Vanden Hoek TL, Morrison LJ, Shuster M. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18):S829-S861.
23. Bouma BJ, Mulder BJ. Changing landscape of congenital heart disease. Circ Res. 2017;120(6):908-922.
24. Jones WS, Roe MT, Antman EM. The changing landscape of randomized clinical trials in cardiovascular disease. J Am Coll Cardiol. 2016;68(17):1898-1907.
25. Rosengart TK, Feldman T, Borger MA. Percutaneous and minimally invasive valve procedures: a scientific statement from the American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Clinical Cardiology, Functional Genomics and Translational Biology Interdisciplinary Working Group, and Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2008;117(13):1750-1767.
26. Taramasso M, Maisano F, Latib A. Conventional surgery and transcatheter closure via surgical transapical approach for paravalvular leak repair in high-risk patients: results from a single-centre experience. Eur Heart J Cardiovasc Imaging. 2014;15(10):1161-1167.
27. Frederix I, Solmi F, Piepoli MF, Dendale P. Cardiac telerehabilitation: a novel cost-efficient care delivery strategy that can induce long-term health benefits. Eur J Prev Cardiol. 2017;24(16):1708-1717.
28. Bangal K. Perioperative challenges and outcome after surgical correction of post-myocardial infarction ventricular septal rupture: a retrospective Single Center study. Ann Card Anaesth. 2024;27(1):17-23.