Ventricular septal rupture .pptx

Contemporary management of ventricular septal rupture

1. Ventricular septal rupture Ahmed ElBorae, MSc Assistant lecturer of Cardiology, Cairo University

2. Introduction (VSR ) remains a devastating complication following MI Incidence: Decreased from 1-3 % “pre-reperfusion era” to “0.17-0.31%” post 1ry PCI, [RCA in 46%- LAD in 42%] Onset: Average 2-8 days post MI, yet might occur earlier Risk factors: Old age-female-Late presentation-extensive MI HTN-Lytic therapy Diagnosis: Acute deterioration-auscultation “ V.important ”- Echo- MSCT Management: Hybrid approach (1ry PTCA of culprit- transient mechanical support e.g. IABP) then definitive (Surgical or percutaneous) Prognosis: Without treatment > 90% mortality at 1 year Venu M, et al. Contemporary Management of Post-MI Ventricular Septal Rupture. JACC 2018

3. Hemodynamics Acute left to right shunt (Volume overload of infarcted ventricle) Decrease cardiac output Acute rise of pulmonary flow Acute rise in PCWP High LV afterload due to peripheral vasoconstriction So, we need do decrease LV afterload VSR

4. IABP Other : ECMO- Tandem heart- Impella

5. Challenges Friable tissue couldn’t hold sutures (need weeks for collagen maturation) Basal septal VSR (following Inferior MI) more serpiginous, larger, with more intra-myocardial dissection, possible extension to free wall For anterior defects, operative mortality ranges from 10% to 15%; and 30% to 35% for posterior defects

6. Early ? Late ? Proper timing of intervention

7. Proper timing Venu M, et al. Contemporary Management of Post-MI Ventricular Septal Rupture. JACC 2018

8. How to interpret these numbers? Patients with more hemodynamic compromise > more urgent intervention> higher operative mortality Patients with more stable hemodynamic > delayed intervention> more stable tissue and dynamics> lowe r operative mortality No data about the mortality rate in patients awaiting delayed surgery strategy Natural selection

9. M. Shahreyar , et al., Post- myocPost -MI VSR.Cardiovascular Revascularization Medicine Practical approach

10. Surgical repair Traditional repair: Infarctectomy + patch sutured to edges of the defect if large defect, direct suture if small David repair Concept: Infarction exclusion strategy to minimize stress on the infarcted wall using pericardial patch Two or three patch repair: Septal + free wall patches

11. Percutaneous device closure Planning: Defect size, site , margins, shape “defects <15 mm are ideal” Crossing Lt to Rt > a rterio -venous rail > closure from RV side P rocedure success rate as high as 89% but 30-day mortality of 32 %, dislocation 13%

12. Timing? Early closure before 14 days M. Shahreyar , et al., Post- myocPost -MI VSR.Cardiovascular Revascularization Medicine

13. Thank You Latham 1845, UK First to describe VSR at autopsy Denton Cooley 1956, USA First VSR repair