Post-infarct septal rupture:: Surgical treatment and evolution

Background: The occurrence of a ventricular septal rupture abruptly worsens the prognosis of the patients who initially survived a myocardial infarction and imposes a surgical correction to reverse the evolving hemodynamic shock. This study reports our experience in the management of post-infarction septal defects. Patients: 54 consecutive patients with a post-infarct ventricular septal defect were reviewed. The rupture was located in the antero-apical septum in 24 patients and in the postero-basal septum in 30. 26 patients presented with a one-vessel disease (the infarct-related artery), 19 with a two- and 9 with a three-vessel disease. 25 patients were in shock preoperatively. The septal rupture was approached through a left ventriculotomy in 53 patients and through a right atriotomy in 1 patient and was closed with a patch of pericardium or synthetic tissue. Aorto-coronary bypasses using vein grafts were performed on the coronary arteries that presented significant stenosis. Results: 14 patients died peroperatively (2 pts) or postoperatively (12 pts) (mortality rate: 26 %) mostly due to cardiac failure or cardiac complications; 25 patients among the 40 survivors suffered significant morbidity post-operatively. During follow-up (median time: 48 months), 19 patients died, again mostly from cardiac causes. Survival rate at 5 and 10 years was 70 and 40 percent, respectively. The necessity to operate within a short delay (less than 36 hours after occurrence of septal rupture) turned to be a significant predictor for increased post-operative mortality (p=0.03). Pre-operative shock showed only a trend for an increased post-operative mortality (p=0.13). Conclusion: The mortality and morbidity after surgical correction of post-infarction ventricular septal rupture remains significant. Early closure of the septal rupture seems, however, indicated in view of the gravity and evolution of the underlying disorder.