Should IJ (Inferior Vena Cava) VSR (Ventricular Septal Rupture) repair be surgical or transcatheter?

Surgical Repair is Recommended for Ventricular Septal Rupture Following Myocardial Infarction

Urgent cardiac surgical repair is strongly recommended for patients with ventricular septal rupture (VSR) following myocardial infarction, as transcatheter approaches remain investigational and are primarily reserved for patients with prohibitive surgical risk. 1

Pathophysiology and Presentation

• VSR is a mechanical complication of acute myocardial infarction (AMI) characterized by rupture of the interventricular septum, creating a left-to-right shunt 1
• The condition presents with a new cardiac murmur, hemodynamic instability, and often cardiogenic shock 1
• Diagnosis is typically confirmed with transthoracic or transesophageal echocardiography 1

Management Algorithm

Initial Stabilization

• Intra-aortic balloon counterpulsation (IABP) is recommended for all patients with VSR to reduce left-to-right shunting and improve hemodynamics 1
• Invasive hemodynamic monitoring is recommended to guide management 1
• Judicious use of inotropes and vasodilators to maintain optimal hemodynamics 1

Definitive Treatment

• Surgical repair is the gold standard treatment and should be performed urgently in most cases 1
• Surgery involves excision of all necrotic tissue and patch repair of the VSR, together with coronary artery bypass grafting (CABG) as needed 1
• CABG should be undertaken at the same time as repair of the VSR 1

Timing of Surgery

• For hemodynamically unstable patients, immediate surgical intervention is indicated 1, 2
• For stable patients, some evidence suggests delaying surgery by 3-4 weeks may improve outcomes by allowing scar formation at the edges of the defect 3, 2
• However, most patients cannot wait due to risk of hemodynamic deterioration, necessitating earlier intervention 2

Risk Factors for Poor Outcomes

• Cardiogenic shock at presentation 3, 4
• Female gender 4
• Anterior AMI location 4
• Lower left ventricular ejection fraction (LVEF) 5
• Time from AMI to VSR less than 4 days 4
• Higher EuroSCORE II 5

Role of Transcatheter Approaches

• Percutaneous transcatheter closure remains investigational and is primarily reserved for:
  • Patients with prohibitive surgical risk 1
  • As a temporizing option in hemodynamically unstable patients 1
• These approaches are still evolving and lack robust long-term outcome data 1

Mechanical Circulatory Support

• Short-term mechanical circulatory support devices are reasonable for hemodynamic stabilization as a bridge to surgery 1
• Options include:
  • Intra-aortic balloon pump (IABP) - recommended for all VSR patients 1
  • Extracorporeal membrane oxygenation (ECMO) - may be considered in severely compromised patients to postpone operation 2

Prognosis

• Despite advances in surgical techniques, operative mortality remains high (19-81%) 3
• Survival is better with preserved left ventricular function 5
• Complete revascularization during surgery provides long-term survival benefit 5

Recommendations for Care Setting

• Patients with VSR should be managed in facilities with cardiac surgical expertise 1
• Transfer to specialized centers with multidisciplinary teams is recommended 1