What is the recommended technique for ventricular septal rupture repair?

Ventricular Septal Rupture Repair Technique

Emergency surgical repair with patch closure and concomitant CABG is the definitive treatment for post-infarction ventricular septal rupture, preceded by immediate IABP insertion for hemodynamic stabilization. 1, 2

Immediate Stabilization Protocol

Upon diagnosis of VSR, the following steps must be taken urgently:

• Insert intra-aortic balloon pump (IABP) immediately in all patients with VSR, regardless of hemodynamic status, as the rupture site can expand abruptly causing sudden collapse even in stable patients 1, 2, 3
• Initiate invasive hemodynamic monitoring with pulmonary artery catheter to guide management 2
• Administer inotropic agents (dopamine/dobutamine) and vasodilators (IV nitroglycerin) as temporizing measures 1, 4
• Consider short-term mechanical circulatory support devices beyond IABP if hemodynamic instability persists 1, 2

Surgical Technique

The definitive repair involves:

• Complete excision of all necrotic myocardial tissue surrounding the rupture site 2
• Patch repair of the VSR using prosthetic material to close the defect 2
• Concomitant coronary artery bypass grafting (CABG) performed simultaneously with VSR repair when coronary disease is present 1, 2, 4
• Pre-operative coronary angiography should be performed to identify vessels requiring bypass 1, 4

Timing Considerations

Emergency surgery is indicated for all patients with VSR, including those who are hemodynamically stable, because the defect can suddenly enlarge due to shear forces and ongoing tissue necrosis 1. The critical reasoning is:

• All septal perforations are exposed to shear forces and macrophage-mediated necrotic tissue removal, causing potential expansion 1
• Previously stable patients can experience sudden hemodynamic collapse without warning 1
• Surgical mortality ranges from 20-87% depending on patient status, with higher mortality in cardiogenic shock 1
• Delayed surgery may allow tissue maturation and scarring at defect edges, but most patients cannot wait due to risk of deterioration 5

Common pitfall: Delaying surgery in hemodynamically stable patients increases risk of sudden decompensation and death 1

Location-Specific Mortality Risk

Surgical outcomes vary by defect location:

• Inferior-basal (posterior) defects carry higher mortality risk than anterior-apical defects 1
• Posterior location is a predictor of poor postoperative outcome 1, 4
• Other poor prognostic factors include cardiogenic shock, right ventricular dysfunction, advanced age, and prolonged delay to surgery 1, 4

Role of Percutaneous Closure

Percutaneous transcatheter closure remains investigational and should only be considered in patients with prohibitive surgical risk 1, 2. Key limitations include:

• Limited experience and lack of robust long-term outcome data 1, 2
• Residual shunts are common after percutaneous closure 1
• Device failure can occur due to friable necrotic tissue 6
• May serve as bridge to definitive surgery in select cases 1, 7

Facility Requirements

All patients with VSR must be managed at facilities with cardiac surgical expertise and multidisciplinary shock teams 1, 2. Transfer from community hospitals to specialized centers is recommended for hemodynamically unstable patients 1.

Expected Outcomes

• Hospital mortality after surgical repair: 25-60% overall, with 11-89% survival in recent series depending on patient selection and timing 1, 4, 3
• 95% of surgical survivors achieve NYHA class I or II functional status 1, 4
• Five-year survival rates average 60-70% in those who survive the perioperative period 1
• Without surgery, mortality is 54% within one week and 92% within one year 1, 4