VENTRICULAR SEPTAL RUPTURE

Emergency Surgical Repair

Indications

An emergency repair is indicated for post-infarction VSR with impending or established hemodynamic instability, heart failure, or shock.

Procedures

The emergency repair requires emergency sternotomy to open the heart and repair the VSR. It is the cardiac surgeon who patches the VSR using a pericardial and synthetic graft. The emergency repair also requires that the coronary arteries be repaired; hence the need for cardiopulmonary bypass. Therefore, emergency repair usually involves the closure of VSR defects using a patch graft to allow normal circulation of the blood in the heart.

Delayed Surgical Repair

Indications

The post-infarction VSR sometimes requires a delayed surgical repair, which is usually recommended when the condition stabilizes after presentation. Delayed repair is usually recommended for patients who can tolerate surgery and those who respond to medical treatment.

Procedures

The delayed repair usually requires similar procedures as emergency repair but is usually performed at a later stage after the initial presentation of the condition. The cardiac surgeon also performs a delayed repair requiring sternotomy and uses a patch graft to repair the defect. The repair also requires cardiopulmonary bypass. In addition, delayed repair surgery also requires mechanical circulatory support (MCS) as a bridge to surgical repair for patients with post-infarction VSR who present with severe and complicated cases. Therefore, the use of left ventricular assist devices (LVADs) and intra-aortic balloon pumps (IABPs) can be used to facilitate blood circulation.

Percutaneous Closure

Indications

Percutaneous closure is a minimally invasive procedure that can be used as an alternative to surgical patch graft repair. Although it has not been widely tested, percutaneous closure can be used to manage post-infarction VSR with high surgical risk. However, this procedure is mainly indicated for ASDs and patent foramen ovale. Furthermore, it can also be used to manage post-infarction VSR.

Procedures

A percutaneous closure usually requires a groin incision to access the femoral vein. Then, the surgeon inserts a catheter into the heart and accesses the defect. The defect closure device is then opened to cover the hole. In addition, the percutaneous closure procedure can also be carried out under fluoroscopic guidance.

LVAD and Heart Transplant

Indications

A LVAD is usually recommended for post-infarction VSR with class IV failure. On the other hand, heart transplant is the preferred intervention for post-infarction VSR with severe failure when the patient is not an LVAD candidate.

Surgical Approach

Preoperative Stabilization

It is always important to stabilize the patient before VSR surgery. Therefore preoperative treatment that can involve the use of inotropic agents to increase the force of contraction of the heart, diuretics to reduce fluid retention, IABPs, or even extracorporeal membrane oxygenation (ECMO) may be needed to stabilize the patient for surgery. Furthermore, patients who are not suitable for VSR surgery are placed on mechanical support devices including IABPs or ECMO to help improve their cardiac functions.

Cardiopulmonary Bypass

A cardiopulmonary bypass is usually necessary for VSR repair surgeries because a heart-lung machine is required during the procedure to maintain the functions of the heart and lungs.

Patch repair

A patch repair procedure is always used together with the use of a graft to repair a VSR defect.

Postoperative Care

The patient is required to stay in the heart care or intensive care unit (ICU) for a few days after VSR surgery to monitor the progress of the heart. The patient is also kept under a ventilator for a while after the procedure until he can start breathing on his own. In addition, the patient may need to take medication to improve the function of his heart after the surgery.

Complications and Risks

Heart failure

Heart failure is the primary morbidity and mortality risk after post-infarction VSR.

Arrhythmia

Atrial fibrillation and other arrhythmias can develop after VSR surgery. Cardiac arrhythmias are also anticipated after open-heart surgery for VSR.

Infection

Infections are always a risk after any form of surgery. Therefore, infection at the incision site and heart infections are some of the risks associated with VSR surgery.

Stroke

Stroke can also occur after VSR surgery due to inadequate supply of blood to the brain. Formation of clots is also a risk that can arise during VSR surgery; hence, the patient may also develop a stroke.

Recurrent VSR

Recurrent VSR is also a risk after VSR repair surgery.

Outcomes and Prognosis

The prognosis of patients with post-infarction VSR undergoing surgical intervention depends on the type of intervention, the extent of myocardial damage, the size and location of the rupture, and the overall patient factors. Patients who undergo early interventions and have minimal damage to the myocardium have a better prognosis after VSR repair surgery. On the contrary, the prognosis of patients who undergo surgery for presenting arrhythmia or shock and those with extensive myocardial damage is poor. Additionally, the prognosis of post-surgery patients also depends on the post-surgery treatment they undergo. Therefore, patients who receive appropriate treatment after VSR repair surgery have a better chance of a positive prognosis compared to those who do not get adequate treatment.

Conclusion
Ventricular septal rupture requires immediate intervention for it to be effectively managed. There are various treatment options for post-infaction VSR. However, surgical repair involving open-heart surgery and patch graft is the preferred intervention for managing post-infarction VSR. Therefore, it is important to ensure that post-infaction VSR is managed early to improve patient outcome. The patient who presents with post-infarction VSR is at an extremely high risk of developing various complications. In addition, it is essential to note that all patients that undergo VSR surgery are at great risk of morbidity and mortality after VSR surgery. As a result, the management of these patients always depends on the timing of intervention as well as the patient’s overall condition.