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Surgical and transcatheter treatments of mechanical complications of acute myocardial infarction
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Surgical and transcatheter treatments of mechanical complications of acute myocardial infarction
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Journal Article
Surgical and transcatheter treatments of mechanical complications of acute myocardial infarction
2024
Overview
In the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial, VSD was seen in 84 of 41 021 patients (0.2%) with a median time of 1 day from symptom onset to diagnosis.1 A recent retrospective analysis of Medicare beneficiaries presenting with VSD in the contemporary era of primary PCI for AMI showed a significant decrease in rates of hospitalisation for VSD from 1999 to 2014.2 Patients who develop VSD are more likely to be female, older and lack traditional cardiovascular risk factors such as hypertension, diabetes, smoking or prior history of AMI. The first, the infarctectomy and closure technique, involves thorough debridement of infarcted myocardium and either suturing the defect closed or incorporating a prosthetic patch.4 The second, the infarct exclusion technique, preserves infarcted myocardium by sewing an endocardial patch larger than the infarcted area directly onto healthy tissue.5 There have been subsequent modifications designed to minimise development of residual shunts, including reinforcement of the RV wall in addition to application of an LV patch to ‘sandwich’ the septal defect.6 For patients surviving the initial operation, a single-centre study of 110 patients showed residual shunt on TTE in over 40% of patients, 12% need for reoperation and 5-year survival of 45%.7 Percutaneous techniques Given an operative mortality in excess of 40% among patients deemed fit enough to undergo sternotomy, percutaneous techniques have emerged for less viable and higher-risk patients. A recent retrospective analysis of Medicare beneficiaries presenting with VSD in the contemporary era of primary PCI for AMI showed a decline in rates of surgical repair from 43.8% in 2006 to 28.4% in 2014.2 In contrast, rates of percutaneous repair increased from 0.3% in 2006 to 5.9% in 2014 with a total of 87 repairs performed. (A) The overlay of colour Doppler on 2D two-dimensional transthoracic echocardiography imaging helps highlight the serpiginous nature of this extensive VSD (yellow arrows).
