If there is severe RV dysfunction or bi ventricular dysfunction flow across the defect is inconspicuous.Brisk left to right shunting may be an indirect marker for good LV systolic function and absence of significant pulmonary hypertension.Both imply a better outcome.
The main determinant of survival is the underlying LV dysfunction and associated co morbidity(Renal function ) and complications .
Infero -posterior ruptures tend to be complex and may have multiple irregular tracks that makes it difficult to repair.
Echo cardiogram is the mainstay .Serial echos should be done to assess the mechanical function and the progress of VSR.Hemodynamic monitoring may be done without injuring the patient .
Timing of surgery
Continues to be a controversy . Surgeons love to operate in a stable patient. But they need to realise , surgery is often needed to stabilise many patients. . The issue of tissue friability is blown out of proportion in the literature .When a life is is at danger we can not worry about friable tissues !
The rule of thumb could be
In our experience each of the above , has a role in a given patient depending upon the logistic , financial , social and even the available expertise. (A good surgeon in bad Institution !)
Is coronary angiogram mandatory before attempting to close VSR ?
Logically yes. If it is not available just do not bother . But, many times , when issue is saving lives , we can not afford to be too scientific , many lives have been saved by not following such strict protocols .A simple emergency thoracotomy and closure of rupture site (Without even touching the LAD ) can be a distinct and viable option in a selected few .
Role of cardiologists
Contrary to the popular belief the role of cardiologists is minimal , except to prepare the patient and hand over to the surgeon.
Interventional approach to close a VSR is currently be termed as an adventurous option ! The VSRs can assume unpredictable shapes and the tears can be multiple in different planes. The devices , catheters and other hard ware are not specifically made to tackle these issues .An acquired VSR should never be compared with congenital VSD.