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Confrontations with ventricular septal rupture !

Posted May 25 2011 12:13am

Mechanical complications are not rare  following acute MI .In fact , it closely competes with electrical deaths . Many times it is not recognised  and get wrongly labeled as  simple pump  failure .

Echocardiography has revolutionised the way , we approach these deadly complication.(Of course , many  deaths  could  not be prevented still !)

The early days of STEMI is critical . This is the time the infarcted muscle softens and invaded by blood components like  neutrophils etc. The biochemical events  in the infarct zone is a least studied aspect by  current generation  cardiologists. Some ,  especially women tend to lyse their interstitial collagen faster. This minute break ups  coalesce to form a tear , When this tear is subjected to hemodynamic stress and mechanical stretch a rupture is  all too likely.

The rupture site is predetermined by the patients fate !. If the tear occur in free wall of LV  , in all likely-hood ,we are going to lose the patient. If he is blessed  , the rupture take place in the interventricular  septum .Here , the issue is less disastrous as the  blood is  simply shunted to a different chamber .In fact , some consider VSR puts an ailing ventricle at  a slight hemodynamic advantage which is referred to as decompression .   The LVEDP has  a biphasic response to VSR  .An  initial raise bfollowed by a flat response.This has a clinical correlation too  with a temporary deterioration and subsequent stabilisation.

The issue of thrombolysis and ventricular rupture  was controversial for decades  .It never got a correct answer and finally we have our own conclusions  .

Thrombolysis as such reduces  the net incidence of ventricular rupture even though  late thrombolysis do  increase the risk of rupture. What does the above statement mean to you ?  confusing is isn’t ?

For population based approach  thrombolysis  has a  no negative impact ,  but in a given individual  one has to weigh  the risk vs benefit .

An irregular tear in the mid ventricular septum

This patient did well with initial medical support and referred for surgery electively

How to manage ?

Unstable patients (Real shock or impending shock  . . .please note every one with  90mmhg  pressure   is not  unstable !)

  • Emergency coronary angiogram  , VSR closure , CABG
  • VSR closure only , without  angio /CABG  (An useful option if your surgeon )

Stable patients

Four approaches available

  • Treat as emergency as above
  • Wait still instability  begins (Yeh . . .I really mean it !)
  • Sort out a  elective  plan.
  • Send the patient home with VSR * ( we have two patients attending our OPDs for >5 years )

* Exceptional case not to be taken as a model for management.

There is rarely an  agreement between surgeon and cardiologist in timing intervention in VSR  patients. Treatment protocols vastly differ in various institutions with the common theme being early  surgery .

Cath based therapy for VSR closure is still  considered a cardiology  adventure sport .

Some  observations about VSR

  • The doppler  VSR jet if  reaches 4-5 m/sec (65-100 mmhg) the prognosis is often good , as it indirectly  reflects the native LV function .A ventricle which could generate 100mmhg pressure head,  even after a supposedly large MI  is great by any standards.These are the ventricles  that fight till the end and patients do well in the  adverse circumstances.
  • In the  other end of the spectrum we have a VSR with a faint murmur and 3m/sec jet .They will be  hypotensive and end up in shock soon.
  • Infero posterior VSRs  do badly due the complexities of tears.
  • Medical management do have an important role in stabilising  these  patients.
  • LVH if present is again a favorable sign
  • Tissue friability could be an important issue why many surgeons fear early surgery.(Some deny this and some say it is never an issue .I am yet to get clarity on this aspect .I expect an answer from cardio thoracic surgeons .)

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