Postmyocardial infarction ventricular septal rupture: optimizing surgical timing and repair.

PURPOSE OF REVIEW: This review summarizes the most recent literature regarding the surgical management of postmyocardial infarction (MI) ventricular septal rupture and the optimal timing and performance of the operation.

RECENT FINDINGS: There are conflicting data surrounding the optimal timing of surgical intervention for post-MI ventricular septal rupture. Patients often present in hemodynamic compromise which limits the ability to delay their intervention. A lack of randomized control trials mandates reliance on retrospective cohort studies that have a selection bias in favor of delayed surgery due to unstable patients requiring emergent intervention. Similarly, mechanical circulatory support may be associated with poorer outcomes in part due to selection bias. There is a trend towards better prognosis in patients with lower preoperative lactate and lower vasopressor requirements.

SUMMARY: A diagnosis of a post-MI ventricular septal rupture carries a poor prognosis. Without surgical intervention, the likelihood of 1-year survival is very low. Percutaneous treatment options have limited success, and the gold standard remains surgical intervention. Surgical timing is often dictated by patients being hemodynamically unstable and requiring emergent surgery. When a patient can have delayed intervention, there is a trend towards better outcomes. Optimized hemodynamics, metabolic parameters, and initial medical management are associated with improved outcomes. Mechanical circulatory support is of benefit in sicker patients if it can assist with preoperative optimization.