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OBJECTIVES Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been recently considered and used for patients with post-acute myocardial infarction mechanical complications (post-AMI MC); however, information in this respect is scarce. The purpose of this study was to evaluate the in-hospital outcomes of patients with post-AMI MC submitted to VA-ECMO, and enrolled in the Extracorporeal Life Support Organizations (ELSO)’s data Registry. METHODS This was a retrospective review of the ELSO Registry to identify adult (>18 years old) patients with post-AMI MC who underwent VA-ECMO support between 2007 and 2018. The primary end point of this study was in-hospital survival. ECMO complications were also evaluated. RESULTS The patient cohort available for this study included 158 patients. The median age was 62.4 years (range 20–80). The most common post-AMI MC was ventricular septal rupture (n = 102; 64.5%), followed by papillary muscle rupture (n = 42; 26.6%) and ventricular free-wall rupture (n = 14; 8.9%). Approximately a quarter of patients (n = 41; 25.9%) had cardiac arrest before VA-ECMO institution. The median duration of VA-ECMO was 5.9 days (range 1 h–40.3 days). ECMO complications occurred in 119 patients (75.3%). Overall, survival to hospital discharge for the entire patient cohort was 37.3%. Patients who had ventricular septal rupture as primary diagnosis had higher in-hospital mortality (n = 66; 64.7%). CONCLUSIONS In patients with post-AMI MC, VA-ECMO provides haemodynamic stabilizations and carries a potential to reverse otherwise lethal course. ECMO complications, however, remain an important limitation. Further investigations are required to better evaluate the efficacy and safety of ECMO in this context.

A 73-year-old man with an acute myocardial infarction experienced severe cardiogenic shock due to an inferior ventricular septal rupture with a massive left-to-right shunt. Emergency surgery was considered a too high mortality risk. The patient was implanted with an extracorporeal membrane oxygenation system as a bridge to surgery. On the seventh day after admission, the ventricular septal defect was successfully repaired. Our case study demonstrates that extracorporeal membrane oxygenation could be an option in cases of ventricular septal rupture as a bridge for stabilizing patients.

OBJECTIVES The effectiveness of delayed surgery for ventricular septal rupture (VSR) following myocardial infarction (MI) in patients with cardiogenic shock remains unknown. We aimed to investigate the outcomes of delayed surgery following mechanical circulatory support for patients in cardiogenic shock after VSR. METHODS We reviewed 8 patients with post-MI VSR and cardiogenic shock who underwent delayed surgery at our institution between July 2015 and November 2017. Surgery was delayed until haemodynamic stabilization and improved organ ischaemia were achieved by initiating intra-aortic balloon pumping with or without veno-arterial extracorporeal membrane oxygenation (ECMO). We investigated the operative mortality, morbidity and late survival. RESULTS All 8 patients had preoperative intra-aortic balloon pump support, and 5 had additional veno-arterial ECMO support. Emergency repair was successfully avoided in all cases. The median time from the onset of MI to operation was 7.1 (3.7–9.9) days, and that from the diagnosis of VSR to operation was 1.9 (1.3–2.3) days. The operative mortality was 12.5%, and complications related to mechanical circulatory support occurred in 1 case (12.5%). The 2-year survival rate was 62.5%. CONCLUSIONS A combination of preoperative mechanical circulatory support and delayed surgery may improve the outcomes of patients with post-MI VSR, which was complicated by cardiogenic shock. The key to a better surgical outcome may be delaying the surgery for improving end-organ perfusion. This requires further investigation, especially for determining the optimal duration of support.

Ventricular septal rupture is an uncommon fatal complication of acute myocardial infarction. In rare cases, the rupture can extend into the right ventricular free wall and cause intramyocardial dissection. We describe the case of a patient who developed postinfarction right ventricular free wall dissection with left-to-right shunting and successfully underwent patch repair.

Because of the difficulty in placing a suture-supporting extension to a non-infarcted area, ventricular septal perforation repair in the presence of large myocardial infarctions can give rise to life-threatening tears or ruptures of the left ventricular free wall. We report a case of successful reinforcement of an infarction area from outside of the left ventricle using a large, thick polytetrafluoroethylene felt patch. After surgery, the patient was weaned from cardiopulmonary bypass without difficulty. Postoperative echocardiography revealed no residual shunting and he was alive without complications 3 years after surgery.

Coronary artery disease in the donor heart is an established cause of early graft failure. However, identification of this before implantation is difficult. Cardiogenic shock associated with significant myocardial infarction during the early postoperative period is rare. Here, we report a case of a 42-year-old man who presented acutely with cardiogenic shock; he was supported by short-term extracorporeal support as a bridge to transplantation. Following successful orthotopic heart transplantation, he sustained coronary artery atheromatous plaque rupture, resulting in acute coronary artery occlusion, and subsequently developed an ischaemic ventricular septal defect on the third postoperative day.

The purpose of this study was to determine the possibility of a new surgical technique for the treatment of ventricular septal rupture after acute myocardial infarction. The operations were conducted under the guidance of real-time three-dimensional echocardiography (RT3DE) (iE33, Philips Medical Systems, Andover, MA). Six pigs were anesthetized, and after median sternotomy, the echo probe was applied directly to the surface of the heart. A ventricular septal defect (VSD) was created in all the six porcine hearts. The VSDs were closed with an Amplatzer septal occluder (AGA Medical Corp, Golden Valley, MN) through the right ventricular free wall under RT3DE monitoring. The procedure was successful in all the six pigs. The VSDs were precisely closed with the septal occluder under RT3DE guidance. Both left ventriculography and color-Doppler echocardiography showed no residual shunt in any of the six pigs. The use of the Amplatzer septal occluder under the guidance of real-time three-dimensional echocardiography made it possible to close the ventricular septal defect safely and successfully without the need to resort to cardiopulmonary bypass. Our results strongly suggest that the application of this new technique is feasible for the treatment of ventricular septal rupture after acute myocardial infarction.

Occurrence of left ventricular free wall rupture following myocardial infarction is an unpredictable event associated with very high mortality rate. The most appropriate surgical approach remains controversial. With recent advances in portable echocardiography machines there has been a progressive rise in the number of cases of left ventricular free wall rupture diagnosed and reported. Early diagnosis and expeditious relief of tamponade followed by emergency surgery could save many lives. We present a review of six patients treated at our institute for ventricular free wall rupture over the last ten years. A literature review of the optimal management strategy follows. All patients were operated using cardiopulmonary bypass. Two patients died following surgery. Intra-aortic balloon pump was used in all patients. One patient had coronary artery bypass grafting empirically based on palpable disease in the epicardial coronary arteries. None of the surviving patients showed any evidence of neurological deficit. We advocate tailoring the type of repair to the status of the tear at the time of operation.

The mortality of postinfarction left ventricular free wall rupture is still high. Several surgical techniques have been used for repairing such ruptures. Here, we describe using an infarction exclusion technique to successfully treat a case of a blow-out type postinfarction left ventricular free wall rupture. This technique has frequently been used for repairing postinfarction ventricular septal perforation. In this case, infarcted myocardial tearing was prevented, and complete haemostasis was achieved by infarct exclusion.

Ventricular septal perforation (VSP) is a serious complication of acute myocardial infarction despite improved procedures for closing the ventricular septal wall defect and/or excluding the infarct. The patient in the present case had VSP after posterior wall infarction and was treated successfully with a new and simple procedure that used a double-patch closure combined with an infarct exclusion technique. The left ventricular patch was attached cohesively to the septal wall and the infarcted area was excluded without reducing the left ventricular cavity.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Is the placement of an Amplatzer septal occluder device across a post-infarction ventricular septal defect a suitable alternative for patients not eligible for surgical repair?' Altogether, 31 papers were found using the reported search, of which 17 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that the insertion of an Amplatzer occluder device in patients with a post-infarction ventricular septal defect (VSD) not amenable to surgical repair can offer benefit in selected patients. Patients with cardiogenic shock frequently have an unfavourable outcome and closure should be considered cautiously. From the literature available, patients have a better outcome if the intervention is delayed by 2 weeks or more possibly due to the maturation of the VSD and recovery of myocardial function. In certain situations, device closure may be complicated by device dislocation or embolization, residual shunting or a tortuous course not amenable to device implantation. In such settings, surgical repair is the only option. In patients who proceed straight to surgical repair with no attempt at percutaneous closure, the overall mortality lies in the region of 43% and similar to percutaneous closure, there is an association observed between those operated within 7 days of the VSD occurrence and those greater than this time. Patients presenting in cardiogenic shock experienced an increased risk of death and if the timing of myocardial infarction to VSD closure could be delayed by 3 weeks, there was a statistically significant reduction in operative mortality. Percutaneous closure of a post-infarction VSD may avoid the requirement for surgical closure. However, in some cases, it provides time to allow the VSD to mature and the patient to stabilize and be optimized acting as a bridge to surgery to offer the best possible outcome for the patient.

We report a successful surgical management of postinfarction ventricular septal perforation by infarction-exclusion technique with the on-pump beating heart approach and concomitant coronary artery bypass grafting. The identification of the suture line by direct inspection and finger palpation could be more accurate in determining contractile, thus viable myocardium supporting the patch, and concomitant coronary artery bypass grafting with on-pump beating heart could minimize the cardioplegia-induced myocardial damage.

We present a 77-year-old female with recent myocardial infarction complicated by antero-apical ventricular septal defect (VSD) and quick development of low cardiac output. Using interrupted horizontal mattress sutures VSD closure was successfully performed on the beating heart. Transthoracic echocardiography at the four-month follow-up did not reveal residual VSD.

Complete ischaemic destruction of the cardiac apex as well as the majority of the ventricular septum is usually a lethal condition with no alternatives except mechanical circulation support and highly urgent heart transplantation. Depending on the mass of the necrotic and destructed myocardium, implantation of a ventricular assist device can be challenging due to insufficient tissue quality. We describe here a new approach to pulsatile Thoratec (Thoratec Corporation, Pleasanton, CA, USA) extracorporeal biventricular assist device implantation.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘in which patients with a post-infarct ventricular septal rupture (PIVSR) might immediate surgery give better results than delayed surgery in terms of mortality’? Altogether, 88 papers were found using the reported search criteria, of which 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The recommendations are based on outcomes from 3238 patients undergoing surgery for PIVSR. Mean age was 67.5 ± 8.8 (40–88 years). Left ventricular function was compromised in most patients with mean ejection fraction of 40%. All papers carried out univariate and/or multivariate analyses of variables that contributed to different in-hospital mortalities. Early surgery, i.e. from >3 days to within 4 weeks after MI, had an overall in-hospital mortality of 52.4%; delayed surgery, typically from 1 week to after 4 weeks post-myocardial infarction, had an overall operative in-hospital mortality of 7.56%. Most authors observe that a shorter time between rupture and surgery is an unfavourable predictor of outcome independent of haemodynamic status. The consensus was that nearly all patients with PIVSR, particularly if >15 mm diameter with a significant shunt and resultant haemodynamic deterioration, should undergo early surgical repair. The precise timing of surgery depends on patients’ haemodynamic status. Exclusion from surgery should be considered if life expectancy or quality is severely limited by another limiting underlying pathology. If the patient is in cardiogenic shock, due to pulmonary to systemic blood flow ratio shunt rather than infarct size, immediate surgery should follow resuscitation measures and cardiac support. If the patient is haemodynamically stable, surgery could be performed after 3–4 weeks of medical optimization with inotropic and mechanical cardiac support. If there is clinical deterioration, immediate surgery is indicated.

Although left ventricular free wall rupture is a comparatively common cause of death in acute myocardial infarction survival is infrequently reported. However, even in cases where surgical expertise is not immediately available the condition can be temporarily controlled by judicious pericardial aspiration and blood transfusion until definitive repair can be undertaken. Here we report the successful management of a patient sustaining combined left ventricular free wall rupture and ventricular septal rupture in a community hospital 130 km from the referral center.

Negative-pressure wound therapy (NPWT) has been used for the treatment of deep sternal wound infection (DSWI) with promising results. However, questions have been raised regarding the potential risk of right ventricle (RV) rupture during treatment. In the present study, we evaluate our clinical experience of NPWT focusing on RV rupture and major bleeding complications and its potentially negative impact on 30-day mortality during an 11-year period. Serious bleeding complications during NPWT were reviewed for 176 patients treated for DSWI between January 1999 and April 2010. The 30-day mortality following DSWI was 1.1% (2/176). Four patients (2.3%) suffered bleeding from the RV rupture during NPWT of the sternal wound (two spontaneous and two debridement related). Furthermore, two patients had debridement-related bleedings from the venous bypass grafts during wound dressing change. The very low 30-day mortality (1.1%) following DSWI supports the use of NPWT. Overall, even if major bleeding complications may occur, the risk of RV rupture seems to be outweighed by the benefit of superior infection control. However, surgical experience is recommended when debriding sternal wounds and we recommend the use of a wound dressing, such as paraffin gauze, in order to protect the RV from direct contact with the polyurethane foam.

A ventricular septal rupture (VSR) is a rare complication of blunt chest trauma. We describe the case of a 25-year-old man who developed a VSR as a result of a high-speed road accident. The rupture was closed by left ventricular remodeling and replacement of the diseased myocardium with a Dacron patch. The patch sutures were reinforced with glue. Redo surgery was necessary at nine months due to patch detachment and embolization of the glue in the right lower lobe. The patient is asymptomatic, at 13-month follow-up. Keywords: Trauma; Blunt; Myocardial injury; Cardiac intervention; Shunts (cardiac); Wound closure. Language: en

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: which patients might be suitable for a transcatheter closure (TCC) of their postinfarction ventricular septal rupture (VSR) rather than immediate surgery? Thirty papers were found using the reported search, five of which represented the best evidence to answer the clinical question. The main limitations were the paucity of level 1 evidence on this topic. Only one study provided a prospective series as part of a registry; the remaining were retrospective cohort analyses. Although multivariate analysis may adequately control for measurable biases, unmeasured bias may still exist and influence the results. All studies agreed that timing of intervention is critical in determining the outcome. Patient's preoperative haemodynamic status was a major determinant of postoperative survival. Successful outcome after TCC was in patients with simple defects,15 mm in diameter that were in the sub-acute (3.5 weeks) or chronic stage following acute myocardial infarct (AMI). Procedural success rate varied from 73.6% to 91%. Three of five studies looking at TCC closure concluded that procedural success does not necessarily translate to improved outcome. TCC in the acute setting (within four weeks of AMI) led to a high mortality (18%-65%) and increased incidence of complications (up to 41%). These included device embolization, major residual shunting, left ventricular rupture and malignant arrhythmias. One recent study correlated mortality to residual VSR [odds ratio (OR) 0.071, P=0.02], increased time from myocardial infarction to VSR diagnosis (OR 0.757, P=0.04) and increased time from VSR diagnosis to treatment (OR 0.758, P=0.04). The overwhelming recommendations were for immediate surgical intervention in cases of large VSR≥15 mm or where another indication for surgery exists. Three of five studies commented on a lack of a suitable device for PIVSR closure, with highest technical success with the Amplatzer device. In conclusion, small or medium PIVSR (15 mm) can be treated definitively with Amplatzer closure in the sub-acute and chronic setting with comparable mortality to surgery. In the acute setting where surgery is deemed prohibitive TCC may provide a bridge to stabilize patients with shunt reduction, prior to surgery. The standard of treatment in large defects and PIVSRs in the acute setting remains early surgery.

Postinfarction ventricular septal perforation (VSP) remains a surgical challenge. The present study describes the use of an interrupted suture technique with the goal of reducing the incidence of postoperative residual shunt. Thirty-four consecutive cases of patients who underwent David's procedure for VSP between 1996 and 2008 were reviewed. A running suture technique was used to close the ruptured septum (C-group: 14 patients) prior to 2002, while the interrupted suture technique (I-group: 20 patients) was used after that point. The overall 30-day mortality was 26.5%, and the mortality rate was not different when comparing the two groups. Postoperative residual shunt was present in five patients (36%) in the C-group and in two patients (10%) in the I-group. In conclusion, use of the interrupted suture technique resulted in a lower incidence of postoperative residual shunt rate. However, the mortality associated with surgical repair of VSP remains high.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients undergoing surgical repair of post-infarction ventricular septal defect (VSD), does concomitant revascularization improve prognosis?'. The scientific literature was reviewed by searching Medline, using Ovid interface, from 1950 to April 2009. Four hundred and five papers were found, of which 18 were deemed relevant to the topics. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, and results of these papers were tabulated. Seven out of 18 papers showed statistical evidence of benefit of concomitant coronary artery bypass grafting (CABG) in patients undergoing surgical repair of VSD. They showed a benefit especially with complete revascularization. Another five papers recommended CABG with VSD even in the absence of statistical evidence. The reported papers showed a mortality benefit from 26.3% without revascularization down to 21.2% with revascularization and an actuarial survival at five years from 29 up to 72%. However, six out of 18 papers did not find any difference. The largest study in this area was by Jeppsson et al. where 119 patients underwent VSD repair with revascularization and 70 underwent VSD repair only, the mortality was 38% vs. 46% (P=0.29). Barker et al. compared a group of 23 patients undergoing repair of VSD only and 42 patients undergoing concomitant CABG. The in-hospital mortality was 39.2% vs. 26.2%, and the four-year survival rate was 33.2% and 88.2%, respectively. Lundblad et al. found that in 66 patients undergoing concomitant CABG out of 102 undergoing repair of VSD, complete revascularization and revascularization of the culprit artery, both resulted in improved 30-day survival and long-term survival. Muehrcke et al. reported on 75 patients undergoing surgical repair of post-infarction VSD. Out of those, 33 (44%) had a concomitant CABG. The authors found that concomitant CABG increases long-term survival when compared with patients with unbypassed coronary artery disease (CAD) (P=0.0015). We conclude that patients undergoing concomitant CABG to all the stenotic coronary arteries, supplying the non-infarcted area, fare better both in improved 30-day survival and long-term survival. The improvement of the collateral flow to the myocardium contributes to its better recovery.

Mechanical complications after myocardial infarction are uncommon with advances in medical reperfusion strategies. However, such strategies are associated with bleeding complications which typically contraindicate surgical management. We describe a patient with a post-infarction ventricular septal defect and an intraventricular hemorrhage following thrombolytic therapy for an acute myocardial infarction.

Early repair of postinfarction ventricular septal rupture is usually associated with significant mortality and morbidity. Assessing conditions to moderately delay the surgical intervention and reduce cardioplegic arrest may be an interesting approach to improve hospital results. Results of five non-selected patients in whom surgery was moderately delayed and performed according a policy of reducing the cardioplegic-induced ischemia were reviewed. Surgical options are discussed as well as observed advantages.

The management of postinfarction ventricular septal defects represents a challenge to both cardiologists and surgeons due to the high morbidity and mortality rate. We report the case of a 79-year-old patient who developed an apical rupture of the ventricular septum, nine days after an anterior myocardial infarction. As the patient was in cardiogenic shock and developed acute pulmonary edema we chose to perform a percutaneous closure of the septal defect using an Amplatzer occluder (AO). Despite the incomplete closure, the placement of the device greatly improved the patient's clinical condition allowing the delay of the surgical procedure, which could be performed ten days later with an excellent result.