Ventricular Septal Rupture After Myocardial Infarction: JACC Focus Seminar 3/5.

Ventricular septal rupture remains a dreadful complication of acute myocardial infarction. Although less commonly observed than during the prethrombolytic era, the condition remains complex and is often associated with refractory cardiogenic shock and death. Corrective surgery, although superior to medical treatment, has been associated with high perioperative morbidity and mortality. Transcatheter closure techniques are less invasive to surgery and offer a valuable alternative, particularly in patients with cardiogenic shock. In these patients, percutaneous mechanical circulatory support represents a novel opportunity for immediate stabilization and preserved end-organ function. Multimodality imaging can identify favorable septal anatomy for the most appropriate type of repair. The heart team approach will define optimal timing for surgery vs percutaneous repair. Emerging concepts are proposed for a deferred treatment approach, including orthotropic heart transplantation in ideal candidates. Finally, for futile situations, palliative care experts and a medical ethics team will provide the best options for end-of-life clinical decision making. [Display omitted] • The incidence of ventricular septal rupture after acute myocardial infarction has declined, yet there has been little improvement in clinical outcomes. • Corrective surgery and percutaneous septal closure are options for patients with severe hemodynamic derangement. • Collaboration among members of an interdisciplinary heart/shock team can help estimate the chances of viability vs futility, determine the role of mechanical circulatory support, and determine the timing of intervention. [ABSTRACT FROM AUTHOR]