The incidence of VSD following AMI has decreased from 2% to around 0.2% due to myocardial revascularization strategies, including thrombolysis and percutaneous coronary intervention (PCI). Without surgical intervention, the outcome remains fatal, with in-hospital mortality ranging from 20 to 65%, showing limited improvement over the past two decades.
Given its high mortality and low incidence, the accumulated evidence on this condition is sparse, mainly limited to small registries and single-center experiences. These works underpin current, albeit weak and controversial, clinical recommendations. Despite the recent CAUTION study (Mechanical Complications of Acute Myocardial Infarction: An International Multicenter Cohort), which represents the most extensive analysis to date with a significant patient sample and has enriched our understanding of VSD surgical outcomes, it has yet to provide the clarity required to establish standardized clinical protocols. Nor has it defined the current role of pre- or postoperative mechanical circulatory support (MCS) devices, such as extracorporeal membrane oxygenation (ECMO) and percutaneous closure devices, which are not yet included in clinical guidelines.
The present study aimed to investigate, through a survey of multiple European centers, the actual practice of surgeons in addressing this pathology. To collect information on all aspects of VSD treatment, a digital questionnaire comprising 38 questions was completed in 39 centers across eight European countries from April to October 2022. Most centers handle between 1 and 5 VSD cases per year, with surgery remaining the preferred treatment over percutaneous closure (71.8% vs. 28.2%). Delayed surgical repair is the favored strategy (87.2%), with the patient’s hemodynamic status influencing the approach in most centers. Although most centers seek to stabilize patients and delay surgery, even in cases of cardiogenic shock, 33.3% do not perform coronary angiography in unstable patients, and a considerable proportion does not pursue revascularization. When performed, revascularization timing and type vary significantly across hospitals. Most centers use MCS, particularly veno-arterial ECMO, primarily as a preoperative measure to stabilize patients and defer surgical repair.
The authors conclude that, in European clinical practice, delayed surgery is the preferred strategy for managing VSD, irrespective of hemodynamic conditions. Moreover, ECMO is emerging as the most widely adopted MCS as a bridge to surgery.
COMMENTARY:
The results of this survey conducted in European centers provide an accurate view of current clinical practices in the management of VSD in Europe, reflecting reality in Spain, as half of the surveyed centers were Spanish. A key takeaway is the significant shift in the management of this condition in recent years, characterized by a delayed surgical approach supported by some form of MCS, particularly veno-arterial ECMO (with or without intra-aortic balloon pump or Impella). ECMO, once considered an alternative and reserved for patients on the brink of multiorgan failure, has become an essential component in treating this complication, allowing for surgery with a prudent delay and in a more stable clinical condition.
Examining survey responses reveals that most centers prefer delayed rather than early treatment. For stable patients, 90% favor delayed intervention, with most opting for initial ECMO use, reserving it only when needed. In other words, in 90% of stable cases, ECMO is considered to enable delayed intervention (minimum of 5 days). For unstable patients, nearly 70% also prefer delayed surgery following stabilization with ECMO, while the remaining centers would consider emergent surgery with prior ECMO implantation. In summary, ECMO use is considered in nearly all cases, both stable and unstable, with delayed surgery representing over 90% for stable and approximately three-quarters for unstable patients.
This represents a drastic change from the findings of the CAUTION study, which analyzed 475 patients across 26 centers over 20 years and serves as a benchmark in post-AMI VSD studies. In CAUTION, ECMO was employed as an adjunct in a minority of cases, even in the most recent years, with an increased associated mortality. This is likely due to patients’ poorer hemodynamic conditions. Furthermore, nearly half of the patients underwent urgent surgery in CAUTION, correlating with higher mortality compared to those treated with delayed surgery, generally reserved for more stable patients. In short, VSD management, from 2000 to 2021, was fundamentally different from the current approach.
Moreover, current clinical guidelines do not yet support the widespread preoperative use of ECMO observed in this survey. In cases of cardiogenic shock, guidelines recommend intra-aortic balloon pump with a class IIa indication, while ECMO and other MCS devices are not addressed. The accumulating evidence from recent studies demonstrates the central, beneficial role of MCS in stabilizing these patients to prevent clinical deterioration, bolstering surgeons’ confidence in these devices. This justifies, at least partially, their use and calls for reconsidering and updating clinical guidelines.
Regarding the optimal timing for surgery, there is no consensus across guidelines. While American guidelines advocate immediate surgery for all VSD patients, European guidelines suggest postponing it in cases where patients respond to aggressive therapy. This discrepancy contributes to the confusion over the best strategy. The notion that delayed surgery results in better outcomes is not new and is based on years of experience, favoring stable patients who reach surgery after several days. Factors contributing to the improved prognosis of delayed cases include potential partial myocardial recovery after revascularization and the transformation of friable, necrotic tissue into firmer, fibrous tissue, allowing for a more secure and successful repair. Additionally, MCS device advancements and their reliability in this context have enabled patients who previously would not have reached delayed surgery to now arrive in better conditions. These advances have led to surgeons adopting MCS as a natural approach to treating this disease.
Conversely, the survey shows that only a minority of centers systematically employ post-surgical ECMO, despite most in-hospital deaths resulting from low cardiac output syndrome.
An emerging trend is the increasing acceptance of percutaneous closure, not only for inoperable patients but also as a first choice in cases where VSD closure is technically feasible. A recent British national registry demonstrated comparable outcomes to surgery in selected cases. However, overall evidence remains insufficient to draw definitive conclusions on this matter. According to this survey, approximately 30% of centers would consider percutaneous closure if technically feasible or if the patient is deemed inoperable. Notably, no information is available on whether percutaneous closure is actually accessible in these centers.
The formation of a shock treatment team is considered in less than 50% of centers, possibly due to the low annual case volume.
Interestingly, approximately one-third of centers do not perform coronary angiography unless the patient is hemodynamically stable, affecting revascularization opportunities. Additionally, revascularization methods, when pursued, vary widely, reflecting a lack of consensus in this area. The CAUTION study indicated that about one-third of patients underwent revascularization before surgery, correlating with higher mortality, possibly due to increased hemorrhagic risk. Additionally, only half of the patients received concomitant surgical revascularization, which showed no association with increased mortality, aligning with other studies.
The survey lacks questions on posterior VSD, associated with higher mortality according to the CAUTION study and various meta-analyses, due to its impact on right ventricular dysfunction and surgical complexity.
The primary limitation of this study is its retrospective nature, relying solely on the information reported by each center, which may not accurately reflect actual procedures. Nonetheless, the study realistically depicts the paradigm shift in post-AMI VSD management. Currently, Spanish cardiac surgeons favor preoperative ECMO stabilization and delayed surgery in almost all cases.
Future prospective studies are needed to enhance our understanding of optimal disease management. Given that we are often one step ahead of clinical guidelines, the adoption of advanced technologies could start to shift the course of this deadly complication.
REFERENCE:
Daniele Ronco, Albert Ariza-Solé, Mariusz Kowalewski, Matteo Matteucci, Michele Di Mauro, Esteban López-de-Sá, et al. The current clinical practice for management of post-infarction ventricular septal rupture: A European survey. European Heart Journal Open, 2023;, oead091, doi: 10.1093/ehjopen/oead091.
Ronco D, Matteucci M, Kowalewski M, De Bonis M, Formica F, Jiritano F, et al. Surgical Treatment of Postinfarction Ventricular Septal Rupture. JAMA Netw Open. 2021 Oct 1;4(10). doi: 10.1001/jamanetworkopen.2021.28309.
