Interventricular septal rupture after acute myocardial infarction remains one of the most severe mechanical complications of ischemic heart disease. Despite advances in coronary disease management and early reperfusion, its occurrence is still linked to extremely high mortality.

Historically, the therapeutic approach was fairly straightforward: once ventricular septal rupture (VSR) had been diagnosed, urgent surgical repair was indicated. However, outcomes with this strategy have traditionally been poor. The main reason is that, during the early phase after infarction, the septal tissue is necrotic and highly friable, making suture anchoring difficult and predisposing to dehiscence and residual defects.

Over recent years, management of this condition has progressively changed with the development of mechanical circulatory support and the emergence of new therapeutic strategies. In this setting, the goal is no longer simply to close the defect as early as possible, but rather to stabilize the patient, optimize the conditions for repair, and select the most appropriate treatment strategy in each individual case.

Recent studies on postinfarction ventricular septal rupture show that surgical repair remains the definitive treatment for most patients, although mortality is still high, ranging from 40% to 60% in contemporary registries, particularly when intervention is performed early after infarction.

Several reports suggest that delaying surgery may be associated with better outcomes. In some systematic reviews, mortality is approximately 54% when repair is performed within the first 7 days, compared with around 18–20% when surgery is deferred beyond the first week, likely because of progressive consolidation of necrotic tissue and technically safer repair (p < .05).

At the same time, mechanical circulatory support has taken on a central role in the management of these patients. Devices such as VA-ECMO or microaxial pumps such as Impella make it possible to stabilize cardiogenic shock, improve systemic perfusion, and facilitate bridge-to-surgical-repair strategies.

In addition, percutaneous defect closure has emerged as a therapeutic alternative in selected patients or in those at high surgical risk. In exceptional cases with extensive ventricular destruction or failure of conventional strategies, mechanical circulatory support may even be used as a bridge to heart transplantation.

Across the available studies, surgical repair remains the standard treatment for postinfarction ventricular septal rupture. Nevertheless, contemporary management increasingly incorporates mechanical circulatory support, selective delay of surgery, and percutaneous techniques within an individualized therapeutic approach tailored to each patient’s hemodynamic and anatomic status.

COMMENTARY:

Postinfarction VSR remains one of the most devastating mechanical complications of acute myocardial infarction. Despite advances in interventional cardiology and critical care, mortality remains exceedingly high. Even so, the management of this condition has gradually evolved over recent decades. More than a single technical breakthrough, what has truly changed is the overall treatment strategy.

In many ways, the history of postinfarction VSR can be understood as the progression through four major therapeutic eras.

• First era: urgent surgery

For decades, the therapeutic paradigm was relatively simple: once septal rupture had been diagnosed, the defect had to be closed as soon as possible by surgery. The rationale was clear: the left-to-right shunt caused rapid hemodynamic deterioration, and delaying intervention seemed to increase the risk of irreversible cardiogenic shock.

However, accumulated surgical experience soon showed the major limitations of this approach. In the acute phase after infarction, myocardial tissue is extremely friable, which makes suture fixation difficult and promotes dehiscence, residual defects, and early repair failure.

It is therefore not surprising that historical surgical series reported extremely high mortality, often exceeding 40–60% even in highly experienced centers.

• Second era: recognition of the benefit of delayed surgery

Over time, several registries began to identify an apparently paradoxical finding: patients who reached surgery several days after infarction had better outcomes than those operated on immediately.

In some systematic reviews, surgical mortality is approximately 54% when repair is performed within the first 7 days, compared with figures close to 18–20% when surgery is delayed beyond the first week. The most widely accepted explanation is that septal tissue evolves from a necrotic and friable stage to a more fibrotic one, thereby allowing a safer and more durable reconstruction.

That said, this apparent benefit of delaying surgery must be interpreted with caution. Many of these studies are affected by substantial survival bias, since only patients who survive the initial phase of cardiogenic shock are able to benefit from deferred surgery.

• Third era: mechanical circulatory support and the “bridge-to-repair” concept

The real paradigm shift in postinfarction VSR treatment has come with the development of mechanical circulatory support. Devices such as VA-ECMO and microaxial pumps have made it possible to stabilize patients in profound shock who previously would have died before reaching surgery.

VA-ECMO provides powerful hemodynamic support and helps preserve systemic perfusion in refractory cardiogenic shock. However, it may also increase left ventricular afterload and potentially worsen interventricular shunting, which in some cases makes concomitant ventricular unloading necessary.

In this context, microaxial devices such as Impella are particularly attractive from a pathophysiological standpoint because they directly unload the left ventricle and reduce intracavitary pressure. This mechanism may decrease flow across the septal defect and facilitate hemodynamic stabilization.

In a recent review including 42 studies and 78 patients treated with microaxial support, approximately 76% of patients were ultimately bridged to surgical repair after a median of 8 days of support, with an in-hospital mortality of around 22% and an overall mortality of approximately 27%.

These data reflect a major conceptual change: mechanical circulatory support is no longer used solely as rescue therapy, but also as a tool to convert urgent surgery on friable tissue into a deferred bridge-to-repair strategy performed under more favorable conditions.

• Fourth era: individualized strategies and advanced therapies

At present, postinfarction VSR management is moving toward increasing individualization. In addition to surgery and mechanical circulatory support, percutaneous closure has become an additional tool within the therapeutic armamentarium.

Although surgery remains the definitive treatment in most cases, percutaneous treatment may play a meaningful role in patients with prohibitive surgical risk, in selected anatomies, or as a rescue option for residual defects after surgical repair.

In parallel, some recent reports have explored even more complex scenarios in which mechanical circulatory support is used as a bridge to heart transplantation in patients with extensive ventricular destruction or failure of conventional strategies. In one review compiling 17 patients reported in the literature, 12 ultimately underwent heart transplantation, illustrating both the complexity and heterogeneity of these cases.

• Looking ahead

The main lesson emerging from recent studies is that the true innovation in postinfarction VSR treatment has not been a specific surgical technique, but rather a shift in the overall management strategy.

The aim is no longer simply to close the defect as early as possible, but to stabilize the patient, optimize the conditions for repair, and choose the most appropriate therapeutic pathway for each individual case.

This approach inevitably requires multidisciplinary care in centers experienced in cardiogenic shock management, where cardiac surgeons, interventional cardiologists, intensivists, and mechanical circulatory support teams can work together to design patient-specific strategies.

REFERENCES:

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Rashid H, Kumar K, Ullah A, Kamin M, Shafique HM, Elahi A, et al. Delayed Ventricular Septal Rupture Repair on Patient Outcomes After Myocardial Infarction: A Systematic Review. Curr Probl Cardiol. 2023 Mar;48(3):101521. doi: 10.1016/j.cpcardiol.2022.101521.

Coyan G, Anand N, Imran M, Gomez H, Ramanan R, Murray H, et al. ECMO and Impella Support Strategies as a Bridge to Surgical Repair of Post-Infarction Ventricular Septal Rupture. Medicina (Kaunas). 2022 Apr 28;58(5):611. doi: 10.3390/medicina58050611.