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The enigma of optimal treatment for acute ventricular septal rupture

  • On Topaz
    Correspondence
    Address for reprints: On Topaz, MD, Division of Cardiology, McGuire Veterans Affairs Medical Center, 1201 Broad Rock Boulevard, Richmond, Virginia 23249, USA.
    Affiliations
    Division of Cardiology, McGuire Veterans Affairs Medical Center, Medical College of Virginia Hospitals, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia, USA.
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      The increased use of thrombolytic therapy for acute myocardial infarction over the last 2 decades resulted in a dramatic decrease in the incidence of mechanically associated complications, such as rupture of papillary muscles, free wall, and interventricular septum.
      • Crenshaw B.S.
      • Granger C.B.
      • Birnbaum Y.
      • Pieper K.S.
      • Morris D.C.
      • Kleiman N.S.
      • Vahanian A.
      • Califf R.M.
      • Topol E.J.
      Risk factors, angiographic patterns and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO I Trial Investigators.
      However, despite this encouraging upswing and improvement in surgical techniques for coronary bypass, acute interventricular septal rupture (ventricular septal defect [VSD]) remains a grave condition with a high likelihood of clinical catastrophe. The structural integrity of the interventricular septum is crucial not only for partitioning, but also for providing mechanical support for both ventricles.
      • Banka V.S.
      • Agarwal J.B.
      • Bodenheimer M.M.
      • Hellfant R.H.
      Interventricular septal motion biventricular angiographic assessment of its relative contribution to left and right ventricular contraction.
      The interventricular septum actively participates in systolic contraction and diastolic relaxation and contains important elements of the conduction system.
      • Vlodaver Z.
      • Edwards J.E.
      Rupture of ventricular septum or papillary muscle complicating myocardial infarction.
      ,
      • Topaz O.
      • DiSciascio G.
      • Vetrovec G.W.
      Septal perforator arteries from angiographic-morphologic characteristics to related revascularization options.
      Therefore, a series of pathologic processes take place consisting of septal infarction, then macrophage-induced necrotic tissue removal, and progressive thinning of the septum, which subsequently leads to tear and rupture with the resultant shunt. Two morphologic types of acute septal rupture are recognized: simple (direct, through-and-through perforation) and complex (perforation tract ascribing a serpiginous course and dissecting into remote septal regions).
      • Edwards B.S.
      • Edwards W.D.
      • Edwards J.E.
      Ventricular septal rupture complicating acute myocardial infarction identification of simple and complex types in 53 autopsied hearts.
      ,
      • Topaz O.
      • DiSciascio G.
      • Vetrovec G.W.
      Acute ventricular septal rupture perspectives on the current role of ventriculography and coronary arteriography and their implications for surgical repair.
      ,
      • Topaz O.
      • Mallon S.M.
      • Chahine R.A.
      • Sequeire R.F.
      • Myerbury R.J.
      Acute ventricular septal rupture angiographic-morphologic features and clinical assessment.
      The severe distortion of cardiac structure, physiology, and function caused by the sudden formation of a septal perforation exerts deleterious effects on ischemic and nonischemic septal tissues alike, and on the adjacent ventricles, valves, and the lungs. The size of the precipitating myocardial infarction, the formation of an associated ventricular aneurysm, the coexistence of right ventricular infarction, and the degree of damage to the papillary muscles each further contribute to adverse effects on a patient’s hemodynamics.
      • Topaz O.
      • Taylor A.L.
      Interventricular septal rupture complicating acute myocardial infarction from pathophysiologic features to the role of invasive and non-invasive diagnostic modalities in current management.
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