Department of Cardiology, Royal Jubilee Hospital, Victoria, British Columbia, Canada.
Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.
Heart. 2020 Jun;106(12):878-884. doi: 10.1136/heartjnl-2019-315751. Epub 2020 Feb 28.
Postinfarct ventricular septal defects (VSDs) are a mechanical complication of acute myocardial infarction (AMI) with a very poor prognosis. They are estimated to occur in 0.2% of patients presenting with AMI, with 1-month survival of 6% without intervention. Guidelines recommend surgical repair, but recent advances in transcatheter technology, and bespoke device development, mean it is increasingly viable as a closure option. Surgical mortality is between 30% and 50% for all-comers, while in series of transcatheter closure, mortality was 32%. Transcatheter closure appears durable, with no evidence of late leaks and low long-term mortality in series with up to 5-year follow-up. Guidelines recommend early closure, which is likely to provide most benefit for patients regardless of the closure method. Multimodality cardiac imaging including echocardiography, CT and cardiac MRI can define size, shape, location of defects and their relationship to other cardiac structures, assisting with treatment decisions. Brief delay to allow stabilisation of the patient is appropriate, but untreated patients risk rapid deterioration. Mechanical circulatory support may be helpful, although the preferred modality is unclear. Transcatheter closure involves large bore venous access and the formation of an arteriovenous loop (under fluoroscopic and trans-oesophageal echocardiographic guidance) in order to facilitate deployment of the device in the defect and close the postinfarct VSD. Guidelines suggest transcatheter closure as an alternative to surgical repair in centres where appropriate expertise exists, but decisions for all patients with postinfarct VSD should be led by the multidisciplinary heart team.
心肌梗死后室间隔缺损（VSD）是急性心肌梗死（AMI）的一种机械并发症，预后极差。据估计，AMI 患者中有 0.2%发生 VSD，未经干预的 1 个月生存率为 6%。指南建议进行手术修复，但经导管技术和定制设备的最新进展意味着经导管闭合作为一种闭合选择越来越可行。对于所有患者，手术死亡率在 30%至 50%之间，而在经导管闭合系列中，死亡率为 32%。经导管闭合似乎是持久的，没有证据表明晚期泄漏，并且在长达 5 年的随访中，长期死亡率较低。指南建议早期闭合，无论采用哪种闭合方法，这对患者都可能最有益。包括超声心动图、CT 和心脏 MRI 在内的多模态心脏成像可以定义缺陷的大小、形状、位置及其与其他心脏结构的关系，从而有助于治疗决策。适当的短暂延迟以稳定患者是合适的，但未治疗的患者风险迅速恶化。机械循环支持可能会有所帮助，尽管首选模式尚不清楚。经导管闭合需要大口径静脉通路和动静脉环的形成（在荧光透视和经食管超声心动图引导下），以便在缺陷处部署器械并闭合心肌梗死后 VSD。指南建议在适当的专业知识中心，将经导管闭合作为手术修复的替代方法，但所有心肌梗死后 VSD 患者的决策都应由多学科心脏团队主导。
