Arsh Hina, Pahwani Ritesh, Arif Rasool Chaudhry Waqar, Khan Rubaiqa, Khenhrani Raja Ram, Devi Sapna, Malik Jahanzeb
Department of Medicine, THQ Hospital, Pasrur, Pakistan.
Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan.
Curr Probl Cardiol. 2023 Oct;48(10):101887. doi: 10.1016/j.cpcardiol.2023.101887. Epub 2023 Jun 17.
Ventricular septal rupture (VSR) is a rare but serious complication that can occur after myocardial infarction (MI) and is associated with significant morbidity and mortality. The optimal management approach for VSR remains a topic of debate, with considerations including early versus delayed surgery, risk stratification, pharmacological interventions, minimally invasive techniques, and tissue engineering. The pathophysiology of VSR involves myocardial necrosis, inflammatory response, and enzymatic degradation of the extracellular matrix (ECM), particularly mediated by matrix metalloproteinases (MMPs). These processes lead to structural weakening and subsequent rupture of the ventricular septum. Hemodynamically, VSR results in left-to-right shunting, increased pulmonary blood flow, and potentially hemodynamic instability. The early surgical repair offers the advantages of immediate closure of the defect, prevention of complications, and potentially improved outcomes. However, it is associated with higher surgical risk and limited myocardial recovery potential during the waiting period. In contrast, delayed surgery allows for a period of myocardial recovery, risk stratification, and optimization of surgical outcomes. However, it carries the risk of ongoing complications and progression of ventricular remodeling. Risk stratification plays a crucial role in determining the optimal timing for surgery and tailoring treatment plans. Various clinical factors, imaging assessments, scoring systems, biomarkers, and hemodynamic parameters aid in risk assessment and guide decision-making. Pharmacological interventions, including vasopressors, diuretics, angiotensin-converting enzyme inhibitors, beta-blockers, antiplatelet agents, and antiarrhythmic drugs, are employed to stabilize hemodynamics, prevent complications, promote myocardial healing, and improve outcomes in VSR patients. Advancements in minimally invasive techniques, such as percutaneous device closure, and tissue engineering hold promise for less invasive interventions and better outcomes. These approaches aim to minimize surgical morbidity, optimize healing, and enhance patient recovery. In conclusion, the management of VSR after MI requires a multidimensional approach that considers various aspects, including risk stratification, surgical timing, pharmacological interventions, minimally invasive techniques, and tissue engineering.
室间隔破裂（VSR）是心肌梗死（MI）后可能发生的一种罕见但严重的并发症，与显著的发病率和死亡率相关。VSR的最佳管理方法仍是一个有争议的话题，考虑因素包括早期手术与延迟手术、风险分层、药物干预、微创技术和组织工程。VSR的病理生理学涉及心肌坏死、炎症反应以及细胞外基质（ECM）的酶降解，特别是由基质金属蛋白酶（MMPs）介导的。这些过程导致室间隔结构弱化并随后破裂。在血流动力学方面，VSR导致左向右分流、肺血流量增加，并可能导致血流动力学不稳定。早期手术修复具有立即闭合缺损、预防并发症以及可能改善预后的优点。然而，它与较高的手术风险以及等待期心肌恢复潜力有限相关。相比之下，延迟手术允许有一段时间进行心肌恢复、风险分层以及优化手术结果。然而，它存在持续并发症和心室重塑进展的风险。风险分层在确定最佳手术时机和制定治疗方案方面起着关键作用。各种临床因素、影像学评估、评分系统、生物标志物和血流动力学参数有助于风险评估并指导决策。药物干预，包括血管升压药、利尿剂、血管紧张素转换酶抑制剂、β受体阻滞剂、抗血小板药物和抗心律失常药物，用于稳定血流动力学、预防并发症、促进心肌愈合以及改善VSR患者的预后。微创技术的进展，如经皮装置闭合，以及组织工程有望实现侵入性更小的干预和更好的结果。这些方法旨在将手术发病率降至最低、优化愈合并促进患者康复。总之，心肌梗死后VSR的管理需要一种多维度方法，该方法要考虑各个方面，包括风险分层、手术时机、药物干预、微创技术和组织工程。
