Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., E.K.I., A.T., J.X.X., P.T.G., I.B., C.M.D., G.S.H., P.C.B., A.B.G., V.C.B.).
Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (B.G.L., W.B.K., A.T., R.A.G.).
Circ Cardiovasc Interv. 2023 Oct;16(10):e013243. doi: 10.1161/CIRCINTERVENTIONS.123.013243. Epub 2023 Sep 21.
Postinfarction ventricular septal defect (VSD) is a catastrophic complication of myocardial infarction. Surgical repair still has poor outcomes. This report describes clinical outcomes after a novel hybrid transcatheter/surgical repair in patients with apical VSD.
Seven patients with postmyocardial infarction apical VSD underwent hybrid transcatheter repair via subxiphoid surgical access. A transcatheter occluder (Amplatzer Septal Occluder) with a trailing premounted suture was deployed through the right ventricular wall and through the ventricular septum into the left ventricular apex. The trailing suture was used to connect an anchor external to the right ventricular wall. Tension on the suture then collapses the right ventricular free wall against the septum and left ventricular occluder, thereby obliterating the VSD. Outcomes were compared with 9 patients who underwent surgical repair using either patch or primary suture closure.
All patients had significant left-to-right shunt (Qp:Qs 2.5:1; interquartile range [IQR, 2.1-2.6] hybrid repair versus 2.0:1 [IQR, 2.0-2.5] surgical repair), and elevated right ventricular systolic pressure (62 [IQR, 46-71] versus 49 [IQR, 43-54] mm Hg, respectively). All had severely depressed stroke volume index (22 versus 21 mL/m) with ≈45% in each group requiring mechanical support preprocedurally. The procedure was done 15 (IQR, 10-50) versus 24 (IQR, 10-134) days postmyocardial infarction, respectively. Both groups of patients underwent repair with technical success and without intraprocedural death. One patient in the hybrid group and 4 in the surgical group developed multiorgan failure. The hybrid group had a higher survival at discharge (86% versus 56%) and at 30 days (71% versus 56%), but similar at 1 year (57% versus 56%). During follow-up, 1 patient in each group required reintervention for residual VSD (hybrid: 9 months versus surgical: 5 days).
Early intervention with a hybrid transcatheter/surgical repair may be a viable alternative to traditional surgery for postinfarction apical VSD.
心肌梗死后室间隔缺损（VSD）是心肌梗死的灾难性并发症。外科修复的效果仍然不佳。本报告描述了经剑突下入路行新型杂交经导管/外科修复的患者的临床结果。
7 例因心肌梗死后发生心尖部 VSD 的患者接受经剑突下入路的杂交经导管修复。通过右心室壁和室间隔将带有预连接缝线的经导管封堵器（Amplatzer 间隔封堵器）放置到位，缝线拖尾穿过室间隔进入左心室心尖部。拖尾缝线用于连接右心室壁外部的锚定物。然后对缝线施加张力，使右心室游离壁向间隔和左心室封堵器靠拢，从而使 VSD 闭合。将这些结果与 9 例行修补术（补片或直接缝合）的患者进行比较。
所有患者均存在显著的左向右分流（Qp:Qs 2.5:1；四分位距 [IQR，2.1-2.6] 杂交修复组与 2.0:1 [IQR，2.0-2.5] 外科修复组），且右心室收缩压升高（62 [IQR，46-71] 与 49 [IQR，43-54] 分别）。每组的射血分数指数（stroke volume index）均严重降低（22 与 21 毫升/米），约 45%的患者在术前需要机械支持。手术分别在心肌梗死后 15 天（IQR，10-50 天）和 24 天（IQR，10-134 天）进行。两组患者均成功完成修补，且无术中死亡。杂交修复组有 1 例患者和外科修复组有 4 例患者出现多器官功能衰竭。出院时，杂交修复组的存活率更高（86%比 56%），30 天时（71%比 56%），但 1 年时（57%比 56%）无差异。随访期间，每组各有 1 例患者因残余 VSD 需要再次介入治疗（杂交修复组：9 个月与外科修复组：5 天）。
对于心肌梗死后心尖部 VSD，早期采用杂交经导管/外科修复可能是传统手术的可行替代方法。
