Moros David, Maigrot Jean-Luc A, Tong Michael Z Y, Smedira Nicholas G, Soltesz Edward G, Bakaeen Faisal G, Unai Shinya, Roselli Eric E, Lee Ran, Svensson Lars G, Blackstone Eugene H, Weiss Aaron J
Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
Department of Cardiovascular Medicine, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
JTCVS Tech. 2024 Sep 4;28:97-108. doi: 10.1016/j.xjtc.2024.08.019. eCollection 2024 Dec.
To characterize the clinical courses and outcomes of patients presenting with post-myocardial infarction (MI) ventricular septal rupture (VSR) receiving temporary microaxial transvalvular left ventricular assist device (tVAD) support.
Between December 2019 and July 2023, 10 consecutive patients presented with a post-MI VSR. All 10 patients received a tVAD. Patient characteristics, hemodynamics, intraoperative details, and postoperative outcomes were reviewed.
Eight patients underwent VSR repair (7 open, 1 percutaneous), and 2 patients died while on tVAD before being treated. Among the 7 patients who underwent open repair, 6 received preoperative tVAD support and 1 required intraoperative tVAD insertion during emergency right ventricular rupture repair. In the 6 patients receiving preoperative tVAD support, improvements from insertion to repair were observed in shunt fraction (from 2.6 [range, 2.3-3.3] to 1.8 (range, 1.5-3.3]), cardiac index (from 1.5 [range, 1.5-6.2] L·min m to 3.1 [range, 2.2-6.9] L·min m), pulmonary capillary wedge pressure (from 25 [range, 14-35] mm Hg to 16 [range, 14-18] mm Hg), central venous pressure (from 14 [range, 7-26] mm Hg to 12 [range, 1-26] mm Hg), creatinine (from 1.5 [range, 1.1-1.8] mg/dL to 1.2 [range, 0.9-1.5] mg/dL) and lactate (from 1.3 [1-1.7] mmol/L to 0.7 [range, 0.4-1.2] mmol/L). The median time from post-MI VSR diagnosis to repair was 15 (range, 13-18) days. Surgical repair was approached via right atriotomy in 4 patients, via left ventriculotomy in 2 patients, and via right ventricular defect in 1 patient, with no residual shunts or operative mortalities.
Perioperative tVAD support for post-MI VSR acutely stabilizes hemodynamics and end-organ function, facilitating delayed intervention with reduced operative risk while also preventing futile interventions. This paradigm shift in management of post-MI VSR from emergency to urgent operations may be associated with improved outcomes.
描述心肌梗死后（MI）室间隔破裂（VSR）患者接受临时微轴经瓣膜左心室辅助装置（tVAD）支持的临床病程及结局。
2019年12月至2023年7月期间，连续10例患者出现心肌梗死后室间隔破裂。所有10例患者均接受了tVAD。回顾了患者特征、血流动力学、术中细节及术后结局。
8例患者接受了室间隔破裂修复（7例开胸手术，1例经皮手术），2例患者在接受治疗前死于tVAD支持期间。在7例行开胸修复的患者中，6例接受了术前tVAD支持，1例在急诊右心室破裂修复术中需要术中插入tVAD。在6例接受术前tVAD支持的患者中，从植入到修复，分流分数（从2.6[范围2.3 - 3.3]降至1.8[范围1.5 - 3.3]）、心脏指数（从1.5[范围1.5 - 6.2]L·min⁻¹·m⁻²升至3.1[范围2.2 - 6.9]L·min⁻¹·m⁻²）、肺毛细血管楔压（从25[范围14 - 35]mmHg降至16[范围14 - 18]mmHg）、中心静脉压（从14[范围7 - 26]mmHg降至12[范围1 - 26]mmHg）、肌酐（从1.5[范围1.1 - 1.8]mg/dL降至1.2[范围0.9 - 1.5]mg/dL）和乳酸（从1.3[范围1 - 1.7]mmol/L降至0.7[范围0.4 - 1.2]mmol/L）均有改善。从心肌梗死后室间隔破裂诊断到修复的中位时间为15（范围13 - 18）天。4例患者经右心房切开术进行手术修复，2例经左心室切开术，1例经右心室缺损修复，无残余分流或手术死亡。
心肌梗死后室间隔破裂围手术期tVAD支持可急性稳定血流动力学和终末器官功能，有助于延迟干预并降低手术风险，同时还可防止无效干预。心肌梗死后室间隔破裂管理从急诊手术到紧急手术的这种模式转变可能与改善结局相关。
