Moumneh Mohamad B, Quader Mohammed A, Teman Nicholas R, Tang Daniel, Ryan Liam, Strobel Raymond J, Joseph Mark, Mazzeffi Michael, Gertz Zachary M, Kontos Michael C, Singh Ramesh, Spier Alan, Sarin Eric, Damluji Abdulla A
Inova Center of Outcomes Research, Inova Heart and Vascular, Fairfax, Virginia.
Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia.
Am J Cardiol. 2025 Apr 1;240:64-67. doi: 10.1016/j.amjcard.2024.12.028. Epub 2024 Dec 30.
Ventricular septal defect (VSD) is a life-threatening complication occurring after delayed presentation of acute myocardial infarction (AMI). We assessed clinical characteristics based on mortality following surgical repair of post-AMI VSD and evaluated trends of mortality, mechanical circulatory support (MCS) device use, and surgical approach. We included all patients who had surgical VSD repair following AMI who were included in a regional quality collaborative from May 2008 through January 2020. The primary outcome was in-hospital mortality. A univariate logistic regression model was utilized for each clinical variable on in-hospital mortality, while a multivariable model was used on age and variables that showed significant association (p <0.05) in the univariable model. Of the 79 patients who received repair, 32 (41%) were ≥70 years, 49 (62%) were male, and 28 (35%) died. The preoperative mean ejection fraction was 35%. Cardiogenic shock (CS) was observed in 53% (alive vs dead: 39% vs 79%, p = 0.001), while 6% required cardiopulmonary resuscitation (alive vs dead: 2% vs 14%, p = 0.05). MCS devices including extracorporeal membrane oxygenation were used in 22% (alive vs dead: 4% vs 54%, p <0.001). Emergent surgery was performed in 37% (alive vs dead: 18% vs 71%, p <0.001), concomitant aortic valve replacement in 10% (alive vs dead: 11% vs 9%, p = 0.029), and delayed intervention (beyond 7 days) in 44% (alive vs dead: 57% vs 21%, p = 0.002). Intraoperatively, blood products were used in 49% (alive vs dead: 45% vs 57%, p = 0.005). Following repair, 22% suffered from renal failure (alive vs dead: 19% vs 48%, p = 0.021). Patients who experienced delayed intervention had higher survival rates probably related to survival bias. Patients who suffered in-hospital mortality were more likely to have CS and to require MCS. Improvement in patient selection by a "Heart Team" approach and new therapeutic options are needed as part of advanced care for mechanical complications of AMI.
室间隔缺损（VSD）是急性心肌梗死（AMI）延迟出现后发生的一种危及生命的并发症。我们根据急性心肌梗死后室间隔缺损手术修复后的死亡率评估了临床特征，并评估了死亡率、机械循环支持（MCS）设备使用情况和手术方式的趋势。我们纳入了2008年5月至2020年1月期间区域质量协作中所有接受急性心肌梗死后室间隔缺损手术修复的患者。主要结局是住院死亡率。对每个与住院死亡率相关的临床变量使用单变量逻辑回归模型，而对年龄和单变量模型中显示出显著关联（p<0.05）的变量使用多变量模型。在接受修复的79例患者中，32例（41%）年龄≥70岁，49例（62%）为男性，28例（35%）死亡。术前平均射血分数为35%。53%的患者出现心源性休克（存活者与死亡者：39%对79%，p=0.001），而6%的患者需要心肺复苏（存活者与死亡者：2%对14%，p=0.05）。包括体外膜肺氧合在内的MCS设备在22%的患者中使用（存活者与死亡者：4%对54%，p<0.001）。37%的患者接受了急诊手术（存活者与死亡者：18%对71%，p<0.001），10%的患者同时进行了主动脉瓣置换（存活者与死亡者：11%对9%，p=0.029），44%的患者进行了延迟干预（超过7天）（存活者与死亡者：57%对21%，p=0.002）。术中，49%的患者使用了血液制品（存活者与死亡者：45%对57%，p=0.005）。修复后，22%的患者出现肾衰竭（存活者与死亡者：19%对48%，p=0.021）。经历延迟干预的患者生存率较高，可能与生存偏倚有关。住院死亡的患者更有可能出现心源性休克并需要机械循环支持。作为急性心肌梗死机械并发症高级护理的一部分，需要通过“心脏团队”方法改善患者选择并采用新的治疗选择。
