Emergency Surgery after Unsuccessful Immediate Primary Percutaneous Post-infarction Ventricular Septal Defect Closure: A Single Center Case Series

Introduction: Ventricular septal defect (VSD) complicating acute myocardial infarction (AMI) still carries a high mortality. Primary transcatheter VSD closure with an occluder in an acute setting will be more frequently applied.

Background: Between April 2004 and September 2012, 6 patients (male= 4; median age: 65 [interquartile range (IQR) 65–70] years; logEuroSCORE= 41.2% (IQR 24.2–71.9)) underwent emergency VSD repair surgery after attempted primary percutaneous device closure. The median VSD left-to-right shunt volume was 51.4% (IQR 48–55). Anterior VSD was present in 3 patients (50%), and posterior VSD in 3 (50%). All patients presented in a decompensated cardiac state; therein 3 patients in cardiogenic shock (50%). The median time from AMI to admission was 5 days (IQR 1–8), from AMI to occluder implantation 7 days (IQR 6–22), from occluder implantation to emergency surgery 26 days (IQR 0–95) and from re-admission to emergency redo surgery 2 days (IQR 0–6).

Discussion: The reasons for surgery were occluder dislocation (5/6 cases) and occluder endocarditis (1 case). The surgical techniques employed included a simple single patch (1/6), simple double septal patch (1/6), and infarct exclusion by David et al. (4/6) with excellent results. The overall-mortality was 16.7% with a median survival of 1,920 days (IQR 428–2478) and 1 persistent left-to-right shunt at discharge. Primary surgical repair of post-infarction VSD should remain the gold standard approach in the emergency setting. Despite cardiogenic shock, immediate surgery may improve mortality while avoiding subsequent cardiac procedures.