Rare ventricular septal defect tied to high mortality rates
Ventricular septal defect after acute myocardial infarctions (MIs) is not common, but it still remains a source of concern due to its association with high mortality rates, according to a recent study.
“This serves as a call for improvement in patient selection, refinement of surgical techniques, innovations in percutaneous closure techniques and development of specialized centres to manage this complication to improve outcome,” researchers said.
Overall, there were 3,373,206 ST-elevation MIs identified in this study. Of these, 10,012 (0.3 percent) were complicated with ventricular septal defects. Patients were mostly >65 years, male (55 percent) and white (63 percent). The development of ventricular septal defects were usually linked to inferior (49.7 percent) and anterior (41.1 percent) MIs. [Am J Med 2017;130:863.e1–863.e12]
“To date, there is no clear evidence to guide the management of these patients, and it remains a challenge in the critical care, imaging, interventional and surgical arenas,” researchers said.
The median length of hospital stay was 7 days (interquartile range, 3.0 to 13.5 days). Intervention was performed on only 7.65 percent of patients (7 percent surgical and 0.65 percent minimally invasive). Of the patients, 36.5 percent used mechanical support devices, with intra-aortic balloon pump (96 percent) being the most common.
In-hospital mortality stood at 30.5 percent (downward trending from 41.6 percent in 2001 to 23.3 percent in 2013), and its statistically significant predictors were age, cardiogenic shock and in-hospital cardiac arrest.
“Mortality is the most dreaded outcome of this MI complication,” researchers said. “This study represents the largest body of evidence that has also reported a downtrend over the last three decades.”
There was a significant decline in the use of corrective procedures. Furthermore, the utilization of mechanical support devices and performing a corrective procedure correlated with higher mortality, length of stay and cost.
“The development of more efficient and less invasive percutaneous closure modalities may help patients in whom surgery has to be delayed or simply be used as a therapeutic modality,” according to researchers.
“Experience with the transcatheter approach is limited, and technical developments and prospective trials are required to identify patients who would benefit the most,” they added.
In this study, patients were identified using the International Classification of Diseases, 9th Revision, Clinical Modification procedure codes from the Nationwide Inpatient Sample between 2001 and 2013. The authors used a multivariate hierarchical logistic regression model to identify significant predictors of in-hospital mortality.
“Our results, although in parallel with most of the previously published data, continue to validate the notion that although outcomes have improved for acute MI, mortality from post-MI ventricular septal defects remains extraordinarily high,” researchers noted.
A lethal complication after an acute MI, ventricular septal defect has become rare with the advent of reperfusion strategies, but it remains a major contributor to mortality.