Indian Journal of Thoracic and Cardiovascular Surgery (July–September 2019) 35(3):433–434
https://doi.org/10.1007/s12055-019-00818-x
INVITED EDITORIAL
Does optimal delay improve outcomes in the surgical management
of post MIVSR?
Chandrasekar Padmanabhan 1
Received: 24 January 2019 / Revised: 18 February 2019 / Accepted: 7 March 2019 / Published online: 7 May 2019
# Indian Association of Cardiovascular-Thoracic Surgeons 2019
Post-myocardial infarct ventricular septal rupture (PMIVSR)
is a serious mechanical complication which carries a very high
mortality if not treated surgically. Since the first closure de-
scribed by Cooley in 1957, techniques have evolved and re-
sults have improved. It is a challenge, not only technically but
also in the management, right from admission preoperatively
to discharge. Mechanical circulatory support has helped im-
prove outcomes in this sick cohort. In spite of this, 30-day
mortality rates in different studies continue to be in the range
of 20 to 60% [1–5]. There are not many large series to deeply
analyze predictors of outcome, which are multivariate.
Cardiogenic shock, posterior infarcts, operating early, and
presence of renal dysfunction have been all known to be as-
sociated with poorer outcomes.
The authors of the paper on post-myocardial infarct
ventricular septal rupture in this issue [6], a series of 71
patients over an 8-year period in a large institution with
multiple surgeons, make a pitch for what they term as an
Boptimal delay^ [6]. The 30-day mortality in this study is
relatively high compared to few other series [1, 3, 5, 6] in
spite of the strategy of optimal delay. The strategy of
optimal delay is probably to obtain a window to gain
some tissue strength, and stabilize the patient medically
with support, to achieve a better outcome. In our experi-
ence, we follow a similar strategy since 2008. Mechanical
support with intra-aortic balloon pump (IABP) benefits
patients up to 48 h, with no added benefit beyond this
period, and is crucial for organ systems to stabilize, aci-
dosis to correct, and tissue strength to get better. The very
high mortality noted in many papers on patients operated
within 48 h [1] is due to the profound myocardial dys-
function and also due to the presence of significant
* Chandrasekar Padmanabhan
chanpad@gmail.com; chandrasekar@gknmh.org
1
Division of Cardiothoracic Surgery, Heart Failure and
Transplantation GKNM Hospital, Coimbatore 641037, India
residual shunts, which is directly related to tissue strength.
Gaining even 1 day matters. Instituting extra corporeal
membrane oxygenation (ECMO) [1, 3] for patients that
are much sicker and in shock may be a better option
and help push this optimal window a little more to the
right favoring better tissue strength. There is no specific
direction and patients’ factors have to be taken in to make
the decision, as the variables are many.
The reason to judiciously delay is one, to stabilize the sys-
tem from shock and low output and the second is to have
reasonable tissue strength, as residual ventricular septal rup-
ture (VSR) has a very adverse outcome. They have also found
that the location of the VSR was not a determinant of poor
outcome, which we also observed, but infero-posterior defects
have been shown to do badly in other series [1–3]. Most of the
patients who get through the 30-day timeline do well and the
results of the authors in terms of survival and major adverse
cardiac events (MACE) are consistent with most observations
including ours [1–6]. Surgical technique has a bearing on the
outcome and the authors have adopted the standard Daggett
sandwich technique. Residual VSR and bleeding can be very
serious in this group of patients and careful attention to tech-
nique is important, especially in handling, suturing, and tying
of knots. Among survivors, the incidence of residual VSRs is
pretty low in this series [4–6], but with a 30-day mortality of
more than 50%, it is a possibility that the incidence of residual
shunts was higher. The goal is to achieve a shunt-free septum
and revascularize as needed [1, 2, 5].
We follow the same strategy of instituting IABP soon after
diagnosis and closely monitor them with hourly urine output
and twice a day serum creatinine. Any change in the pattern,
suggesting a low cardiac output, is the time to intervene. Most
of the patients improve over a 24 to 72-h period and decision to
intervene is taken on a continuous basis. Waiting for more than
7 days, even if the patient is stable does not add any benefit and
only raises the risk of sudden deterioration, which we have
seen. The optimal window is 48 h post-IABP and before the
end of the week. The strategy of optimal delay is justified.
434
Long-term survival depends on left ventricular function
and freedom from congestive heart failure. Many series have
shown that once the 30-day period is over, the survival rates
are encouraging. Ventricular arrhythmias [1, 5, 6] are an issue
and may be a cause of sudden death. We routinely place all our
patients on amiodarone postoperatively for at least 6 months
[4]. It may be a good idea in some patients with aneurysmal
ventricles to have some low-dose anticoagulation on board.
The scoring system proposed by the authors is the nucleus
of the paper [4]. It is based on five preoperative parameters [4,
6]. The myocardial infarction (MI) to VSR time and VSR to
surgery time have been known very well as prognostic indi-
cators as they are surrogate markers for the extent of myocar-
dial injury [1–3, 5]. The shorter the time, the poorer the prog-
nosis. The authors recommend three values as a strategy for
timing the surgery, with scores less than 25 calling for imme-
diate surgery and scores more than 75 for elective closure,
even by device. They also propose a cut-off of 65 as a prog-
nostic marker with a negative predictive value of 86.70% [4,
6].
The scoring system is a good tool to stratify the pre-op
variables and give a predicted chance of survival, but one
cannot recommend waiting for 4 to 6 weeks based on a score
of 75 or more [4, 6]. It will be a very difficult proposition to do
a large multicentric study to validate this as suggested by the
authors but may be a good idea to use this as a risk stratifica-
tion tool and not a decision-making one.
Our take on this subject would be somewhat along the lines
of the authors, to get the optimal window with IABP support
with critical monitoring and close observation and not to wait
Indian J Thorac Cardiovasc Surg (July–September 2019) 35(3):433–434
more than 7 days, even if the patient is extremely stable. We
would call it rather as preoperative optimization than delay.
This strategy has helped us with good results over a 15-year
period of over 44 patients with a 30-day mortality of 20% and
a linearized survival of 77.7% at 5 years and 67% at 10 years.
The golden window, if one may call, is 2–5 days after institu-
tion of the IABP, not exceeding 7 days. With the current usage
and comfort of ECMO, extended optimization is possible to
achieve better outcomes in future.
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