The following are key points to remember from a clinical consensus statement on ventricular septal defect (VSD) complicating acute myocardial infarction (MI):

1. VSD after MI (MI-VSD) (incidence 0.1-0.4%) has a dismal prognosis, approaching 100% fatality if treated conservatively. It results from interventricular septal rupture (usually within 48 hours of MI) leading to left and right ventricular (LV and RV) communication causing heart failure, pulmonary edema, and cardiogenic shock.
2. Medical management aims to stabilize the patient, optimize hemodynamics, and reduce myocardial workload. Surgical repair or interventional closure remain the definitive treatment for MI-VSD, but still are associated with excessively high mortality.
3. Transthoracic echocardiography (TTE) with Doppler imaging is the initial investigation of choice. Besides diagnosing the MI-VSD, TTE is crucial to detect important differential diagnoses, which sometimes might even co-exist, such as acute mitral valve regurgitation due to papillary muscle rupture or (contained) free-wall rupture.
4. Medical management serves only as a bridge to surgical or percutaneous intervention and centers around optimizing hemodynamics. Afterload reduction will improve cardiac output but may also cause hypotension. Use of inotropes like dobutamine and milrinone can be helpful but therapy should be monitored closely. Similarly, norepinephrine can be used to address hypotension but can be challenging.
5. Surgical techniques include excision and exclusion. The "excision technique" includes resection of the residual septal necrotic tissue by single patch reconstruction of the septum sutured. The "exclusion technique" consists of the use of pericardial or prosthetic material for the creation of a new ventricular septum with the autologous or prosthetic patch sutured far from the necrotic VSD edge at the noninfarcted part of the LV-related site of the septum directly along the edge of the VSD. For the "triple-patch technique," a smaller patch is used to close the defect and two large patches are used to exclude both ventricles.
6. Transcatheter closure of MI-VSD was first described in 1988 and progressively became an alternative to surgical interventions in select cases. Observational data suggest significant high mortality rates (55%) and highlight the need for technical advances and device iterations.
7. According to the 2023 European acute coronary syndrome guidelines, intra-aortic balloon pump support represents the first-line mechanical circulatory device (MCS) in patients with MI-VSD. Other MSC options such as extracorporeal membrane oxygenation, micro-axial pump, left atrial to systemic shunt, or a combination can be considered but lack an evidence base. MCS may have a role to temporarily bypass some of the hemodynamic alterations of MI-VSD as a bridge to definitive repair as the only viable treatment option.
8. Timing of closure remains debated. The biological rationale of delaying closure is based on the assumption that scarring of the infarcted tissue may facilitate patch suturing. Based on current evidence and experience, an approach that integrates the patients’ hemodynamic status and VSD characteristics seems reasonable. Among patients who are hemodynamically stable, elective repair in 1-2 weeks may be considered. Patients who are hemodynamically unstable and refractory to medical stabilization may need emergent repair, while those who can be stabilized medically should be considered for urgent repair after evaluation by the Heart/Shock team.
9. Choice of therapy (palliative, percutaneous, or surgical) should be based on anatomy, comorbidities, and center experience.
10. MI-VSD-associated morbidity and mortality remains very high. Invasive strategies have to be weighed against the associated risks and the potential of futility despite aggressive therapy. Future systematic scientific investigations into MI-VSD may provide enhanced treatment recommendations.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Cardiac Surgery and CHD and Pediatrics, Congenital Heart Disease, Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention

Keywords: Heart Septal Defects, Ventricular, Myocardial Infarction

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