Both Surgical, Percutaneous Closure Boost Survival in Post-STEMI VSD

BOSTON, MA—Rare, postinfarction ventricular septal defects (VSDs), which saw a worrisome resurgence during the COVID-19 pandemic, can effectively be treated surgically or percutaneously, with similar survival out to 5 years, new registry data suggest.

Importantly, in-hospital mortality following percutaneous repair in this series was significantly higher than that seen with surgery, but this tracked strongly with some form of multidisciplinary team discussion, suggesting that percutaneous strategies were only pursued after surgery was deemed too risky.

“Both percutaneous and surgical management are complementary in real world clinical practice and offer significant survival advantages compared to historical data on medical therapy,” said Joel Giblett, MD (Liverpool Heart and Chest Hospital, England), who presented the retrospective, observational study as part of a late-breaking clinical science session here at TCT 2022 today.

Giblett stressed that VSDs complicating STEMI are “relatively rare,” seen in approximately one in 500 patients, often in those who present to hospital after a protracted delay. The rupture or tear between the left and right ventricle amounts to a “double insult,” Giblett explained at a morning press conference: “A large territory infarct combined with exposing the right ventricle and pulmonary vasculature to systemic pressures.”

The study by Giblett et al, including co-principal investigator Patrick A. Calvert, BMBCh, PhD (Royal Papworth Hospital, Cambridge, England), was simultaneously published in the European Heart Journal.

A Decade of Data

The analysis included 362 patients (with a total of 412 procedures) stratified according to their initial management strategy, either surgical repair (230 patients) or percutaneous (131) using a VSD occluder, with patients treated at 16 sites across the United Kingdom. A majority of patients had NYHA class III or IV heart failure; 52% of patients treated percutaneously and 63% of those treated surgically presented in cardiogenic shock.

“These were late-presenting infarcts,” Giblett emphasized in his presentation today. Time from acute MI to hospital presentation was a median of 2 days in both groups, and delay to repair was 9 days in both groups. Of note, 52% of patients treated surgically were not first reviewed by a heart team, whereas 38% patients treated percutaneously were first discussed informally by a multidisciplinary team, and a full 47% were treated with a percutaneous approach following a formal heart team review.

There was no difference in long-term mortality between groups (61.1% for percutaneous vs 53.7% for surgery, P = 0.17), but in-hospital mortality was significantly higher in the percutaneous patients (55% vs 44.2%; P = 0.048). A landmark analysis confirmed that in patients surviving to hospital discharge, there was no difference in 5-year mortality between patients according to their treatment type.

Key predictors of mortality, Giblett noted, were cardiogenic shock and use of a percutaneous approach, both of which point to a more seriously ill and deteriorating patient population. “Some patients were only offered percutaneous treatment once surgical repair was deemed unfeasible,” he noted, and “involvement of heart team decision-making was inconsistent.” Clearly, he continued, “prospective studies are needed to evaluate the optimal timing of treatment.”

Timing Is Everything?

During Giblett’s late-breaking presentation, several panelists said that they didn’t think it would be possible to randomize patients to percutaneous versus surgical management, given the critical nature of the condition, let alone its rarity. What does need more consensus, they agreed, is better insights around timing and the gains that could be made by intervening earlier, as opposed to waiting for patients to be deemed stable enough for a procedure.

As David Cohen, MD (St. Francis Hospital, Roslyn, NY), who moderated the morning press conference, pointed out, “surgeons will typically try to delay—not maliciously—but simply to give the area they are suturing into more stability and to accept the sutures, but that means that the patients who get the surgery are the survivors, they are probably healthier.”

To TCTMD, Giblett said that his research plan going forward is to try to look prospectively at the issue of timing, which he agreed is more important than the choice of intervention.

These retrospective data do not capture the patients who were never referred for VSD repair because they were deemed too sick and/or were managed medically, said Giblett, nor do they offer any insights into the impact of the COVID-19 pandemic since the overall numbers of repairs were lower during the pandemic in the UK.

Delayed STEMI presentations have been widely reported during COVID lockdowns and likely increased the numbers of VSDs. For a range of reasons, said Giblett, these defects likely weren’t being managed surgically or percutaneously and, in many cases, may have been diagnosed postmortem, if at all.

Despite the unknowns, Giblett said there are important takeaways from his analysis, chief among them the fact that doing something is better than doing nothing.

“What we can see is that the survival in these patients is better than historic data with medical treatment,” with mortality rates as high as 94%. “Hopefully this is a stimulus to say, look, this can be done. . . . There is more you can do that will help.”