Early Percutaneous VSD Closure Promising in High-risk, Post MI Patients
While patients who undergo percutaneous closure of ventricular septal defect (VSD) have a high rate of in-hospital mortality, long-term outcomes are generally favorable in those who survive to discharge, according to a large British registry study published online ahead of print in Circulation.
Researchers led by David Hildick-Smith, MD, of Royal Sussex County Hospital (Brighton, United Kingdom), looked at 53 post MI VSD closure attempts at 11 British centers from 1997 to 2011 that reported cases to the British Cardiovascular Intervention Society. The majority of cases were performed using the Amplatzer post infarction VSD device (NMT Medical, Boston, MA), “but sometimes the muscular VSD device [was used] if the hole was small,” Dr. Hildick-Smith said in an email with TCTMD.
Two-thirds (66%) of MIs were anterior, while the median time from MI to closure procedure was 13 days. Mean patient age was 72 years, while under half (42%) were female.
High In-hospital Mortality Rate
The rate of successful device implantation was 89%. Immediate complete or partial shunt reduction was seen in 22% and 63% of patients, respectively. Sixteen percent of patients experienced no shunt reduction. Major immediate complications included 2 deaths (3.8%) and 4 emergency cardiac surgeries (7.5%). Blood transfusion was required in 4 patients (7.5%). Six patients went on to have surgical repair after attempted percutaneous closure due to hemolysis, device embolization and failed percutaneous closure attempt.
Slightly more than half (58%) of patients survived to discharge. Over long-term follow-up of 395 days, only 4 additional patients died. Factors associated with death at long-term follow-up included:
- Female sex (HR 2.33; 95% CI 1.03-5.26; P = .043)
- NYHA class IV (HR 4.42; 95% CI 11.70-1.51; P = .002)
- Cardiogenic shock (HR 3.37; 95% CI 1.55-9.09; P = .003)
- Creatinine (HR 1.007 per µmol/mL; 95% CI 1.003-1.012; P = .003)
- Size of defect (HR 1.09 per mm; 95% CI 1.01-1.17; P = .026)
- No revascularization therapy (HR 3.28; 95% CI 1.34-7.99; P = .009)
- Use of inotropes (4.18; 95% CI 1.55-11.26; P = .005)
Prior surgical closure of the VSD (HR 0.12; 95% CI 0.02-.91; P = .040) and immediate shunt reduction (HR .49; 95% CI.25-.96; P = .037) were associated with reduced mortality.
The study authors note that in this series of unselected cases, “overall the outlook remains poor.” In addition, they note, “Amongst those who have a successful procedure, in-hospital mortality remains high due to the underlying condition.” However, they note, “those who survive to hospital discharge have a good long-term outlook.”
Patient Selection is Key
Dr. Hildick-Smith and colleagues note that from a technical aspect, “percutaneous post-infarct VSD closure is a demanding procedure, requiring expertise and collaboration between interventionalists, anesthetists and imaging specialists. . . . Ventricular septal rupture is a mortal complication of myocardial infarction. Our data demonstrate that in selected patients, device closure is possible. . . .However, in-hospital mortality is high, even after apparently successful procedures. We believe that consideration should be given to early attempted percutaneous closure in patients presenting with this calamitous condition. Patients who do survive to discharge have excellent outcomes on long-term follow-up.”
Dr. Hildick-Smith said the main takeaway messages for physicians are twofold.
“Firstly, if you have a patient with a post-infarct VSD, do consider the option of percutaneous closure. Many surgeons will wait until patients have had a ‘trial of life,’ or ‘wait and see approach,’ which, for most, means death,” he noted. “A percutaneous option is an alternative to this. Second, if patients have a successful closure procedure done, and survive to hospital discharge, their survival thereafter is remarkably good— i.e. it is really worth putting the effort in to try to get a good outcome for these patients because those that survive do really well in the long term.”
But Dr. Hildick-Smith stressed that experience is paramount since it “is a demanding procedure with a measurable procedural mortality.”
Calvert PA, Cockburn J, Wynne D, et al. Percutaneous closure of post-infarction ventricular septal defect: in-hospital outcomes and long-term follow-up of UK experience. Circulation. 2014; Epub ahead of print.
- Dr. Hildick-Smith reports serving as a proctor for St. Jude AGA Medical.