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Strategies for repairing post-MI ventricular septal defects: each has its place for now

BOSTON — The first registry study comparing percutaneous versus surgical repair of post-infarction ventricular septal defect (VSD) has revealed baseline differences in survival that have uncertain impact on long-term outcomes.

Based on a few hundred cases, 5-year all-cause mortality was approximately 60% between patients receiving an initial surgical management strategy and those receiving percutaneous treatment (log-rank P=0.059). Despite in-hospital mortality rates initially disadvantaging the percutaneous group (55.0% versus 44.2%, P=0.048), historical analysis of hospital discharge revealed no long-term difference in survival.

Nevertheless, after multivariable adjustment, cardiogenic shock was the best predictor of 5-year mortality (adjusted HR 1.97, 95% CI 1.37-2.84), followed by percutaneous management (adjusted HR 1 .44, 95% CI 1.01-2.05) in the retrospective analysis. , according to Joel Peter Giblett, MD, of Liverpool Heart and Chest Hospital in England.

Selection bias may have been at play given that some patients were only offered percutaneous treatment once surgical repair was deemed infeasible, he warned in a presentation at the meeting. Transcatheter Cardiovascular Therapeutics (TCT) hosted by the Cardiovascular Research Foundation.

“Percutaneous and surgical management are complementary in real-world clinical practice and provide a significant survival advantage over historical medical therapy data,” Giblett said. “Shared decision-making by the cardiac team is essential for patients.”

He said that when the study results were shared with site investigators, most concluded that timing trumps the issue of repair method – whether having someone nearby to perform a operation quickly is preferred rather than waiting for the patient to deteriorate.

The choice between percutaneous and surgical management of VSD should depend on each hospital’s local situation and whether or not there are experienced operators for either approach, agreed TCT session panelist Horst Sievert , MD, of the Cardiovascular Center Frankfurt CVC.

A rare but life-threatening complication of acute myocardial infarction (MI), a VSD is a new tear between the left and right ventricles exposing the latter to systemic pressures. Left alone without repair, mortality exceeds 94% at 1 month with medical treatment alone, Giblett said.

He reports that the incidence of device embolization reaches 7.6% with the percutaneous approach in the registry.

At a TCT press conference, Ralph Stephan Von Bardeleben, MD, of the Universitätsmedizin Heart Valve Center Mainz in Germany, suggested that innovative hybrid procedures – in which operators suture occluding devices into the septum – show promise in eliminating the risk of device embolization.

Even so, post-MI VSD patients are an “incredibly difficult population to study and treat” because not all defects are created equally and can be difficult to imagine, maintained Michael Young, MD, of Dartmouth Hitchcock. Medical Center in Lebanon, New Hampshire.

For the study, Giblett’s group relied on a UK National Register that included data from 16 sites. This is the largest percutaneous post-infarction VSD case registry to date.

Participants were divided into heart attack survivors undergoing surgical (n=230) or percutaneous (n=131) repair as initial treatment for post-MI VSD in 2010-2021.

Compared to the surgical cohort, the percutaneous group was older (72 vs 67, PP=0.167). These patients were also more likely to have MIs in the anterior region compared to the inferior region, but less likely to have cardiogenic shock (51.9% versus 62.8%, P=0.044).

Patients in both cohorts waited a median of 2 days from acute MI to presentation, and 9 days from acute MI to VSD repair.

Postoperatively, percutaneous support was associated with fewer procedural strokes (0.8% versus 5.6%, P=0.021), new implantable cardiac pacemakers and cardioverter defibrillators (1.5% vs 6.9%, P=0.023), and pneumonia (8.4% versus 23.4%, PP

Notably, a longer delay between acute MI and VSD repair was a marginal predictor of lower 5-year mortality (adjusted HR 0.99, 95% CI 0.98-0.99).

TCT press conference co-moderator David Cohen, MD, MSc, of Saint Francis Hospital in Roslyn, New York, warned that it is “almost impossible to make this direct comparison” as surgeons will delay usually the repair of the VSD to make the area stronger when they operate, and the patients who survive this time frame are probably the healthiest who can be expected to have better long-term outcomes.

The available dataset also suggested fewer surgically or percutaneously managed VSDs early in the pandemic, raising the question of whether fewer people presented with them or simply avoided the operating room during this time. , Giblett said.

He urged that prospective studies be carried out to identify the optimal method and timing of VSD management. A randomized trial should be undertaken, but that would be difficult and would take many years, he acknowledged.

  • Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

Giblett did not disclose any relationship with the industry.

Sievert disclosed institutional relationships with 4tech Cardio, Abbott, Ablative Solutions, Adona Medical, Akura Medical, Ancora Heart, Append Medical, Axon, Bavaria Medizin Technologie GmbH, BioVentrix, Boston Scientific, Cardiac Dimensions, Cardiac Success, Cardimed, Cardionovum, Celonova , Contego, horn; Hangzhou Nuomao Medtech, Holistick Medical, InterShunt, Intervene, K2, Laminar, Lifetech, Magenta, Maquet Getinge Group, Metavention, Mitralix, Mokita, Neurotronics, NXT Biomedical, Occlutech, Recor, Renal Guard, Shifamed, Terumo, Trisol and Vascular Dynamics.

Von Bardeleben disclosed relationships with Abbott Vascular, Edwards Lifesciences, Medtronic and NeoChord.

Young disclosed a relationship with Medtronic.