eComment. Percutaneous closure of post-myocardial infarction septal defect

We read with great interest the paper by Papalexopoulou et al. regarding the best timing of surgery in patients with post-infarct ventricular septal rupture [1]. After carefully reviewing the literature, the authors conclude that the best strategy is to delay the surgery by 3-4 weeks if the haemodynamic status of the patient allows. However, current guidelines advocate immediate surgical closure of the ventricular septal defect (VSD) irrespective of the patient's haemodynamic status to circumvent further haemodynamic decline [2].

First described by Lock et al. in 1988, the transcatheter closure of VSD has gained a widespread use, and devices originally intended to close the patent foramen ovale or atrial septal defects, have been modified for closure of muscular VSD. This less-invasive interventional approach allows, in the majority of cases, rapid haemodynamic stabilization by reducing the left-to-right shunt [3]. Anatomical considerations, best depicted by echocardiography, represent a major limitation of this procedure. Large VSDs exceeding 35 mm, apical VSDs without suitable rim or basal VSDs in the vicinity of mitral apparatus or the aortic valve represent a contraindication to the percutaneous closure with Amplatzer devices [4]. Another important drawback is the limited number of centres with sufficient expertise in performing these challenging procedures, because percutaneous closure of an acute postinfarct VSD remains one of the most demanding procedures in interventional cardiology.

Costache et al. used an Amplatzer occluder as a bridge-to-surgical procedure in a 79-year old woman in cardiogenic shock secondary to a post-infarct VSD [5]. The combined approach enabled them to perform surgery on a more stable patient. Recently, Thiele et al. [4] evaluated, in a prospective study, the outcomes of primary interventional closure of postinfarction VSD in an acute setting as an alternative to surgical closure. The overall 30-day mortality of this less-invasive approach was 35%. Not surprisingly, the mortality rate was higher in patients with cardiogenic shock. Major complications occurred in 41% and these included free ventricular wall rupture, device embolization or dislocation and residual left-to-right shunting.

Despite advances in medical and surgical care intervention, mortality of postinfarction VSD remains high, especially in patients with haemodynamic compromise. Future multicentre studies are warranted to identify patients best suited for surgical or interventional closure, in the era of evolving alternative technologies.

Conflict of interest: none declared