Post-infarction ventricular septal defect: percutaneous or surgical management in the UK national registry
Joel P. GiblettAndrija MatetićDavid P. JenkinsChoo NgShreenidhi VenurajuTobias MacCarthyJonathan VibhishananJohn P O’NeillBilal H. KirmaniD. Mark PullanRod StablesJack AndrewsNicolas ButtingerWan KimRitesh KanyalMegan ButlerRobert J. ButlerSudhakar GeorgeAyush KhuranaDavid CrosslandJakub MarczakWilliam SmithJohn ThomsonJames R. BenthamBrian ClappMamta BuchNicholas HayesJonathan ByrnePhilip MacCarthySuneil AggarwalLeonard M. ShapiroMark TurnerJ De GiovanniDavid B. NorthridgeDavid Hildick‐SmithMamas A. MamasPatrick A. Calvert
Key result
Surgical post-MI VSD repair linked to lower in-hospital mortality than percutaneous repair, but similar long-term survival.
Why the study?
Does percutaneous repair compared to surgical repair improve long-term mortality in patients with post-infarction ventricular septal defect?
Key Points
- To evaluate and compare long-term mortality and in-hospital outcomes between percutaneous closure and surgical repair for post-infarction ventricular septal defects.
- Conducted a retrospective multicenter registry study across 16 UK centres reviewing 362 patients who received 416 procedures between 2010 and 2021.
- Categorized patients based on their primary management strategy (131 percutaneous, 231 surgical) to assess long-term and in-hospital mortality.
- Long-term mortality did not significantly differ between the percutaneous and surgical cohorts (61.1% vs. 53.7%, P = 0.17), but in-hospital mortality was significantly lower in surgical patients (55.0% vs. 44.2%, P = 0.048).
- Independent risk factors for long-term mortality included cardiogenic shock (aHR 1.97, 95% CI 1.37–2.84, P < 0.001), percutaneous intervention (aHR 1.44, 95% CI 1.01–2.05, P = 0.042), and number of diseased coronary vessels (aHR 1.22, 95% CI 1.01–1.47, P = 0.043).
Study Design
Type
Cohort (n=362)
Multicenter
Yes
Structured PICO
Does percutaneous repair compared to surgical repair improve long-term mortality in patients with post-infarction ventricular septal defect?
P
Population
362 patients with post-infarction ventricular septal defect treated with surgical or percutaneous repair between 2010 and 2021 across 16 UK centers.
E
Exposure
Percutaneous repair of PIVSD (n=131)
C
Comparator
Surgical repair of PIVSD (n=231)
O
Outcome
Long-term mortalityhard clinical
Main Result
Hazard Ratio: 1.44 (95% CI 1.01–2.05)
Absolute Event Rate: 61.1% vs 53.7%
p-value: p=0.042
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The choice between percutaneous and surgical management of VSD should depend on the local situation of each hospital and whether they have experienced operators for either approach.”
“innovative hybrid procedures -- wherein operators suture occluder devices into the septum -- show promise at eliminating the risk of device embolization.”
JPJoel Peter GiblettInterventional cardiologist, Liverpool Heart and Chest Hospital
“Both percutaneous and surgical management are complementary in real-world clinical practice and offer significant survival advantage compared to historical data on medical therapy. Shared decision-making through the heart team is key for patients.”
Implication
While unadjusted long-term mortality is similar between percutaneous and surgical repair of PIVSD, surgical repair is associated with lower in-hospital mortality and the percutaneous approach is an independent predictor of long-term mortality.
Abstract
AIMS: Post-infarction ventricular septal defect (PIVSD) is a mechanical complication of acute myocardial infarction (AMI) with a poor prognosis. Surgical repair is the mainstay of treatment, although percutaneous closure is increasingly undertaken. METHODS AND RESUTS: Patients treated with surgical or percutaneous repair of PIVSD (2010-2021) were identified at 16 UK centres. Case note review was undertaken. The primary outcome was long-term mortality. Patient groups were allocated based upon initial management (percutaneous or surgical). Three-hundred sixty-two patients received 416 procedures (131 percutaneous, 231 surgery). 16.1% of percutaneous patients subsequently had surgery. 7.8% of surgical patients subsequently had percutaneous treatment. Times from AMI to treatment were similar [percutaneous 9 (6-14) vs. surgical 9 (4-22) days, P = 0.18]. Surgical patients were more likely to have cardiogenic shock (62.8% vs. 51.9%, P = 0.044). Percutaneous patients were substantially older [72 (64-77) vs. 67 (61-73) years, P < 0.001] and more likely to be discussed in a heart team setting. There was no difference in long-term mortality between patients (61.1% vs. 53.7%, P = 0.17). In-hospital mortality was lower in the surgical group (55.0% vs. 44.2%, P = 0.048) with no difference in mortality after hospital discharge (P = 0.65). Cardiogenic shock [adjusted hazard ratio (aHR) 1.97 (95% confidence interval 1.37-2.84), P < 0.001), percutaneous approach [aHR 1.44 (1.01-2.05), P = 0.042], and number of vessels with coronary artery disease [aHR 1.22 (1.01-1.47), P = 0.043] were independently associated with long-term mortality. CONCLUSION: Surgical and percutaneous repair are viable options for management of PIVSD. There was no difference in post-discharge long-term mortality between patients, although in-hospital mortality was lower for surgery.
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Cite This Study
Giblett et al. (2022) conducted a cohort in Post-infarction ventricular septal defect (PIVSD) (n=362). Percutaneous repair vs. Surgical repair was evaluated on Long-term mortality (aHR 1.44, 95% CI 1.01-2.05, p=0.042). Percutaneous repair of post-infarction ventricular septal defect was associated with higher adjusted long-term mortality compared to surgical repair (aHR 1.44; 95% CI 1.01-2.05; P=0.042).