The critical window: surgical timing and mortality in post-infarction ventricular septal rupture - insights from a brazilian cohort

Background Post-myocardial infarction ventricular septal rupture (post-MI VSR) is a rare yet catastrophic complication of transmural infarction. Despite a declining incidence with contemporary reperfusion strategies, mortality remains high, ranging from 40% to 80%, even after surgical repair. The interval between the ischaemic event and surgery is a key determinant of outcome. Early surgery risks friable tissue and patch dehiscence, whereas delay may precipitate haemodynamic collapse and multiorgan failure. The optimal surgical timing remains controversial. Purpose To evaluate the impact of the interval from myocardial infarction to surgical repair on in-hospital mortality in patients with post-MI VSR, and to assess whether the delay from symptom onset to hospital admission influenced survival. Methods This retrospective cohort study included 59 consecutive patients diagnosed with VSR secondary to acute myocardial infarction, admitted between 2000 and 2024 to a specialised cardiology centre in Brazil. Temporal variables were collected: time from symptom onset to hospital admission, time from symptom onset to surgery, and time from admission to surgery. Statistical analyses were performed using R software (v4.2.2). Continuous and categorical variables were compared using the Mann-Whitney and chi-square tests, respectively. Variables with p ≤ 0.20 in univariate analysis were included in a stepwise logistic regression model, with statistical significance defined as p < 0.05. Results The mean time from symptom onset to admission was 26.8 ± 47.4 days, to surgery 39.1 ± 57.7 days, and from admission to surgery 11.2 ± 30.6 days. Overall in-hospital mortality was 54.4%. Non-survivors experienced longer delays from symptom onset to surgery (52.4 vs 23.3 days; p = 0.015) and from admission to surgery (p = 0.006). Conclusions In patients with VSR following acute myocardial infarction, in-hospital mortality was exceptionally high and independently associated with a longer interval from symptom onset to surgical repair. A trend towards poorer outcomes was also observed with delayed hospital admission. These findings suggest that survival hinges not only on surgical timing but on the entire timeline from symptom onset to intervention, including early recognition and stabilisation. Minimising diagnostic and logistical delays could significantly improve outcomes in this critical condition.