Temporary microaxial transvalvular left ventricular assist device for post–myocardial infarction ventricular septal rupture: Bridging a paradigm shift

Objective To characterize the clinical courses and outcomes of patients presenting with post–myocardial infarction (MI) ventricular septal rupture (VSR) receiving temporary microaxial transvalvular left ventricular assist device (tVAD) support. Methods Between December 2019 and July 2023, 10 consecutive patients presented with a post-MI VSR. All 10 patients received a tVAD. Patient characteristics, hemodynamics, intraoperative details, and postoperative outcomes were reviewed. Results Eight patients underwent VSR repair (7 open, 1 percutaneous), and 2 patients died while on tVAD before being treated. Among the 7 patients who underwent open repair, 6 received preoperative tVAD support and 1 required intraoperative tVAD insertion during emergency right ventricular rupture repair. In the 6 patients receiving preoperative tVAD support, improvements from insertion to repair were observed in shunt fraction (from 2.6 [range, 2.3-3.3] to 1.8 (range, 1.5-3.3]), cardiac index (from 1.5 [range, 1.5-6.2] L·min −1 m −2 to 3.1 [range, 2.2-6.9] L·min −1 m −2 ), pulmonary capillary wedge pressure (from 25 [range, 14-35] mm Hg to 16 [range, 14-18] mm Hg), central venous pressure (from 14 [range, 7-26] mm Hg to 12 [range, 1-26] mm Hg), creatinine (from 1.5 [range, 1.1-1.8] mg/dL to 1.2 [range, 0.9-1.5] mg/dL) and lactate (from 1.3 [1-1.7] mmol/L to 0.7 [range, 0.4-1.2] mmol/L). The median time from post-MI VSR diagnosis to repair was 15 (range, 13-18) days. Surgical repair was approached via right atriotomy in 4 patients, via left ventriculotomy in 2 patients, and via right ventricular defect in 1 patient, with no residual shunts or operative mortalities. Conclusions Perioperative tVAD support for post-MI VSR acutely stabilizes hemodynamics and end-organ function, facilitating delayed intervention with reduced operative risk while also preventing futile interventions. This paradigm shift in management of post-MI VSR from emergency to urgent operations may be associated with improved outcomes.