Precision in cardiology: should all cases of myocardial infarction with ventricular septal rupture require early repair?

Though the incidence of ventricular septal rupture (VSR) after myocardial infarction (MI) has reduced from 3%1 to 0.2%2 due to improvements in cardiac pharmacotherapy and intervention, the mortality rate still exceeds 87%1 in medically managed patients. The median time period between MI onset to VSR detection was 16–24 h 2 It has been described to occur in a bimodal pattern—within 24 h and between 3 and 5 days after MI.3 It is considered a surgical emergency as it causes cardiogenic shock and worsens the haemodynamics and rapidly culminates in death. The mortality rate in surgically treated patients varies between 20% and 60%.4 ,5This heterogeneity is attributable to timing of surgery for VSR, cardiogenic shock and recurrence of VSR. Independent predictors of mortality include posterior VSR, cardiogenic shock, inferior MI and renal failure. Because of the dismal prognosis associated with VSR, American College of Cardiology and American Heart Association recommends immediate surgical repair. But various studies illustrate the improved mortality rate when the surgery was done after haemodynamic stabilisation.5 ,6 In a largest study, the operative mortality rate was 54% when the surgery was done within 7 days and it reduced to 18% when the surgery was done after 7 days.5 The mortality was quite high when the surgery was done in an emergency basis, especially within 6 h of MI.5 Thiele et al 6 described a higher mortality rate of 83% with early surgical repair of post-MI VSR and a lower mortality rate of 29% with delayed repair after initial medical stabilisation and haemodynamic support. The mortality seen with the use of intra-aortic balloon pump (IABP) was 56.5% in that study. Papalexopoulou et al 7 described the operative mortality in early repair group to be around 31–75% and in the late repair group to be …