Optimal management of acute ventricular septal rupture

Each year in the UK since 1988, an average of 165 patients have undergone surgical repair of interventricular septal rupture complicating myocardial infarction (cardiac surgical registry of the Society of Cardiothoracic Surgeons of Great Britain and Ireland). From each surgeon’s viewpoint this operation is a rare event. Given that there are now some 200 or so consultant cardiac surgeons in the UK, the current workload averages out at less than one case per surgeon per year. The overall hospital mortality of patients undergoing surgical repair in the UK in the same time period was 38%. So that it is not only a rare operation but it is also difficult to end up with a survivor. The national figures suggest that hospital mortality has increased with time (fig 1). In addition, in the last five years for which data are available, the number of patients undergoing repair has decreased. These two statistics are almost certainly associated with the increasing use of thrombolytic agents in the management of patients with acute myocardial infarction. Figure 1 Incidence and mortality of surgical closure of ventricular septal rupture in the UK (1988–1999). So ventricular septal rupture is a rare surgical intervention with a high complication rate. On the other hand, it is a condition that when untreated has such a high mortality1 that each survivor is something to treasure. This article will attempt to describe best practice and the evidence on which such practice is based. Acute ventricular septal rupture only rarely comes to the attention of each surgeon, but it is a relatively common condition. Before the introduction of thrombolysis it complicated 1–2% of all myocardial infarctions. The incidence has declined to about 0.2% in the thrombolysis era. At this rate, of the 270 000 myocardial infarctions suffered in the UK in 2002, approximately 550 …