Surgical, percutaneous options for postinfarction VSD boost survival vs. medical therapy
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BOSTON — In patients with postinfarction ventricular septal defects, percutaneous and surgical treatments reduced mortality rates compared with historical medical therapy data, researchers reported at TCT 2022.
The percutaneous and surgical strategies for postinfarction ventricular septal defects (VSD) did not differ significantly from each other in all-cause mortality at 5 years, but the rate of in-hospital mortality was higher with the percutaneous approach, Joel Giblett, MD, consultant interventional cardiologist at Liverpool Heart and Chest Hospital, Liverpool, U.K., said during a press conference.
“Postinfarct VSD is a relatively rare complication of acute myocardial infarction that occurs in about 1 in 500 cases,” Giblett said at the press conference. “Essentially it’s a tear between the right and left ventricles which provides a double-insult large-territory infarct combined with exposure of the right ventricle to systemic pressures.”
In patients with postinfarction VSD treated with medical therapy, the 1-month mortality rate is more than 94%, Giblett said.
He said that mortality rates after surgery for postinfarction VSD are high, but not as high as those associated with medical therapy, and that until now little was known about outcomes after percutaneous treatment for postinfarction VSD.
In a retrospective observational study, Giblett and colleagues analyzed 362 patients with postinfarction VSD from the U.K. National Registry who were treated with an initial surgical repair strategy (n = 230) or an initial percutaneous repair strategy (n = 131) between 2010 and 2021.
The primary outcome of all-cause mortality at 5 years did not significantly differ between the groups (log-rank P = .059), and both groups had much lower mortality rates compared with historical data from patients treated with medical therapy, Giblett said at the press conference.
The percutaneous group had a higher in-hospital mortality rate than the surgical group (55% vs. 44.2%; P = .048), but that result could have been influenced by selection bias, he said.
“Many of the percutaneous patients in this analysis were unable to have surgical repair,” Giblett said at the press conference. “They would have been turned down for it.”
Stroke (P = .021), repeat interventions (P < .011), new pacemaker/implantable cardioverter defibrillator (P = .023) and pneumonia (P < .001) all occurred more frequently in the surgical group than in the percutaneous group, he said.
In a landmark analysis from after hospital discharge to 5 years, mortality rates were similar between the groups (log-rank P = .646), he said.
In a multivariate analysis, percutaneous treatment was associated with 5-year mortality (adjusted HR = 1.44; 95% CI, 1.01-2.05; P = .042), as were shorter time between acute MI and VSD repair, creatinine level, multivessel CAD and cardiogenic shock, Giblett said at the press conference, noting that right ventricular dysfunction, traditionally a metric used to identify patients with postinfarction VSD who should not be treated invasively, was not independently associated with mortality.
“Deferring treatment appears to reduce mortality,” he said.
The registry is more than double the size of any previous series in this population, and now “we really need to move to prospective studies,” Giblett said at the press conference.
He said that in the final year of the study period, there were fewer patients treated surgically or percutaneously due to the impact of the COVID-19 pandemic. “I’m not clear as to whether that was because there were fewer presenting or whether that was because [hospitals] during the pandemic weren’t prepared to take these patients to the cath lab,” he said.
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Giblett J, et al. Late-Breaking Science in Structural Heart Disease: Session II, in Collaboration With The European Heart Journal/Eurointervention. Presented at: TCT Scientific Symposium; Sept. 16-19, 2022; Boston (hybrid meeting).
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