Post-infarct ventricular septal defect (VSD) is a life tethering complication of acute myocardial infarction which is associated to high in-hospital mortality (90-95%). The optimal peri-operative management including timing of surgical correction is still debated. There is a large body of evidence demonstrating that surgical repair is also associated to poor post-operative outcomes due to cardiogenic shock and multiorgan failure (MOF). The use of extracorporeal membrane oxygenation (ECMO) system in adult cardiac surgery is not routine, occurring in a minority of critically ill patients, typically postoperatively. Here we present our single centre experience of patients with post-infarct VSD managed preoperatively with ECMO support as a bridge to definitive surgical closure.
Materials and methods
Between February 2020 to July 2021, 5 patients presented to our unit with diagnosis of post-infarct VSD and were managed with preoperative veno-arterial (V-A) ECMO implantation and enrolled in our study. Clinical parameters (such as mean arterial pressure, central venous pressure, ECG, pulmonary artery pressure), blood tests, trans-thoracic and trans-esophageal echocardiography, chest X-rays have been evaluated both before and after surgery. Primary end-point was all causes in-hospital mortality.
Three (60%) patients were male and mean age was 70,4 (60-78) years. All patients underwent surgical repair. ECMO was positioned between 1 and 9 days prior to surgical correction, giving the chance to reduce the pharmacological inotropic support while still reverting the MOF as demonstrated by the reduction of AST, ALT, bilirubin level, decreased CVP and systemic lactate levels. Two (40%) patients were successfully weaned off from the mechanical support and discharged home in good clinical conditions. Two (40%) patients developed MOF after surgery leading to the exitus.
We postulate that the use of V-A use preoperatively in patients with cardiogenic shock secondary to post-infarct VSD is appropriate and where feasible should be considered. It allows restoration of haemodynamic stability and resolution of MOF. This provides for a delayed surgical repair with a likely higher chance of operative success and reduced mortality.