Marius Berman
Transplant Surgeon Papworth Hospital, United Kingdom
Title: Multi-disciplinary approach to post-infarct ventricular septal defect
Biography
Biography: Marius Berman
Abstract
In an era of PPCI, mortality due to AMI has fallen substantially over the past three decades. Nevertheless, patients with post-infarction ventricular septal defect (PIVSD) carry a grim prognosis and resource demanding. The management of PIVSD is complicated, and requires substantial critical care, imaging, interventional, and surgical expertise. It is therefore advisable, when clinically feasible, to transfer these patients to regional centers with adequate individual experience in the care of these patients. Traditionally, the main stream of treatment was surgery, pending hemodynamically stability and size of left to right shunt. There is no clear evidence to guide the surgical management of patients who are in shock, as all approaches have shown extremely high mortality. Possible strategies include emergency surgery, a period of mechanical circulatory support in the form of IABP or ECMO, prior to a delayed surgical or percutaneous intervention, or emergency placement of a percutaneous closure device to reduce the shunt. Often, there is a natural selection when pathway chosen was optimized, with those surviving a healing phase proceeding to therapy. Percutaneous closure may also be a viable option for patients in the sub-acute to chronic period whose comorbidities preclude surgical repair, and whose septal anatomy is favorable to device placement. We encounter incidences of percutaneous closure post-surgical closure where the patch dehisced due to further progression of the ischemic insult. We favor the establishment of a multidisciplinary PIVSD team, including interventional cardiologist, cardiac surgeon, anesthetist and radiographer in order to tailor patient specific treatment based on presenting symptoms and co-morbidities.