Timing of Repair in Postinfarction Ventricular Septal Defect

Abstract

The optimal timing of postinfarction ventricular septal defect (PI-VSD) repair is subject to debate. Patients with ventricular septal defect (VSD) and ST-elevation myocardial infarction (STEMI) were queried using appropriate International Classification of Diseases, Ninth and Tenth Revision Clinical Modification codes from the National Inpatient Sample (2003 to 2018). VSD repair was identified using appropriate International Classification of Diseases, Ninth and Tenth Revision Procedure Coding System codes. Data were stepwise stratified by cardiogenic shock (CS) and time of repair from admission to create 6 clinically relevant groups: shock 1 (CS; 0 to 7 days), shock 2 (CS; 8 to 14 days), and shock 3 (CS; >14 days). Nonshock groups were classified similarly. The primary outcome was in-hospital mortality. Multilevel hierarchical logistic regression was used to adjust for confounders for each group. We identified 10,902 patients with PI-VSD. In shock 1 (n = 5,794), VSD repair was associated with lower mortality (OR 0.76; 95% CI 0.68 to 0.86, p <0.001) compared to no VSD repair. In shock 2 (n=1,009) mortality was numerically lower in those who received VSD repair, but not statistically different. In shock 3 (n=483), mortality was numerically higher in those who received VSD repair, but not statistically different. In nonshock 1 (n=5,108), VSD repair was associated with higher mortality (odds ratio [OR] 1.59; 95% confidence interval [CI] 1.33 to 1.90; p <0.001). In nonshock 2 (n = 1,265), mortality was numerically higher in patients with VSD repair, although not statistically different. In nonshock 3 (n = 472), mortality was numerically lower in patients with VSD repair, although not statistically different. Mechanical circulatory support use increased over the 16 years (relative change + 18%, p <0.001), with no significant change in mortality among patients with PI-VSD. In conclusion, in patients with CS, early PI-VSD repair was associated with lower mortality. However, in patients without CS, early PI-VSD repair was associated with higher mortality.