Percutaneous or surgical management of post-infarction ventricular septal defects: The United Kingdom National Registry
Reported from TCT 2022
Elad Asher provides his take on the UK National Registry which was presented at the TCT congress 2022 by Joel Peter Giblett on behalf of the UK PIVSD investigators.
Rationale
Post infarction ventricular septal defect (VSD) is a rare but life-threatening complication of acute myocardial infarction. Mortality with medical therapy alone is as high as 94% at one month. Nevertheless, mortality following surgical repair remains high.
Evidence of percutaneous treatment of post-infarct VSD is confined to small case series. Hence, the UK -Post infarction ventricular septal defect (PIVSD) registry sought to investigate current practice in the UK and characterize patients treated with either percutaneous or surgical techniques.
Design
- Retrospective observational registry, with detailed case note review in each UK centre.
- The study included 362 patients in 16 centres between Jan 2010 - Dec 2021 with a total of 412 procedures.
- It was Stratified by initial management strategy (ITT) with an initial surgical repair strategy of 231 patients and initial percutaneous strategy of 131 patients.
- Primary objective: To evaluate 5-year all-cause mortality in both surgical repair and percutaneous closure.
- Secondary objective: To evaluate survival to hospital discharge, analyze contemporary trends in treatment of post-infarct VSD, and assess predictors of survival.
Endpoints
Primary outcomes: There was no significant difference in the primary outcome regarding the 5-year cumulative all-cause mortality.
Secondary outcomes: The in-hospital mortality was lower in the initial surgical group as compared with the initial percutaneous group (44.2% vs. 55%, respectively, p=0.048).
Moreover, stroke and new pacemaker/ICD implantation rates were higher in the initial surgical group, while repeat intervention (especially surgical closure) were higher in the initial percutaneous group (21.4% vs. 9.1, respectively, p<0.001).
A cox regression analysis for association with all-cause 5-year mortality found that: Percutaneous management (vs. surgical) (HR=1.31); time from AMI to VSD repair per-day (HR=0.97); creatinine per 10-unit increase (HR=1.03); number of vessels with CAD (HR=1.14) and most importantly cardiogenic shock (HR=2.25) to be associated with mortality.
The authors concluded that there was no significant difference in the primary outcome at 5 years. There was an increase in in-hospital mortality in the percutaneous group compared to surgical repair but with strong caveats regarding selection bias.
Cardiogenic shock was the strongest predictor of mortality in the multivariate analysis and percutaneous treatment also predicted mortality in this analysis with the same caveats.
In summary
- This was the largest registry of percutaneous post-infarction VSD and the first to offer comparison with surgical cases.
- A significant selection bias remains where some patients were only offered percutaneous treatment once surgical repair was deemed unfeasible, moreover, the timing of intervention remains uncertain.
- Both percutaneous and surgical management are complementary in real-world clinical practice and offer significant survival advantages compared to medical therapy.
- Prospective studies are needed to evaluate optimal method and timing of treatment, and guide clinical practice.
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