The Role of VA-ECMO and Heart Transplantation in the Management of Ischemic Ventricular Septal Rupture

Ventricular septal rupture (VSR) is a rare and often fatal complication of myocardial infarction when managed conservatively. Management strategies for ischemic VSR have evolved in recent years. This retrospective study includes patients with ischemic VSR admitted between July 2014 and October 2023 at the Quebec Heart and Lung Institute. Primary outcomes were 30-day and three-year all-cause mortality. Among the 31 patients included (66 ± 11 years; 61% men), 19 had antero-apical and 12 had posterior VSR. Twenty patients developed cardiogenic shock before surgery, including nine who required veno-arterial extracorporeal membrane oxygenation (VA-ECMO). These patients more frequently had severe right ventricular dysfunction (p < 0.001) and posterior VSR (p = 0.041). Two patients died before surgery, 23 underwent VSR repair, and six underwent heart transplantation. Compared with patients undergoing VSR repair, transplant recipients more frequently had severe right ventricular dysfunction (p < 0.001) and posterior VSR (p = 0.012). Four of six transplant recipients were still alive at one year. Survivors had a longer median interval between myocardial infarction and surgery than non-survivors (10 vs. 4 days, p = 0.009). Thirty-day all-cause mortality was 35.5% and the three-year all-cause mortality was 45.2%. This study supports VA-ECMO and heart transplantation as potential options in highly selected patients with post-infarction VSR.