The first head-to-head comparison of surgical vs. transcatheter repair of a post-infarct ventricular septal rupture found no significant difference in 5-year cumulative all-cause mortality.
The U.K. national registry study results for the rare but life-threatening acute myocardial infarction (AMI) complication were presented Saturday by Liverpool Heart and Chest Hospital's Joel Giblett, MD, at the Transcatheter Cardiovascular Therapeutics (TCT) 2022 conference in Boston.
Post-infarction ventricular septal defect (PIVSD) – a tear between the left and right ventricles, exposing the right ventricle to systemic pressures – has a >94% mortality rate with medical therapy at 1 month.
According to the U.K. National Health Service (NHS) record for the study, mortality rates remain high, at 30% to 60%, even after surgical repair.
Percutaneous repair is an alternative treatment option, though the evidence is confined to small studies, Giblett noted, with the largest case series published in just 53 patients.
The current study, therefore, set out to gather demographic, procedural and outcomes data for patients undergoing surgical or transcatheter repair of PIVSD in the U.K. using existing NHS records, comparing hospital mortality and long-term survival.
The 5-year results cover 68.5% of the 362 patients treated in 16 clinical sites (230 with an initial surgical repair strategy and 131 with an initial percutaneous repair strategy) between January 2010 and December 2021, with a total of 412 procedures.
There was no significant difference in cumulative overall mortality rates between initial percutaneous and initial surgical strategies at 5 years (log-rank [Mantel-Cox]: P = 0.059).
Although there was also no statistically significant difference in in-hospital mortality, there was an increase seen in the percutaneous group (55% for percutaneous vs. 44.2% for surgical: P = 0.048), Giblett said. “That was despite more strokes, more pneumonia, [and] more pacemakers needed in the surgical group,” he said.
However, he highlighted “strong caveats” to in-hospital mortality data in terms of selection criteria, noting that: “Some patients were only offered percutaneous treatment once surgical repair [was] deemed unfeasible."
A Cox regression analysis for association with 5-year all-cause mortality resulted in an adjusted hazard ratio (HR) of 1.44 for percutaneous management (95% confidence interval [CI}: 1.01-2.05; P = 0.042). This comes with the "same caveats," Giblett stressed.
Cardiogenic shock was the strongest predictor of mortality in this multivariate analysis (adjusted HR: 1.97; 95% CI: 1.37-2.84; P < 0.001), he noted.
Giblett added that it is "worth noting" that right ventricular dysfunction – "which is often, at least in my experience and experience of the investigators, used as a criterion to avoid treatment of these patients" – was not predictive of mortality (adjusted HR: 0.88; 95% CI: 0.60 – 1.29; P = 0.522).
"Both percutaneous and surgical management are complementary in real-world clinical practice and offer significant survival advantage compared to historical data on medical therapy," Giblett said in his presentation, calling for prospective studies to evaluate the optimal method and timing of treatment.
Image Credit: Jason Wermers/CRTonline.org