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CLINICAL STUDY

Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry

Venu Menon, MD, FACC^*, John G. Webb, MD, FACC, L. David Hillis, MD, FACC, Lynn A. Sleeper, ScD, Rasha Abboud, MS, Vladimir Dzavik, MD^||, James N. Slater, MD, FACC^*, Robert Forman, MD, FACC^¶, E. Scott Monrad, MD^¶, J. David Talley, MD, FACC, Judith S. Hochman, MD, FACC^* for the SHOCK Investigators

^* Division of Cardiology, St. Luke’s–Roosevelt Hospital Center, Columbia University, New York, New York, USA
Division of Cardiology, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada
Division of Cardiology, University of Texas–Southwestern Medical Center, Dallas, Texas, USA
New England Research Institutes, Watertown, Massachusetts, USA
^|| Division of Cardiology, University of Alberta Hospital, Edmonton, Canada
^¶ Division of Cardiology, Weiler Hospital and Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

Manuscript received February 16, 2000; revised manuscript received May 31, 2000, accepted June 7, 2000.

Reprint requests and correspondence: Dr. Venu Menon, St. Luke’s–Roosevelt Hospital Center, 1111 Amsterdam Ave., New York, New York 10025
VMenon{at}aol.com

OBJECTIVES

We wished to assess the profile and outcomes of patients with ventricular septal rupture (VSR) in the setting of cardiogenic shock (CS) complicating acute myocardial infarction (MI).

BACKGROUND

Cardiogenic shock is often seen with VSR complicating acute MI. Despite surgical therapy, mortality in such patients is high.

METHODS

We analyzed 939 patients enrolled in the SHOCK Trial Registry of CS in acute infarction, comparing 55 patients whose shock was associated with VSR with 884 patients who had predominant left ventricular failure.

RESULTS

Rupture occurred a median 16 h after infarction. Patients with VSR tended to be older (p = 0.053), were more often female (p = 0.002) and less often had previous infarction (p < 0.001), diabetes mellitus (p = 0.015) or smoking history (p = 0.033). They also underwent right-heart catheterization, intra-aortic balloon pumping and bypass surgery significantly more often. Although patients with rupture had less severe coronary disease, their in-hospital mortality was higher (87% vs. 61%, p < 0.001). Surgical repair was performed in 31 patients with rupture (21 had concomitant bypass surgery); 6 (19%) survived. Of the 24 patients managed medically, only 1 survived.

CONCLUSIONS

There is a high in-hospital mortality rate when CS develops as a result of VSR. Ventricular septal rupture may occur early after infarction, and women and the elderly may be more susceptible. Although the prognosis is poor, surgery remains the best therapeutic option in this setting.

Abbreviations and Acronyms   BP = blood pressure   CAD = coronary artery disease   CK = creatine kinase   CS = cardiogenic shock   ECG = electrocardiogram, electrocardiographic   IABP = intra-aortic balloon pump   LV = left ventricular, left ventricle   MI = myocardial infarction   MR = mitral regurgitation   RV = right ventricular, right ventricle   SHOCK = SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?   TIMI = Thrombolysis In Myocardial Infarction   VSR = ventricular septal rupture

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