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\begin{document}

\title{Insight into surgical outcomes of post infarct-ventricular septal defect
repair through a 23-years retrospective study-invited commentary}



\author[1]{Doniparthi Pradeep}%
\affil[1]{All India Institute of Medical Sciences}%


\vspace{-1em}



  
  \date{May 24, 2024}


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\selectlanguage{english}
\begin{abstract}
The authors present an excellent retrograde analysis of a rare condition
of a phenomenal number of cases and their surgical outcomes. A majority
of the studies in published literature are anecdotal case reports which
are a rare and dreadful entity. A comprehensive countrywide view of the
UK National Adult Cardiac Surgery Audit database is presented in this
study. This study represents the changing trends in the risk factors,
management strategies, and outcomes of ventricular septal rupture for
over 23 years in a nutshell.%
\end{abstract}%



\sloppy


\textbf{Insight into surgical outcomes of post infarct-ventricular
septal defect repair through a 23-years retrospective study-invited
commentary}

\textbf{Running Title:} Ventricular septal rupture in a nutshell

\textbf{Doniparthi Pradeep, MS\textsuperscript{1}}

Department of Cardiothoracic and Vascular Surgery

All India Institute of Medical Sciences, New Delhi\textsuperscript{1}

\emph{Correspondence:}

\textbf{Dr.Doniparthi Pradeep, MS}

Senior Resident

Department of Cardiothoracic and Vascular Surgery

AIIMS, New Delhi-110029, INDIA

Ph: +91-9501626593

Email:pradeepdhoni023.pd@gmail.com

Orcid ID: \emph{https://orcid.org/0000-0002-3693-7271}

\textbf{Insight into surgical outcomes of post infarct-ventricular
septal defect repair through a 23-years retrospective study-invited
commentary}

\textbf{Abstract:}

The authors present an excellent retrograde analysis of a rare condition
of a phenomenal number of cases and their surgical outcomes. A majority
of the studies in published literature are anecdotal case reports which
are a rare and dreadful entity. A comprehensive countrywide view of the
UK National Adult Cardiac Surgery Audit database is presented in this
study. This study represents the changing trends in the risk factors,
management strategies, and outcomes of ventricular septal rupture for
over 23 years in a nutshell.

\textbf{Commentary:}

This paper holds a rather exclusive position in the domain of cardiac
surgery; representing a rare, lethal, and mortal condition in a large
number, 1010 cases, and spanning over 23 years, representing a single
population. Ventricular septal rupture (VSR) is known to cause extensive
damage to the myocardium with shunting across the ventricular chambers
rendering volume overload. In the EuroScore II, risk assessment scale
for cardiac surgery, VSR holds the maximum score on the scale (1).

Although excellent early reperfusion strategies for the myocardium
following myocardial infarction (MI), have decreased the occurrence of
VSR, the overall surgical mortality due to VSR reported in this paper is
38.9\%. Ventricular septal rupture is seen in the first week following
MI. Myocardium differs from the rest of the tissues owing to the
potential ''limited blood supply to the damaged myocardium for healing
due to narrowing of coronary arteries and the myocardium, which must
continue to function during the process of repair, whereas other tissues
can be immobilized''. Most of the patients are elderly with hypertension
leading to increased afterload to the left ventricle (LV), furthermore
leading to stress at the junction of the healthy and infracted tissues,
which allows the paradoxical systolic movement leading to the rupture of
the necrosed myocardium(2).

In the study, the data collected by the authors, indicate that early
surgery in cases with VSR leads to mortality(1 to 30 days Vs
\textgreater{}30 days: Odds ratio of 0.35 Vs 0.25) owing to technical
difficulties, more fragile tissues, which leads to the suture to cut
through the necrosed myocardium, should be operated as late as possible
if hemodynamics permit.

The authors also highlight the importance of concomitant coronary artery
bypass grafting (CABG)(p=0.544) and Mitral Valve Repair (p=0.524)
alongside VSR repair, adding that no additional risk was being imparted
and it could prove to be beneficial to revascularize the weak myocardium
in long run.

The study also mentions the role of percutaneous closure to bail out the
crisis, pros \& cons, indications, success rate (90\%), and mortality.

In 1957, Denton Cooley first succeeded in surgical repair of VSR but
unfortunately, the patient died 6 weeks later. The first successful
long-term survivor was operated by Spencer Payne in 1960 by opening the
right ventricular outflow tract (RVOT). The patient was asymptomatic 2 \selectlanguage{ngerman}½
yrs after surgery when followed up regularly (3). Early surgical repair
of VSR following MI has drawbacks of its own, for example, suture cut
through necrosed tissue. Via different approaches also, either through
RV or LV, via direct suture closure, prosthetic closure, or percutaneous
closure, outcomes are not satisfactory. Despite understanding the
pathophysiology, early diagnosis, and revascularization, advances of
cardiopulmonary bypass techniques and mechanical circulatory support
like Intra Aortic Balloon Pump (IABP), ventricular assist devices,
outcomes are dismal owing to the loss of functional myocardial reserve.
A tailor can design the garment in the desired fashion, but can't change
the quality of cloth, the same analogy is applied to the surgeon as
well, till the quality of the myocardium is good.

\textbf{Conclusion:}

In summary, reading this paper gives provides an insight into the
gravity of the scenario, possible interventions, and evident outcomes.
The bottom line and what we most need is ''functional myocardial
reserve''

\textbf{References:}

\begin{enumerate}
\tightlist
\item
  Nashef SA, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR,
  Lockowandt U. EuroSCORE II. Eur J Cardiothorac Surg. 2012
  Apr;41(4):734-44; discussion 744-5. doi: 10.1093/ejcts/ezs043. Epub
  2012 Feb 29. PMID: 22378855.
\item
  Mallory GK, White PD, J. Salcedo-Salgar, The speed of healing of
  myocardial infarction: a study of the pathologic anatomy in
  seventy-two cases, Am. Heart J. 18 (6) (1939) 647--67
\item
  Payne WS, Hunt JC, Kirklin JW. Surgical Repair of Ventricular Septal
  Defect Due to Myocardial Infarction: Report of a Case. JAMA.
  1963;183(7):603--605. doi:10.1001/jama.1963.63700070040020d
\end{enumerate}

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