Postinfarction ventricular septal defect.

Despite improved screening and diagnostic capabilities for the presence of coronary artery disease (CAD), with the promise of improved outcomes from earlier therapeutic interventions, postinfarction ventricular septal perforation (VSD) continues to be a very difficult therapeutic challenge. In our experience with VSD, the incidence of this complication per year has decreased, almost certainly related to earlier and more effective medical therapy in patients with CAD. By contrast, the outcomes of surgical repair have not improved, even with an aggressive strategy about bypassing involved coronary arteries. Furthermore, the earliest possible surgical approach and the incorporation of a number of technical advances, especially those relating to myocardial preservation, have not had an apparent effect. Because the number of patients who underwent operation is small, it is not possible from our single-institutional experience to define statistical significance to our continuing observations of this condition, suggesting that the clinical spectrum of postinfarction VSD is still evolving. Important changes appear to be associated with an increase in the number of female patients observed (60%), in contrast to their lesser frequency of uncomplicated coronary bypass (18%) and a change in the anatomic substrate, with posterior infarctions and rupture now accounting for 73% of cases at Cedars-Sinai. For the present, earliest possible surgical intervention to minimize the severity of multi-organ failure and use all of the advanced therapeutic modalities of cardiac support and surgical therapy that are available continues to be indicated. For the long term, continuing advances in the earlier diagnosis and more aggressive management of CAD, especially in females, may hold the best promise for a continued decrease in the occurrence of this very difficult-to-treat postinfarction complication.