AMI with VSR is a rare but dangerous complication, which often occurs in acute ST segment elevation myocardial infarction . VSR mostly occurs within 1 week after AMI. The patient has a sudden left ventricular shunt at the ventricular level, increased cardiac load, and rapid heart failure, cardiogenic shock, etc., which in turn causes severe pulmonary congestion and/or hemodynamic deterioration The effect of conservative drug treatment is extremely poor. At the same time, due to the poor texture of myocardial tissue, the difficulty of suture and the high incidence of low cardiac output after myocardial infarction, surgical operations also face great challenges. In this study, the clinical characteristics and different treatment methods of patients with AMI combined with VSR were compared, the relevant risk factors affecting the 30-day mortality of the patients were analyzed, and the long-term survival rates of the patients were compared.
Previous studies have found that the risk factors of AMI combined with VSR include: old age, female, smoking, combined history of hypertension, anterior wall or large area myocardial infarction, lack of good coronary collateral circulation, etc. [5-6]. In this study, there was no significant difference between the two groups of patients in terms of age, gender, smoking, history of hypertension, anterior myocardial infarction, and previous myocardial infarction (P>0.05).
Early diagnosis of echocardiography in AMI patients to diagnose and guide clinical treatment is of great value to the prognosis of patients. Echocardiography can be used to determine the location, size, end diastolic diameter of left ventricle, whether there is ventricular aneurysm, pulmonary artery pressure and whether there is bicuspid valve regurgitation, etc, and to preliminarily evaluate the cardiac function and prognosis of patients . In this study, echocardiography showed that most of the perforations were located near the apex of the interventricular septum, but there was no significant difference between the two groups in the location, size, ejection fraction, end diastolic diameter of the left ventricle, whether the VSR was associated with aneurysm, pulmonary artery pressure and whether the bicuspid or tricuspid valve returned (P > 0.05).
If the condition of the VSR patient allows, complete coronary angiography before surgery can determine the relevant coronary artery disease, determine whether to perform coronary artery bypass grafting during the same period and determine the corresponding target vessel site. Some studies suggest that if the stenosis degree of the main coronary artery and its branches is more than 50% and the blood supply area is non-infarcted area, coronary artery bypass grafting should be performed at the same time [8,9]. Previous literature studies have found that VSR is mostly single vessel disease, and the infarct related vessels are mostly anterior descending . We compared the coronary angiography results of the two groups of patients, and found that the proportion of patients in the survival group who underwent coronary angiography before surgery was 75% (12/16), all of which were coronary vascular lesions of 2 or more; The ratio of pulse angiography was 61.5% (8/13), including 5 cases of anterior descending branch lesions alone. The proportion of patients in the non-surviving group who had a simple anterior descending vessel was higher than that in the surviving group, and there was a statistical difference between the twogroups (P < 0.05), which is consistent with the results of previous studies, and most of the infarct-related blood vessels are completely occluded, lacking effective collateral circulation, the infarct size is large, the degree of myocardial ischemia in the patient is more serious than that in the survival group, and eventually the 30-day mortality rate of the patient is more obvious than that in the survival group Rise. Therefore, patients with VSR should actively improve coronary angiography before surgery to clarify coronary vascular lesions to decide whether to perform coronary artery bypass grafting during the same period.
Surgical operation is an effective method to reduce the hospital mortality of VSR patients, especially for the patients with complicated condition and large perforation area, and it is difficult to intervene through intervention means. Due to the high risk of ventricular septal perforation, the timing of surgery is particularly important.However, when is the best operation time for VSR has always been controversial. Previous studies have suggested that the shorter the time from diagnosis to operation, the higher the operative mortality rate. Papalexopoulou and other researchers believe that under the condition of stable hemodynamics, surgery should be delayed as much as possible ; however, current European guidelines recommend that patients with VSR should undergo surgery as soon as possible to reduce the incidence of heart failure[13,14]. In the early period of perforation, the edges of the perforation were unclear and the surrounding tissues were brittle, which increased the difficulty of surgical repair and the risk of repair failure ; and the purpose of delayed surgery was to reduce the difficulty of repair. It may cause some patients to die due to the worsening of circulatory conditions while waiting for surgery, and lose the chance of surgery. Amaoutakis et al.'s large sample study found that the mortality of surgery within 1 week of AMI combined with VSR was 54.1%, while the mortality of AMI combined with VSR for more than 1 week before surgery was only 18.4% . We compared the perioperative data of the two groups and found that the emergency operation rate of the survival group was lower than that of the non-survival group, there was a statistical difference between the two groups (P < 0.05); from the diagnosis of VSR to the operation time, the average time of the survival group was 22.38 ± 12.27 days, the average time of the non-survival group was 14.38 ± 14.61 days, although there was no significant statistical difference between the two groups (P > 0.05), however, the time from the diagnosis of the VSR to the operation in the survival group was significantly longer than that in the non-survival group, and the emergency surgery rate of the survival group was significantly lower than that of the non-survival group. The above two points further confirmed the importance of the timing of VSR surgery.
Previous studies have shown that the rapid deterioration of preoperative circulatory state is an important risk factor for poor perioperative prognosis of patients , while critical preoperative state is closely related to the time of perforation after myocardial infarction, the degree of interventricular septum involvement and perforation . In general, VSR usually occurs in the first week after AMI, with an average time of 3-5 days . This study shows that the overall average time of perforation is 5 days (2.0, 10.0). Compared with the time from AMI to VSR diagnosis in the two groups, the average time of survival group is 6 days (2.0, 13.25), while the average time of non-survival group is 2 days (1.5, 10.0), Although there was no significant statistical difference between the two groups (P>0.05), it also supported the previous point to some extent.
Previous studies have found that complete revascularization and revascularization of culprit vessels in VSR patients can reduce 30-day mortality and improve long-term prognosis [20,21,22]. Lundblad et al. also found that simultaneous bypass during operation can reduce the early and long-term mortality of VSR patients ; perotta et al. also reported that simultaneous bypass can reduce the mortality of VSR patients . In this study, we found that the proportion of patients in the survival group who underwent coronary artery bypass, complete revascularization and culprit revascularization at the same time was much higher than that in the non-survival group, and there was a significant statistical difference between the two groups (P < 0.05), which was consistent with the results reported in the previous studies, and fully reflected the importance of the simultaneous revascularization and culprit revascularization in patients with AMI and VSR during the operation. Logistic regression analysis showed that complete revascularization (or = 0.021, 95% confidence interval 0.001-0.374, P = 0.009) and recanalization of culprit vessels (or = 0.045, 95% confidence interval 0.004-0.548, P = 0.015) were independent risk factors for 30-day mortality of VSR patients. Telephone follow-up of surviving patients in the hospital was conducted between 3 months and 136 months. The KM survival curve shows that during the follow-up period, the long-term survival rate of patients after surgical operation and complete revascularization is significantly higher than that of conservative medical treatment and patients who have not undergone complete revascularization despite surgical treatment. There are obvious statistics between the two groups of patients Academic differences (P <0.05).The results of this study further confirm the previous research. The reason may be that complete revascularization and revascularization of culprit vessels can effectively improve the blood supply of myocardial tissue, thus reducing the 30-day mortality rate of VSR patients and improving the long-term prognosis, but there is no retrospective study to confirm the direct causal relationship between them. If we want to confirm this, we need to conduct a large-scale prospective control trial, and the patients in the control group must deliberately ignore the same period of coronary artery bypass grafting, it is obvious that this prospective control trial is never possible . From the K-M survival curve, it can be seen that the long-term prognosis of VSR patients treated by surgery and complete revascularization is better than that of patients treated by drug conservative therapy and surgery but not complete revascularization (P < 0.05). It is also confirmed once again that drug treatment can only be used as a transitional treatment for the VSR patients, but not as an independent treatment. Surgical surgery is still the preferred treatment option for patients with AMI and VSR.
In summary, our study found that whether complete revascularization and revascularization of criminals are independent risk factors that affect the 30-day mortality rate in patients with AMI and VSR; surgery and complete revascularization can significantly improve the hospital survival rate and the long-term prognosis of the VSR patients. Since this study is a single-center retrospective study, it is inevitable that there is a certain bias, and the sample size is small, and the statistical power will also be affected to a certain extent. In the future, a larger sample size and longer follow-up time for multiple centers will be needed to further validate our findings.