Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction

Background-Ventricular septal defect (VSD) complicating acute myocardial in farction has been studied primarily in small, prethrombolytic-era trials. O ur goal was to determine clinical predictors and angiographic and clinical outcomes of this complication in the thrombolytic era. Methods and Results-We compared enrollment characteristics, angiographic pa tterns, and outcomes (30-day and 1-year mortality) of patients enrolled in the Global Utilization of Streptokinase and TPA for Occluded Coronary Arter ies (GUSTO-I) trial with and without a confirmed diagnosis of VSD. Univaria ble and multivariable analyses were used to assess relations between enroll ment factors and the development of VSD. In all, 84 of the 41 021 patients (0.2%) developed VSD, a smaller percentage than reported in the prethrombol ytic era. The median time from symptom onset to VSD diagnosis was 1 day. En rollment factors most associated with this complication were advanced age, anterior infarction, female sex, and no previous smoking. The infarct arter y was more often the left anterior descending and more likely to be totally occluded in patients who developed VSD. Mortality at 30 days was higher in patients with VSDs than in those without this complication (73.8% versus 6 .8%, P<0.001). Patients with VSDs selected for surgical repair (n=34) had b etter outcomes than patients treated medically (n=35; 30-day mortality, 47% versus 94%). Conclusions-Compared with historical control subjects, patients who undergo thrombolysis within 6 hours of infarction onset may have a reduced risk of later VSD. If patients develop this mechanical complication, however, it t ypically occurs sooner than described in the prethrombolytic era. Despite i mprovements in medical therapy and percutaneous and surgical techniques, mo rtality with this complication remains extremely high.