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Formica et al. Vessel Plus 2019;3:37 I http://dx.doi.org/10.20517/2574-1209.2019.19 Page 5 of 10

Risk factors for VSD include advanced age, hypertension, absence of angina, extensive myocardial
infarction and single vessel disease [27,28] .

The acute rupture occurs 3-7 days after a wide transmural infarction but may occur rarely after 2 weeks [28,29] .
VSD results in a left-to-right shunt which is the main cause of low cardiac output, decreased urine output,
[30]
shortness of breath, altered mental status and finally cardiogenic shock . At physical examination, a harsh
and loud pan-systolic murmur at the left lower sternal border is present in over 90% of cases. A palpable
thrill can be detected in up to 50% of patients.

VSDs has been categorized in two other categories: simple and complex. Simple rupture is a discrete lesion,
with defect located at a similar level in both ventricles. That is typical pattern of anterior myocardial
infarction. Inferior myocardial infarction usually is associate to a complex type [31,32] .

In both cases, the defect may vary in size from some mm to more than 15 mm. The size of defect may
affect the magnitude of left-to-right shunting, and therefore influencing the clinical presentation and the
likelihood of survival. Trans-thoracic and transesophageal echocardiography with Doppler imaging is
considered a high sensitive and specific diagnostic tool for immediate diagnosis.

Medical therapy is usually managed with the use of vasodilators, which reduce afterload and decrease
left ventricular pressure and the left to right shunt, with inotropic agents, which may increase the
cardiac output, diuretics, and IABP. Use of preoperative ECMO was reported in patients with refractory
cardiogenic shock [33,34] . Some authors have reported the use of the Impella to achieve haemodynamic
stabilization with acceptable results. However, the use of Impella is limited in selected patients and only
few experiences with few patients were published so far [35-37] .

Timing of surgery is still debating. Recently, Papalexopoulou and co-workers published a review
reporting that early surgery is advocated if VSD size is more than 15 mm and an instable haemodynamic.
While delayed surgery might be performed up to 3 or 4 weeks in case of clear hemodynamic clinical
status. Emergency surgery should be performed in patients with refractory cardiogenic shock and rapid
[38]
deterioration . A review form the Society of Thoracic Surgeon National Database identifies that mortality
of patients who underwent surgery within 7 days was approaching to 54% compared to patients who
[39]
underwent surgery after 7 days. In this latter clinical scenario, mortality was 18% . Early mortality is
[34]
affected also from the VSD location. In patients with basal or inferior VSD mortality is as high as 70% .
Apical or anterior VSD are affected from a lower early mortality (30%) .
[27]
Right ventricular dysfunction is an issue to be considered in VSD. The right ventricular dysfunction
maybe consequence of right ventricular infarction and right ventricle acute overload depending on the
magnificence of the left-to-right shunt.

Multiple surgical techniques have been described [Figure 5]. Apical amputation is the simpler in patients
with apical defects. Other techniques involve infarct exclusion and defect closure with a patch (biological
or synthetic) using both stitches or glues [40,41] . Despite continuous advances in surgical approaches,
operative mortality remains high (ranging from 20% to 71.4%), with no clear differences between different
techniques [41-43] . Female gender and depressed left ventricular dysfunction at admission are linked with a
[43]
high hospital death .
Table 2 reports the in-hospital mortality rates and long-term survival percentages of studies with relatively
large number of patients.