849 Factors determining left ventricular remodeling in patients with acute myocardial infarction after primary PCI

Objective: Rupture of the left ventricle wall (VSD) in patients with acute myo- cardial infarction (MI) is severe and often life threatening complication. The aim of the study was to assess the risk of early surgical treatment in this group of patients, outcome and long term prognosis using echocardiography and clinical data. Material and methods: Clinical and echocardiographic parameters were analyzed in 14/17 patients operated due to VSD which was confirmed by echocardiography and angiography before the operation (11 men, 3 women, mean age 63.2±7.9). The following clinical parameters were analyzed: NYHA class, heart rate (HR), blood pressure (BP), cardiac rhythm, ECG. The fol- lowing echocardiographic parameters were measured: left atrium diameter (LA), end-diastolic (EDD), and end-systolic (ESD), left ventricle diameter, ejection fraction (EF), severity of mitral (MR) and tricuspid (TR) regurgitation. The pressure gradient on the site of VSD and systolic pressure of the right ventricle (RVSP) were also measured. Results: All patients were in NYHA III class, in sinus rhythm with average heart rate 86±18/min. LA and LV diameters were normal and average EF assessed by Simpson was decreased (32.9±7.5%). In 6 patients with infe- rior MI, VSD was located in the basal segment of the inferior LV wall, in 4 patients with anteroseptal MI at the site of interventricular septum and in 4 patients at the posterior wall of the LV. All patients had significant left-to- right shunt whereas in 2 patients small right-to-left shunt also existed. Pres- sure gradient at the site of VSD was 75.25±27 mm Hg. All patients had mild MR and TR. RVSP was moderately increased (48.8±22.1 mm Hg). Dacron patch was placed on the VSD site in the majority of patients (12/14) with additional coronary artery by-pass grafting in 7 patients. In two patients di- rect suture was done. Haemodinamically insignificant residual shunt was detected immediately after operation in only two patients. One patient died immediately after operation and one 42 months after the operation. Conclusion: Patients with VSD after acute MI could be successfully surgi- cally treated with good early as well as long term prognosis. Although these are high risk patients, in our study group surgical intervention was found to be justified and efficient treatment with good results. Echocardiography as non-invasive technique is a method of choice for early assessment for pre- cise localization of the ruptured site and haemodinamic parameters as well as for early and late postoperative follow up.