Invest Clin 65(1): 70 - 82, 2024 https://doi.org/10.54817/IC.v65n1a07

Corresponding Author: Yiming Ni, Department of Cardiac Vascular Surgery, The First Affiliated Hospital of Medical

College of Zhejiang University, Shangcheng District, Hangzhou, ZhejiangChina.. Email: 1183020@zju.edu.cn

Comparison of clinical efficacy and

prognosis between interventional occlusion

and surgical treatment for acute myocardial

infarction with ventricular septal

perforation.

Chenyao Ni, Peng Hu and Yiming Ni

Department of Cardiac Vascular Surgery, The First Affiliated Hospital of Medical College

of Zhejiang University, Hangzhou, China.

Keywords: acute myocardial infarction; interventricular septal perforation; interventional

occlusion; Killip class; EuroScore II; NYHA class; 6-minute walk test.

Abstract. This retrospective study compared the clinical outcomes and

prognostic factors in acute myocardial infarction-related patients with inter-

ventricular septal perforation (AMI-VSP) who underwent interventional occlu-

sion (IO group) or surgical intervention (SI group). Forty-six patients were ana-

lyzed based on comprehensive clinical data, laboratory results, and follow-up

evaluations. The SI group had higher EuroScore II scores and more patients in

Killip class IV. Both treatments showed improved laboratory indices, but the IO

group had higher left ventricular ejection fraction and lower levels of specific

biomarkers. The postoperative hospital stay and total hospitalization time were

shorter in the IO group. Survival rates did not significantly differ between the

two groups during the follow-up period. Logistic regression analysis identified

a history of coronary heart disease as a significant risk factor affecting progno-

sis and survival rates. Both interventional occlusion and surgical intervention

proved effective, with IO showing faster recovery and more favorable prognoses,

while surgery was preferred for severe cases. Coronary heart disease was a key

factor influencing postoperative survival in AMI-VSP patients.

Acute myocardial infarction with ventricular septal perforation: intervention vs. surgery 71

Vol. 65(1): 70 - 82, 2024

Comparación de la eficacia clínica y el pronóstico entre

la oclusión intervencionista y el tratamiento quirúrgico

en el infarto agudo de miocardio con perforación del septo

ventricular.

Invest Clin 2024; 65 (1): 70 – 82

Palabras clave: infarto agudo de miocardio; perforación del septo interventricular;

oclusión intervencionista; clasificación de Killip; EuroScore II; clase

NYHA; prueba de marcha de 6 minutos.

Resumen. Este estudio retrospectivo comparó los resultados clínicos y

los factores pronósticos en pacientes con infarto agudo de miocardio con per-

foración del septo interventricular (AMI-VSP) que se sometieron a oclusión in-

tervencionista (grupo OI) o intervención quirúrgica (grupo IQ). Se analizaron

cuarenta y seis pacientes en función de datos clínicos completos, resultados de

laboratorio y evaluaciones de seguimiento. El grupo IQ tenía puntajes más altos

de EuroScore II y más pacientes en la clase IV de Killip. Ambos tratamientos

mostraron mejoras en los índices de laboratorio, pero el grupo OI tenía una

fracción de eyección ventricular izquierda más alta y niveles más bajos de cier-

tos biomarcadores. La estancia hospitalaria posoperatoria y el tiempo total de

hospitalización fueron más cortos en el grupo OI. Las tasas de supervivencia

no diferían significativamente entre los dos grupos durante el período de segui-

miento. El análisis de regresión logística identificó la historia de enfermedad

coronaria como un factor de riesgo significativo que afecta el pronóstico y las

tasas de supervivencia. Tanto la oclusión intervencionista como la intervención

quirúrgica resultaron efectivas, con la oclusión intervencionista mostrando una

recuperación más rápida y pronósticos más favorables, mientras que la cirugía

se prefería para casos graves. La enfermedad coronaria fue un factor clave que

influyó en la supervivencia posoperatoria en pacientes con AMI-VSP.

Received: 06-08-2023 Accepted: 07-11-2023

INTRODUCTION

Acute myocardial infarction (AMI) is

characterized by severe ischemic necrosis re-

sulting from coronary artery occlusion, lead-

ing to high clinical morbidity and mortality

rates. Complications such as interventricu-

lar septal perforation (VSP), papillary mus-

cle rupture, cardiogenic shock, and free wall

rupture are all frequently observed in AMI

patients 1,2. Among these complications, VSP

is a rare and lethal complication of AMI that

is mainly represented by cardiogenic shock

or acute heart failure 3,4. Available data indi-

cate that the clinical incidence of this condi-

tion is approximately 0.17% to 0.31% among

AMI patients, with a meagre one-month sur-

vival rate of only 6% under drug treatment

alone 5,6. Surgical intervention currently rep-

resents an effective approach for managing

VSP following AMI. Compared to pharmaco-

therapy, timely surgical intervention can sig-

nificantly enhance surgical success rates and

improve patient survival rates 7. In recent

72 Ni et al.

Investigación Clínica 65(1): 2024

years, interventional techniques have rap-

idly advanced, and interventional occlusion

has emerged as a viable treatment method

for VSP patients, boasting advantages such

as reduced trauma, shorter procedure dura-

tion, and rapid postoperative recovery. For

patients with suitable anatomical charac-

teristics, including the appropriate size and

shape of the VSP, interventional occlusion

may serve as a potential alternative to sur-

gical intervention 8. However, it should be

noted that interventional occlusion is fre-

quently associated with residual shunting

in postoperative patients, as the underlying

myocardial infarction causes necrosis of car-

diomyocytes, leading to the thinning of the

infarcted myocardium and interstitial fibro-

sis 9,10.

Consequently, even with successful clo-

sure, residual shunting may persist due to

cardiac alterations. Residual shunting is a

critical factor impacting cardiac function

and postoperative recovery 11. In order to

comprehensively evaluate the clinical utility

of interventional occlusion, a retrospective

analysis was conducted on 46 AMI-VSP-relat-

ed patients at The First Affiliated Hospital

of Medical College of Zhejiang University,

aiming to assess the therapeutic effects and

prognosis of interventional occlusion and

surgical intervention, and providing valu-

able insights to enhance the clinical survival

rates of AMI-VSP related patients.

MATERIALS AND METHODS

Study design and patients

In this retrospective study, a total of 55

patients diagnosed with AMI complicated by

VSP treated at The First Affiliated Hospital

of Medical College of Zhejiang University

from January 2015 to December 2021 were

included. The subjects in this study met the

following criteria. (1) Patients were older

than 18 years old. (2) Patients with AMI di-

agnosed by ECG, coronary angiography and

transthoracic echocardiography (TTE). (3)

TTE confirmed the existence of interventric-

ular septal echo continuity with shunt from

left to right. (4) Left ventriculography indi-

cated that the contrast medium flows from

the left ventricle to the right ventricle. Pa-

tients with a history of congenital heart dis-

ease or old myocardial infarction with VSP

were excluded.

Clinical data collection procedure

The clinical data of the patients were

obtained from the hospital’s medical record

system following standardized protocols.

Trained professionals conducted follow-up

assessments via telephone. The collected

clinical data encompassed various aspects,

including patient demographics such as age

and gender, as well as the presence of co-

morbidities (hypertension, diabetes, hyper-

lipidemia, coronary heart disease, ventricu-

lar aneurysm, and renal disease). The data of

the examination results of the patients after

admission, the time from AMI to VSP, the to-

tal hospitalization time and the postopera-

tive hospital stay were also collected.

Examination results mainly included

infarction location (anterior/extensive ante-

rior or others), culprit lesion (left anterior

descending artery (LAD), left circumflex

artery (LCX), right coronary artery (RCA),

diameter of VSR, pulmonary circulation /

systemic circulation (Qp/Qs), EuroScore II

score and Killip classification. Additionally,

preoperative and postoperative laboratory

examination results were recorded, encom-

passing parameters such as left ventricular

ejection fraction (LVEF), left ventricular

end-diastolic diameter (LVEDD), cardiac

troponin I (cTNI), creatine kinase-MB (CK-

MB), N-terminal pro-brain natriuretic pep-

tide (NT-proBNP), low-density lipoprotein

(LDL), high-density lipoprotein (HDL), as-

partate aminotransferase (AST), and alanine

aminotransferase (ALT). Before discharge,

one patient died of operation failure in the

IO group, and two patients died in the SI

group, so the data from postoperative labo-

ratory examination were not included in the

statistics.

Acute myocardial infarction with ventricular septal perforation: intervention vs. surgery 73

Vol. 65(1): 70 - 82, 2024

During the follow-up period, adverse

events (death and residual shunting) were

documented. Additional data collected

during follow-up included LVEF, LVEDD,

New York Heart Association (NYHA) class,

6-minute walk test results, and specific time

points for the initial and final follow-up as-

sessments.

Statistical analysis

The data in this study were analyzed us-

ing IBM Statistic Package for Social Science

(SPSS)® 26.0 statistical software (IBM, Ar-

monk, NY, USA). Continuous variables were

described using mean ± standard deviation

(x±SD), and the differences between groups

were compared by t-tests. The continuous

variables that were not normally distributed

are expressed in the form of medians and

quartiles, and the differences between groups

were analyzed by the Mann-Whithey U-tests.

The classified variables were described in the

form of frequency (percentage) [n (%)], and

the differences between groups were com-

pared by analysis of variance or Fisher exact

tests. The survival rate of patients during the

follow-up period was analyzed using the Ka-

plan-Meier survival curve, generated using

the https://hiplot.com.cn website, and the

log-rank tests were used to assess the differ-

ences between groups.

Furthermore, univariate and multi-

variate logistic regression was performed to

evaluate the factors affecting the prognosis

and survival of AMI-VSP-related patients, age,

treatment modality, hypertension, diabetes,

hyperlipidemia, coronary heart disease, Eu-

roScore II, LVEF, LVEDD, NT-proBNP, cTnI,

and CK-MB were included as variables in the

analysis. Variables with statistically signifi-

cant results in the univariate analysis were

subsequently subjected to multivariate logis-

tic regression analysis. The logistic regres-

sion analysis results were expressed as odds

ratio (OR) with corresponding 95% confi-

dence intervals. Statistical significance was

p<0.05, indicating a statistically significant

difference between the analyzed data.

RESULTS

Results of patient recruitment

From a total of 55 AMI-VSP-related pa-

tients screened for inclusion in the study

were excluded three patients with congeni-

tal heart disease, two patients with VSP re-

sulting from old myocardial infarction, and

four patients who were unable to comply

with the follow-up protocol. Ultimately, 46

patients were enrolled in the study, and all

the patients were divided into two groups

based on the treatment modality, includ-

ing the interventional occlusion group (IO

group, n=20) and the surgical intervention

group (SI group, n=26). The follow-up peri-

od ranged from July 14th, 2015, to February

18th, 2021, with a maximum follow-up dura-

tion of 1069 days, a minimum of 11 days,

and an average follow-up time of 625.00

(417.05-811.00). The mean follow-up time

was 605.00 (445.00-815.00) days in the IO

group and 657.50 (398.75-795.75) days in

the SI group (Fig. 1).

Characteristics of AMI-VSR-related

patients

The average age of all the patients

was 63.50 ± 3.86 years, with 35 (76.09%)

patients over 60 years and 35 (60.87%) fe-

male. Regarding comorbidities and past

medical history, there were 23 (50.00%)

patients with hypertension and diabetes, 24

(52.17%) patients with hyperlipidemia, 15

(32.61 %) patients with coronary heart dis-

ease, 13 (28.26%) patients with ventricular

aneurysms and nine (19.57%) patients with

renal diseases. There were no significant dif-

ferences in age, gender, or distribution of

comorbidities between the IO group and the

SI group (p>0.05). Analysis of hospitaliza-

tion time revealed that the total hospital-

ization time and postoperative hospital stay

were significantly shorter in the IO group

compared to the SI group (p<0.001). The

time from AMI to VSP was similar between

the two groups (p>0.05). The EuroScore

II score in the IO group was 12.00 (12.00,

74 Ni et al.

Investigación Clínica 65(1): 2024

13.00), which was lower than that in the SI

group (p>0.05). It was also found that the

Killip grade of most patients (interventional

occlusion group vs surgery group = 85% vs.

84.62%) was grade III/IV, and there was no

significant difference in the distribution of

Killip grades between the two groups (p>

0.05). The above information is shown in

Table 1.

Results of coronary angiography

and trans thoraciceechocardiography

Analysis of coronary angiography re-

sults showed that 84.78% of patients had

anterior wall infarction or extensive ante-

rior wall infarction, and 58.70% had apical

perforation. Most patients had involvement

of a single culprit lesion (63.04%), with the

LAD (91.30%) being the most frequent one.

There were no significant differences in the

location of myocardial infarction, location of

VSP and culprit lesion between the IO group

and the SI group (p>0.05).

TTE results revealed that the diameter

of VSP in the IO group was 11.30±1.75 mm,

which was significantly smaller than that

in the SI group (p<0.001). The Qp/Qs ra-

tio was 2.82±0.37 and also lower in the IO

group compared to the SI group (p<0.001).

Preoperative and postoperative variables

in AMI-VSR related patients

Table 2 presents the preoperative and

postoperative laboratory examination re-

sults in both groups. In the preoperative pe-

riod, the IO occlusion group exhibited sig-

nificantly lower levels of cTNI (47.30±8.53

ng/mL) and ALT (466.05 ± 170.35 U/L)

compared to the SI group (p<0.05). The

two groups had no significant difference

in other laboratory tests (p>0.05). The

value of LVEF in both groups increased in

Fig. 1. Cumulative survival curves during the follow-up period of IO group and SI group. The survival rate of

IO group was 85.00% (the blue line), and the SI group was 80.77% (the red line).

Acute myocardial infarction with ventricular septal perforation: intervention vs. surgery 75

Vol. 65(1): 70 - 82, 2024

Table 1. Data and examination results of AMI-VSP related patients after admission.

Variables Total (n=46) IO group (n=20) SI group (n=26) t /χ2/Z value p

Age (year, x±s) 63.50±3.86 64.10±4.46 63.35±3.86 0.305 0.762

Age over 60 [n(%)] 35(76.09) 16(80.00) 19(73.08) 0.039 0.844

Gender (female,%) 28(60.87) 12(60.00) 16(61.54) 0.011 0.916

Comorbidities [n(%)] Hypertension 23(50.00) 10(50.00) 13(50.00) 0.000 1.000

Diabetes 23(50.00) 11(55.00) 12(46.15) 0.354 0.552

Hyperlipidemia 24(52.17) 11(55.00) 13(50.00) 0.113 0.736

Coronary heart disease 15(32.61) 6(30.00) 9(34.62) 0.110 0.741

Ventricular Aneurysm 13(28.26) 6(30.00) 7(26.92) 0.053 0.818

Renal disease 9(19.57) 4(20.00) 5(19.23) 0.000 1.000

Location of infarction [n(%)] Anterior/Extensive anterior 39(84.78) 16(80.00) 23(88.46) 0.143 0.705

Others 7(15.22) 4(20.00) 3(11.54)

Number of Culprit lesion [n(%)] 1 29(63.04) 13(65.00) 16(61.54) 0.297 0.862

2 11(23.91) 5(25.00) 6(23.08)

3 6(13.04) 2(10.00) 4(15.38)

Culprit lesion [n(%)] LAD 42(91.3) 17(85.00) 25(96.15) 0.114 0.945

LCX 16(34.78) 7(35.00) 9(34.62)

RCA 11(23.91) 5(25.00) 6(23.08)

VSR location [n(%)] Apical 27(58.70) 13(65.00) 14(53.85) 0.630 0.730

Anterior 13(28.26) 5(25.00) 8(30.77)

Posterior 6(13.04) 2(10.00) 4(15.38)

Echocardiographic findings (x±s) Diameter of VSR (mm) 15.50±4.36 11.30±1.75 18.73±2.62 10.944 ＜0.001

Qp/Qs 3.11±0.49 2.82±0.37 3.34±0.46 4.157 ＜0.001

Time elapsed [days,M(P25,P75)] From AMI to VSR 2.00(1.00,3.00) 2.00(1.00,3.00) 2.00(1.00,3.00) 0.323 0.746

Total hospitalization time 15.00(13.00,18.25) 13.00(13.00,15.00) 18.00(17.00,20.00) 5.749 ＜0.001

Postoperative hospital stay 11.00(9.00,14.00) 9.00(8.00,11.00) 13.50(13.00,14.00) 5.835 ＜0.001

EuroSCORE II [%,M(P25,P75)] 12.00(13.00,14.00) 12.00(12.00,13.00) 13.00(12.00,14.75) 1.454 0.146

Killip class [n(%)] I/II 7(15.22) 3(15.00) 4(15.38) 0.006 0.997

III 14(30.43) 6(30.00) 8(30.77)

IV 25(54.35) 11(55.00) 14(53.85)

▲ VSR, ventricular septal rupture; AMI, acute myocardial infarction; LAD, left anterior descending artery; LCX, left circumflex artery; RCA, right coronary

artery; Qp/Qs, pulmonary circulation / systemic circulation; EuroSCORE II, European heart surgery risk assessment system II.

76 Ni et al.

Investigación Clínica 65(1): 2024

Table 2

Preoperative and postoperative laboratory examination results of patients.

Variables Pre-operation t /Z p p Post-operation t /Z pp

IO group (n=20) SI group (n=26) IO group (n=19) SI group (n=24)

LVEF [%,M(P25,P75),

x±s]

43.00

(41.00,45.00)

45.00

(41.00,48.00) 1.527 0.127 48.84±1.80 46.83±3.57 2.397 0.022

LVEDD (mm,x±s) 50.70±2.05 51.85±2.78 1.545 0.129 49.84±1.77 50.00±1.72 0.295 0.769

NT-pro BNP [pg/

mL,M(P25,P75),x±s]

7523.00

(6523.00,9631.00)

8662.00

(7533.00,9674.00) 1.396 0.163 5527.11±1647.88 5552.38±1607.29 0.051 0.960

LDL (mmol/L,x±s) 1.89±0.27 1.89±0.23 0.070 0.945 1.71±0.21 1.68±0.23 0.467 0.643

HDL [mmol/

L,M(P25,P75),x±s]0.73(0.65,0.81) 0.69

(0.59,0.93) 0.078 0.938 0.80±0.16 0.81±0.18 0.143 0.887

CTnI (ng/mL,x±s) 47.30±8.53 53.15±5.90 2.750 0.009 43.00±6.94 48.29±8.17 2.380 0.022

CK-MB [ng/

mL,M(P25,P75)]

6.38

(5.19,8.51)

6.82

(5.69,8.84) 1.385 0.166 3.59(3.25,4.85) 4.95(3.84,5.41) 2.423 0.015

AST (U/L,x±s) 42.85±4.84 39.81±8.65 1.512 0.138 36.00±4.99 37.75±9.01 0.808 0.424

ALT (U/L,x±s) 466.05±170.35 565.23±131.41 2.231 0.031 216.05±146.73 387.38±122.81 4.168 <0.001

▲ LVEF, left ventricular ejection fraction; LVEDD, left ventricular end-diastolic diameter; NT-pro BNP, N-terminal pro-brain natriuretic peptide; LDL, low-den-

sity lipoprotein; HDL, high-density lipoprotein; cTnI, cardiac troponin I; CK-MB, creatine kinase-MB; AST, aspartate transaminase; ALT, alanine transaminase.

Acute myocardial infarction with ventricular septal perforation: intervention vs. surgery 77

Vol. 65(1): 70 - 82, 2024

the postoperative period, and the result of

the IO group was higher than that of the SI

group (p<0.05). The results of cTNI and CK-

MB in both groups were significantly lower

than those in the preoperative period, and

the treatment results in the IO group were

lower than those in the SI group. Moreover,

the values of LVEDD, NT-proBNP, LDL, AST

and ALT decreased in the postoperative pe-

riod, but there was no significant difference

between the two groups (p>0.05). The HDL

levels increased in both groups in the post-

operative period, with the SI group exhibit-

ing slightly higher average values, although

the difference was not significant (p>0.05).

Characteristics of AMI-VSP-related

patients during the follow-up period

As shown in Table 3, the survival rate

during the follow-up period was 85.00% (17

/20) in the IO group and 80.77% (21/26) in

the SI group. The results of the NYHA class

revealed that 31.58% of patients had class I,

and 47.37% had class II. The IO group dem-

onstrated higher average LVEF and better

results in the 6-minute walk test compared

to the SI group (p>0.05), while the average

LVEDD was lower in the IO group (p>0.05).

Analysis of survival curves in AMI-VSP-

related patients

We employed the Kaplan-Meier curve to

analyze the survival rates of the two groups

of patients. The analysis indicated no sig-

nificant difference in survival rates between

the two groups during the follow-up period

(p>0.05).

Univariable and multivariable regression

analyses for prognostic factors

Univariable logistic regression and

multivariable logistic regression were used

to analyze the risk factors affecting the sur-

vival of patients in both groups in the post-

operative period. The results showed that

coronary heart disease, EuroScore II, LVEF,

NT-proBNP, cTNI, and CK-MB were all signifi-

cant influencing factors (p<0.05). Multivar-

iate logistic regression analysis revealed that

coronary heart disease may significantly af-

fect patients’ prognosis and survival rate (p

<0.05). The analysis results of each index

are presented in Table 4.

DISCUSSION

Interventional occlusion and surgical

intervention have demonstrated efficacy

in enhancing patients’ survival rate

and prognosis

This retrospective study aimed to ana-

lyze the clinical outcomes and prognosis of

46 patients with AMI complicated by VSP who

underwent either interventional occlusion or

surgical intervention. Our analysis of patient

data revealed a higher prevalence of female

Table 3

Results of prognostic indexes of patients in two groups.

Variables Total (n=46) IO group (n=20) SI group (n=26) t /χ2 p

Adverse events 8(17.39) 3(15.00) 5(19.23) 0.000 1.000

12(26.09) 5(25.00) 7(26.92) 0.022 0.883

LVEF (%, x±s) 50.84±2.27 51.59±1.66 50.24±2.55 1.967 0.057

LVEDD (mm, x±s) 47.26±2.31 46.65±2.29 47.76±2.26 1.505 0.141

NYHA class [n(%)] 12(31.58) 6(35.29) 6(28.57) 0.306 0.858

18(47.37) 8(47.06) 10(47.62)

8(21.05) 3(17.65) 5(23.81)

6-min walk test (m, x±s) 339.92±55.50 347.12±58.14 334.10±53.99 0.714 0.480

▲ LVEF, left ventricular ejection fraction; LVEDD, left ventricular end-diastolic diameter; NYHA class, New York

Heart Association class.

78 Ni et al.

Investigación Clínica 65(1): 2024

individuals and those over 60 years old, align-

ing with the findings of Yip et al. 12, who ob-

served a higher risk of AMI with VSP in older

individuals and women. The underlying mech-

anism for this higher incidence in advanced

age and females remains unclear, but it may

be attributed to age-related changes in left

ventricular compliance and myocardial struc-

ture 12. Differences in the cardiac collagen

skeleton and collagen matrix in the infarcted

myocardium between genders may contrib-

ute to the observed disparities 13. The loca-

tion of myocardial infarction and perforation

was found to be closely associated with post-

operative mortality, with the anterior wall and

extensive anterior wall of the myocardium be-

ing predominantly affected and the infarcted

vessels primarily involving the left anterior

descending branch 14,15.

Notably, there were no significant dif-

ferences in baseline characteristics, includ-

ing sex, age, location of myocardial infarc-

tion and VSP between the two groups. Thus,

comparing both groups’ preoperative and

postoperative laboratory measurements

could better elucidate the clinical effects of

the different treatments. A comparison of

preoperative and postoperative laboratory

measurements revealed higher LVEF and

LDL levels and decreased LVEDD, NT-proB-

NP, HDL, CTnI, CK-MB, AST, and ALT lev-

els in both groups. Clinically, LVEF reflects

the extent of myocardial injury or myocar-

dial stunning in AMI patients and serves as

an important prognostic indicator for AMI

mortality 16. NT-proBNP, derived from B-type

natriuretic peptide released by cardiomyo-

cytes, reflects heart injury to some extent 17.

CTnI and CK-MB are specific markers with

clinical sensitivity for myocardial injury 18.

Moreover, Kaplan-Meier survival analy-

sis showed that the postoperative survival

rates of both groups were approximately 80%

and had no significant difference. Previous

studies have highlighted a generally higher

clinical mortality rate of AMI combined with

VSP, ranging from 40% to 80% 19. So our re-

sults indicate that both interventional oc-

clusion and surgery intervention are effec-

tive treatment measures for AMI-VSP-related

Table 4

Correlation analysis of prognostic and survival factors in patients with AMI-VSP.

Predictor Univariables OR (95% CI) pMultivariables OR (95% CI) p

Age 0.846(0.668-1.072) 0.166

Modality of treatment 0.741(0.155-3.554) 0.708

Hypertension 0.242(0.043-1.361) 0.107 0.285(0.028-2.895) 0.288

Diabetes 3.706(0.661-20.765) 0.136 0.159(0.012-2.068) 0.160

Hyperlipidemia 0.6(0.125-2.873) 0.523

Coronary heart disease 0.103(0.018-0.605) 0.012 0.074(0.006-0.891) 0.040

EuroScore II 18.957(1.879-191.235) 0.013

LVEF 0.663(0.445-0.988) 0.044

LVEDD 1.245(0.915-1.694) 0.164

NT-proBNP 1.001(1.000-1.002) 0.032 1.001(0.999-1.003) 0.272

cTnI 1.231(1.026-1.476) 0.025 1.04(0.770-1.404) 0.798

CK-MB 3.302(1.394-7.823) 0.007

▲ EuroSCORE II, European heart surgery risk assessment system II; LVEF, left ventricular ejection fraction;

LVEDD, left ventricular end-diastolic diameter; NT-pro BNP, N-terminal pro b-type natriuretic peptide; cTnI, cardiac

troponin I; CK-MB, creatine kinase-MB.

Acute myocardial infarction with ventricular septal perforation: intervention vs. surgery 79

Vol. 65(1): 70 - 82, 2024

patients, effectively improving cardiac func-

tion and survival rates.

Furthermore, the prognosis of the two

groups was analyzed, revealing further im-

provements in the LVEF and NYHA classes.

The results of the 6-minute walk test also

demonstrated significant enhancement in

cardiovascular function among the patients.

While the reliability and validity of NYHA

scores have been debated, they are widely

used to assess cardiac function improve-

ments following heart disease treatment

20,21. The 6-minute walk test is commonly

employed to evaluate endurance and walk-

ing ability in patients with various condi-

tions and serves as a reference indicator for

assessing the recovery of cardiac function

22. The improvements observed in the above-

mentioned indices in both groups support

the notion that interventional occlusion and

surgery intervention can effectively improve

patient prognosis.

Patients in the SI group were relatively

more severely affected

Significant differences were observed

in VSP diameter and Qp/Qs results between

the two groups. The SI group displayed sig-

nificantly larger perforation diameters and

higher Qp/Qs values. Additionally, the Eu-

roScore II score and the number of patients

with Killip class IV were slightly higher in

the SI group compared to the IO group.

EuroScore II is one of the effective scoring

systems for evaluating the risk of cardio-

vascular surgery. The higher the score, the

higher the risk 23. The Killip classification is

one of the ways to reflect the cardiac func-

tion of patients with AMI. Generally, a high

Killip class means that the cardiac function

of patients is poor and the area of myocar-

dial infarction is larger 24. Notably, the pre-

operative cTnI value was significantly higher

in the SI group than in the IO group. These

findings collectively suggest that while both

groups presented with severe conditions,

the SI group exhibited a more severe clinical

profile. Surgical intervention becomes an ef-

fective life-saving measure when the size and

shape of the VSP hinder successful occlusion

through interventional means 25.

Interventional occlusion is more conducive

to postoperative patient recovery

Our results show that the therapeutic

effect of the IO group was relatively better,

and patients’ recovery rate was faster than

surgical treatment. Postoperative labora-

tory measurements indicated lower levels

of NT-proBNP, cTnI, and CK-MB in the IO

group compared to the SI group. Notably,

the reductions in cTnI and CK-MB, specific

markers of myocardial injury, were more pro-

nounced in the IO group. Additionally, the

total hospitalization time and postopera-

tive hospital stay were significantly shorter

in the IO group, indicating a faster recovery

rate among these patients. Prognostic in-

dices in the IO group also showed slightly

better outcomes. Yi et al. 26 have noted that

timely interventional occlusion stabilizes he-

modynamics and improves patient survival

rates when the perforation diameter is less

than 12 mm. The interventional occlusion

procedure primarily employs the femoral

artery or internal jugular vein for occluder

insertion, resulting in a lesser impact on the

patient’s body than surgical thoracotomy.

Furthermore, due to the smaller perforation

diameter, patients in the IO group likely ex-

perienced a milder clinical condition, con-

tributing to faster recovery.

Coronary heart disease represents

an important factor influencing the

prognosis and survival rate of AMI-VSP-

related patients

Despite advancements in medical tech-

nology that have improved the success rate

of surgical treatment for AMI-VSP-related pa-

tients, many patients still succumb to post-

operative complications, particularly cardio-

genic shock 27. In this study, the majority of

patients were older and presented with one

or more comorbidities, including hyperten-

sion, hyperlipidemia, diabetes, and coronary

80 Ni et al.

Investigación Clínica 65(1): 2024

heart disease. Previous studies have identi-

fied hypertension and hyperlipidemia as

risk factors affecting the prognosis of AMI

patients 28. Our logistic regression analysis

identified a history of coronary heart dis-

ease as an essential factor influencing pa-

tient prognosis and survival rates. Coronary

heart disease represents a significant cause

of cardiac systolic dysfunction, and AMI is

an acute manifestation of this condition

29,30. Obstructive coronary heart disease has

been associated with a higher incidence of

myocardial infarction 31. Therefore, when

patients possess a history of coronary heart

disease, careful consideration should be giv-

en to the selection of appropriate treatment

methods and timing to improve postopera-

tive survival rates.

The results of our study demonstrate

that interventional occlusion is a viable al-

ternative to surgical intervention for pa-

tients with AMI complicated by VSP under

specific conditions, exhibiting satisfactory

clinical efficacy and survival rates. There-

fore, interventional occlusion represents an

ideal choice for the clinical treatment of AMI

patients with VSR. We also found that coro-

nary heart disease can serve as a significant

factor affecting the prognosis and survival

rate of patients. It should be noted that this

study employed a retrospective design, and

the research data were limited. Moreover,

the follow-up duration for some patients was

relatively short, which may have affected the

study’s outcomes. Future considerations

should include prospective studies with ex-

panded sample sizes to reduce the potential

for bias and further support the conclusions

drawn in this study.

ACKNOWLEDGMENTS

None.

Ethical compliance

The ethics committee of The First Affil-

iated Hospital of Medical College of Zhejiang

University approved this study. Signed writ-

ten informed consent were obtained from all

participants before the study.

Funding

This study did not receive any funding

in any form.

Conflict of interests

The authors declared no conflict of in-

terest.

Author’s ORCID numbers

• Chenyao Ni: 0009-0000-9662-4093

• Peng Hu: 0009-0000-4780-0492

• Yiming Ni: 0000-0002-2909-6734

Author contributions

CN and YN designed the study and per-

formed the experiments, CN and PH collect-

ed the data, YN and PH analyzed the data,

and CN and YN prepared the manuscript. All

authors read and approved the final manu-

script.

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