Discussion
In our report, the patient did not seek medical treatment. Studies have
shown that most VSD occurs 3-5 days after AMI[3].
The patients receiving drug therapy alone have a median survival time of
5 days; more than 75% of patients die within 12 days after the onset of
VSD symptoms, with 93.6% of 30-day mortality rate, and 96.2% of
long-term mortality rate[4]. Therefore, based on
the experience, the patient’s onset of VSD might be approximately 4
weeks before the first visit. The patient had no discomfort such as
chest pain and no obvious hemodynamic disorder at the first visit. Based
on the above-mentioned factors, we dared to make the clinical decision
of agreeing to the patient’s temporary refusal of closure and choosing
follow-up observation. Regular follow-up is a vital guarantee for
delayed ventricular septal closure. For patients who need to perform
delayed closure, it is crucial to closely monitor whether patients have
organ dysfunction and hemodynamic disorder.
Closure of ventricular septal perforation is the key to the treatment of
post-AMI VSD. Current guidelines still recommend surgical treatment for
post-AMI VSD[5]. According to the STS database
report on the results of VSD surgery after infarction, however, only
2,876 patients received surgery in 666 participating
institutions[6], and most surgeons operated on no
more than 1 patient per year. Moreover, patients were often complicated
with complications such as shock and high surgical trauma. The patients
undergoing surgical treatment still face the mortality rate of
40%[7]. For the patients with severe hemodynamic
disorders, it is particularly important to close ventricular septal
defects as early as possible[8]. Such patients,
however, often cannot be treated surgically immediately. Transcatheter
closure of the ventricular septum may be a more feasible option for
these patients. In addition, increasing number of evidences show that
percutaneous transcatheter closure of post-AMI VSD is an effective
treatment. It can immediately reduce shunt and thus prevent hemodynamic
deterioration[9]. Besides, it does not require
general anesthesia and has little trauma and is tolerable for vast
majority of patients.
At present, the optimal intervention time for post-AMI VSD remains
controversial. Guidelines recommend early ventricular septal closure for
the patients with severe hemodynamic disorders. However, current studies
have shown that using supportive treatments including cardiopulmonary
bypass, stable hemodynamics and delay closure can also benefit
patients[10] and reduce the mortality of
patients[11].In this case, the patient underwent
the occlusion 22 months after the onset of VSD, much later than the
recommended time in the guidelines. It could provide clinical evidence
for delayed closure of patients with post-AMI VSD. This case shows that
it is necessary to reevaluate whether early ventricular septal closure
is needed for all patients with post-AMI VSD.
The patient reported in this case delayed medical care due to COVID-19,
which is a common phenomenon during the epidemic. According to related
data, during the epidemic period, the number of emergency visits has
been reduced by nearly 50%, and the out-of-hospital mortality has
increased accordingly because of patients’ fear of coronavirus infection
and other factors[12]. Evidence has shown that the
incidence of mechanical complications of AMI is significantly higher
than that in previous years due to patients’ delayed medical treatment
during COVID-19[13]. Enough attention should be
paid to the consequences of delayed medical care during the COVID-19
pandemic. Besides, the impact of the COVID-19 epidemic on patients’
long-term health-seeking habits still needs to be observed in the longer
term.