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.