Heart Transplantation in post-infarction ventricular septal rupture: Contemporary outcomes from the 2016-2021 National Inpatient Database

Abstract

Introduction

Ventricular septal rupture (VSR) is a devastating complication of myocardial infarction (MI), with high mortality, particularly in cardiogenic shock (CS). Heart transplantation (HT) has emerged as a potential alternative to surgery or transcatheter closure (TCC). This study evaluates contemporary trends and outcomes of HT in post-MI VSR using the National Inpatient Sample (NIS) database.

Objectives

To assess in-hospital mortality and resource utilization of HT compared to surgical repair or TCC for post-MI VSR with CS.

Methods

We analyzed NIS data (2016–2021) for MI-VSR hospitalizations with CS. Patients undergoing HT were compared to those receiving surgical repair or TCC. Primary and secondary endpoints included in-hospital mortality (IHM), total hospital charges (TOTCHG), and length of stay (LOS). Multivariable logistic regression adjusted for age, sex, race, comorbidities, and hospital characteristics, with surgical repair as the control.

Results

Of 2,514,025 acute MI hospitalizations, 4765 (0.20%) had VSR. IHM was 82% with CS vs. 60% without. Among VSR-CS patients, 30 (1.2%) underwent HT, 600 (24.1%) surgical repair, 225 (9.2%) TCC, and 1635 (65%) medical therapy. IHM was 0% for HT vs. 66% (surgery), 75% (TCC), and 97% (medical therapy). All HT patients received mechanical circulatory support [IABP (50%), Impella (27%), ECMO ± Impella (10%), ECMO (13%)].). Patients undergoing HT had an average LOS approximately 20 days longer than those treated surgically (p = 0.004; 95% CI: 13.78–47.29) and 15 days longer with TCC (p = 0.008; 95% CI: 19.32–54.23). Similarly, mean total hospital charges (TOTCHG) were higher for HT patients ($1,456,693) compared to surgical repair ($325,032; p = 0.001; 95% CI: $145,002–$634,293) and TCC ($210,032; p = 0.001; 95% CI: $119,230–$542,200).

Conclusions

From 2016 to 2021, among VSR-CS admissions in the United States, patients who underwent HT had no in-hospital mortality, in contrast to the high in-hospital-mortality observed with surgical or transcatheter closure. Despite inherent selection biases, including survival to transplantation, HT was associated with favorable outcomes compared to surgical repair. While promising, these findings are preliminary due to the small sample size and selective nature of the patient cohort. Further studies are required before HT can be broadly recommended as a primary treatment option.