The paper by Belyaev et al.¹ presented a relatively large case series of patients operated for postinfarction ventricular septal rupture (VSR) addressing a relevant and often debated issue regarding this condition: the role of the surgical technique on the incidence of residual VSR (rVSR) and on patients' early (in-hospital) and late survival.² Indeed, VSR represents a severe and often life-threatening condition, associated with high mortality despite prompt treatment.² By describing their modification of Tabuchi's “double-patch” technique, they demonstrated a low rate of rVSR, no intraoperative mortality, and a relatively low in-hospital mortality.^{1, 3} In fact, while most studies traditionally reported in-hospital mortality ranging from 20% to 60%, as confirmed by the recently published results from the CAUTION multicenter study, where early mortality among 475 patients was 40.4%, their observed rate of in-hospital deaths was 26.5%.⁴ The series by Belyaev et al. has several peculiarities which deserve specific comments and analysis. Indeed, only five patients presented a nonhemodynamically significant postoperative rVSR, with two of them dying during hospitalization, and one patient required emergent reoperation due to hemodynamically relevant rVSR. Despite some studies reporting an rVSR rate as high as 40%, the relatively low incidence of VSR recurrence observed by Belyaev et al. is not far from the 12.9% reported in the CAUTION study, where, however, almost half of patients required reoperation, although not impacting on in-hospital mortality.^4-6 Nevertheless, while all the patients considered for this paper underwent a repair through the “double-patch frame” technique, in the population considered in the CAUTION study a quite variable set of techniques was adopted.^{1, 4}

Based on the above-mentioned aspects, while we congratulate the authors for the good results observed in this group of patients undergoing the “double-patch frame” repair, we believe that several features must be also highlighted and most likely imputed as a potential favorable predisposing factor for such favorable outcome in the reported series. Indeed, although the advantages of left ventricular aneurysm exclusion in reducing ventricular volume, restoring ventricular shape, and reducing the arrhythmic risk related to necrotic scar, have been well addressed in the past decades, and might potentially contribute to the better survival of this population compared to other techniques not addressing ventricular aneurysm, it is also possible that the patient cohort considered in the paper is somehow different from the patients generally presented and managed in other studies about VSR.^{2, 7, 8} For instance, although the current study included patients diagnosed with acute or subacute VSR, the time frame considered for patients' eligibility reached 1 year from myocardial infarction (MI). Notwithstanding, the median time from MI to VSR repair was 56 days. As a matter of fact, such a delayed timing of VSR repair may intrinsically identify a subset of patients who were stable enough to wait for surgery, indicating more favorable hemodynamic conditions and clinical status at the time of the surgical correction. Furthermore, such a rather unusual long time between the VSR onset/diagnosis and the operation, allowing the development of a stronger fibrous scar, which is more suitable for durable repair, while achieving myocardial recovery from ischemia.^{4, 8} These aspects might partially justify the low rate of rVSR, in addition to the advantages related to the technique itself. Similarly, the timing of surgery has been often advocated to strongly influence patients' mortality, as described in the report of the Society of Thoracic Surgeons, where among 2876 subjects operated for VSR, in-hospital mortality dropped from 54.1% to 18.4% if patients were operated 1 week after rupture occurrence.^{4, 8}

However, despite the possible selection bias attributed to these patients, in this paper still 20.4% of them presented in the critical preoperative state, whereas other studies generally reported preoperative cardiogenic shock in almost half of the patients.^{4, 8} Moreover, although the significant delay from MI occurrence, urgent and emergent surgery was required in 71.4% and 20.4% of patients, respectively, possibly suggesting that delayed treatment is not completely free of risks for patients' worsening. Indeed, while waiting for intervention, the interventricular communication may expand, thereby increasing the shunt fraction and worsening right ventricular overload.⁹ For these reasons, our group recently proposed a management algorithm aimed at delaying surgery for at least 7 days, while maintaining hemodynamic stability, possibly with the adoption of appropriate mechanical circulatory support devices.⁹

Nevertheless, only three patients were supported preoperatively with intra-aortic balloon pumps (IABP). Moreover, even though after surgery all patients developed low cardiac output requiring inotropes, IABP was adopted in 42.9% of subjects and only one patient received extracorporeal membrane oxygenation. This could also explain why 8 patients out of 13 died due to multiorgan or cardiac failure after surgery. Indeed, the role of mechanical circulatory support is gaining progressively more credits in the management of VSR, both for achieving patients' stabilization before surgery and for providing a protected early perioperative course, possibly protecting from suture dehiscence and rVSR even in case of early surgery, when the necrotic myocardium is still friable and fragile.^{9, 10}

In conclusion, while surgical techniques for VSR repair have evolved and improved over the last decades, even incorporating the rationale and advantages of combined procedures, as in the case of the “double-patch frame” technique, in-hospital mortality has often remained substantially unchanged and unsatisfactorily high. Nevertheless, the real impact of the surgical technique on patients' outcomes, as in the case of this paper, may actually be blunted by many other more relevant factors, such as the baseline patients' characteristics, and an adequate preoperative and perioperative management, to optimize the hemodynamic conditions and the timing from VSR diagnosis-to-surgery, possibly with the appropriate adoption of mechanical circulatory supports to improve the still suboptimal in-hospital mortality even for the subset of patients with the poorest preoperative conditions and the ones developing/perpetuating low cardiac output after surgery.

Belyaev 等人的论文。^图1展示了一个相对较大的为梗死后室间隔破裂 (VSR) 手术的患者系列，解决了与这种情况相关且经常争论的问题：手术技术对残余 VSR (rVSR) 的发生率和患者早期 (院内）和晚期生存。²事实上，VSR 是一种严重且经常危及生命的疾病，尽管及时治疗，但仍与高死亡率相关。²通过描述他们对 Tabuchi 的“双贴片”技术的修改，他们证明了低 rVSR 发生率、无术中死亡率和相对较低的住院死亡率。^1、3事实上，虽然大多数研究传统上报告的住院死亡率在 20% 到 60% 之间，但最近发表的 CAUTION 多中心研究结果证实了这一点，其中 475 名患者的早期死亡率为 40.4%，但他们观察到的住院率死亡人数为 26.5%。⁴Belyaev 等人的系列。有几个特点值得具体评论和分析。事实上，只有 5 名患者出现了非血流动力学显着的术后 rVSR，其中 2 人在住院期间死亡，1 名患者由于血流动力学相关的 rVSR 需要紧急再次手术。尽管一些研究报告 rVSR 率高达 40%，但 Belyaev 等人观察到的 VSR 复发率相对较低。与 CAUTION 研究中报告的 12.9% 相差不远，然而，几乎一半的患者需要再次手术，尽管对住院死亡率没有影响。^4-6然而，虽然本文考虑的所有患者都通过“双补丁框架”技术进行了修复，但在 CAUTION 研究中考虑的人群中，采用了一组相当可变的技术。^1、4

基于上述方面，虽然我们祝贺作者在这组接受“双贴片框架”修复的患者中观察到的良好结果，但我们认为还必须强调几个特征，并且很可能将其归为潜在的有利在报告的系列中产生这种有利结果的诱因。事实上，尽管左心室动脉瘤排除在减少心室容积、恢复心室形状和降低与坏死性瘢痕相关的心律失常风险方面的优势在过去几十年中得到了很好的解决，并且可能有助于提高该人群的生存率。对于其他不解决心室动脉瘤的技术，^{2, 7, 8}例如，虽然目前的研究包括被诊断为急性或亚急性 VSR 的患者，但考虑患者资格的时间范围达到了心肌梗死 (MI) 后 1 年。尽管如此，从 MI 到 VSR 修复的中位时间为 56 天。事实上，这种延迟的 VSR 修复时间可能本质上识别出足够稳定以等待手术的患者子集，表明手术矫正时更有利的血流动力学条件和临床状态。此外，VSR 发病/诊断和手术之间的如此长的时间相当不寻常，允许形成更坚固的纤维疤痕，更适合持久修复，同时实现心肌从缺血中恢复。^4、8除了与技术本身相关的优势之外，这些方面可能部分证明了 rVSR 的低比率是合理的。同样，正如胸外科医师协会的报告中所描述的那样，手术时机经常被提倡强烈影响患者的死亡率，在该报告中，在接受 VSR 手术的 2876 名受试者中，如果患者的住院死亡率从 54.1% 下降到 18.4%破裂发生1周后进行手术。^4、8

然而，尽管这些患者可能存在选择偏倚，但在本文中仍有 20.4% 的患者处于术前危急状态，而其他研究普遍报告了近一半患者的术前心源性休克。^{4, 8}此外，尽管 MI 发生显着延迟，但分别有 71.4% 和 20.4% 的患者需要紧急和急诊手术，这可能表明延迟治疗并非完全没有患者恶化的风险。事实上，在等待干预时，心室间通讯可能会扩大，从而增加分流分数并恶化右心室负荷。⁹出于这些原因，我们小组最近提出了一种管理算法，旨在将手术延迟至少 7 天，同时保持血流动力学稳定性，可能采用适当的机械循环支持装置。⁹

然而，只有 3 名患者在术前接受了主动脉内球囊泵 (IABP) 的支持。此外，尽管手术后所有患者都出现需要正性肌力药物的低心输出量，但 42.9% 的受试者采用了 IABP，只有一名患者接受了体外膜肺氧合。这也可以解释为什么 13 名患者中有 8 名在手术后死于多器官或心力衰竭。事实上，机械循环支持在 VSR 管理中的作用越来越受到重视，既可以实现患者在手术前的稳定，也可以提供受保护的早期围手术期，即使在早期手术的情况下也可能防止缝线裂开和 rVSR，当坏死的心肌仍然脆弱易碎时。^9、10

总之，虽然 VSR 修复的手术技术在过去几十年中得到了发展和改进，即使结合了联合手术的基本原理和优势，如“双贴片框架”技术，住院死亡率通常保持在相当大的水平不变且高得令人不满意。然而，手术技术对患者结局的真正影响，如本文所述，实际上可能会因许多其他更相关的因素而减弱，例如基线患者的特征，以及适当的术前和围手术期管理，以优化血流动力学条件和从 VSR 诊断到手术的时机，