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Eur J Cardiothorac Surg 2002;21:725-732
© 2002 Elsevier Science NL
a Department of Cardio-Vascular Surgery, Hopital Haut-Lévêque, Avenue de Magellan, 33604 Bordeaux-Pessac, France
b Hopital d'Instruction des Armées Robert Picqué, 33140 Villenave d'Ornon, France
c Department of Intensive Care of Cardiology, Bordeaux Heart University Hospital, 33604 Bordeaux-Pessac, France
Received 20 September 2001; received in revised form 3 January 2002; accepted 16 January 2002.
* Corresponding author. Tel.: +33-5-5655-6437; fax: +33-5-5615-8157
e-mail: louis.labrousse{at}chu-bordeaux.fr
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Abstract |
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 Top Abstract 1. Introduction2. Patients and methods3. Results4. Discussion5. ConclusionAppendix A. The variables...Appendix B. Conference...References |
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Key Words: Myocardial infarction • Ventricular septal defect • Coronary disease • Cardiac surgery
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1. Introduction |
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TopAbstract1. Introduction2. Patients and methods3. Results4. Discussion5. ConclusionAppendix A. The variables...Appendix B. Conference...References |
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The aim of this retrospective study was to assess if technical changes in the surgical procedure were followed by an improvement in recurrence of the VSD and operative results.
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2. Patients and methods |
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TopAbstract1. Introduction2. Patients and methods3. Results4. Discussion5. ConclusionAppendix A. The variables...Appendix B. Conference...References |
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Preoperative intra-aortic balloon pump (IABP) support, available in our institution since 1974, was used in 81 patients (95%). Before 1980, it was only use in patients with cardiogenic shock or severe congestive heart failure (groups 1 and 2). Since 1980 it was routinely used in all patients except for patients in whom peripheral vascular arterial disease prevented its use.
2.2. Cineangiography and coronarography
All available preoperative cineangiograms were blindly reviewed. Left ventriculography was available in 65 patients and right ventriculography in 57. The right ventricular function was estimated from the percentage of reduction of the right ventricular mid cavity diameter as proposed by Fananapazir [9] and Jones [10]. From the left anterior oblique projection, the right ventricular mild cavity diameter was measured at end systole and end diastole, and the percentage of reduction in right ventricle diameter calculated as follows:
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Coronary angiograms available in 72 patients, were analyzes in order to establish a preoperative coronary score. The method used has been previously described in our previous study [7]. The postoperative score derived from the preoperative score remained the same unless a lesion was treated by coronary bypass graft. In that case the lesion was quantified 0 in the postoperative score.
The main cardiac catheterization data studied were: pulmonary arterial pressure (systolic, diastolic and mean), right and left atrial pressure, right ventricular pressure, left ventricular end diastolic pressure, cardiac index and pulmonary to systemic flow ratio.
2.3. Surgical management
All patients were operated on through a median sternotomy with extracorporeal circulation and moderate hypothermia (28–33°C). Cardiopulmonary bypass was established between both caval veins with caval tapes and ascending aorta. A bubble oxygenator was used in the first 28 patients and a membrane oxygenator in the next 57. Pulsative flow has been used since 1976. All operations were performed from 1 to 6 days (mean 3.4) after the septal defect occurrence. The ventricular septal defect repair was performed according to the principles of the technique described by Daggett [9,12]. The main principles were: approach to the interventricular septum through the area of the infarcted myocardium; closure of the VSD without tension with a dacron patch; closure of the ventriculotomy without tension, usually with prosthetic material, mainly for posterior infarction; buttressing of suture line with Teflon (pledgets or strips) and use of glue to reinforce friable tissue. GRF® glue was first used since 1982, followed in 1997 by Bioglue® (Cryolife International®, USA).
From 1970 to 1986, the patch was placed over the VSD in the left ventricle and sutured through a unique left ventriculotomy as previously described [8,11]. Since 1986, we introduced the double patch and glue technique using a double ventriculotomy. The left ventriculotomy, similarly to that done in the one patch technique, is made in the infarct area and parallel either to the left anterior descending artery or to the posterior descending artery. So, the exact position of the VSD and of the septum is confirmed, and then allows to make the second incision through the right ventricle, parallel to the first one and nearer as possible of the septum. By this second ventriculotomy, another Dacron patch is positioned widely over to the VSD and sutured to the left Dacron patch with a continuous 4-0 polypropylene suture. Special attention to shape the right patch is required. Indeed, usually two incisions have to be done in the patch to allow a way for the moderator band and for the for tricuspid's papillary muscle tip. Thus, each patch is used as a support for the suture on the other. Moreover, biological glue (GRF® replaced in 1997 by Bioglue®) is placed between the two patches to reinforce necrotic myocardium septal tissue, which is not resected at all. After that, ventriculotomies are closed as in the usual technique.
Associated procedure included aneurysmectomy in 23 patients, coronary artery bypass graft in 40 (mean of 1.2 graft per patient), mitral valve replacement in one and permanent pacemaker implantation in four.
Recurrences were established by clinical examination and echocardiography analysis when it became available (1978).
2.4. Data collection and statistical analysis
Preoperative and perioperative data (Appendix 1) were collected on retrospective review of patients’ record. Follow-up information were obtained between February and May 2001 by physician or patient contact and was obtained in all patients except three. Hospital mortality was defined as death within 30 days of operation or during the same hospital admission. SPSS for Windows version 10.0 (SPSS Inc., Chicago, IL) was used to perform statistical calculations. Data are expressed as mean±standard deviation. Continuous variables were analyzed using independent t-test or Mann–Whitney U-test when data was not normally distributed. Pearson 
2 or Fisher's exact test were used to determine differences when variables were expressed by dichotomous values. The univariate analysis was followed by multivariate logistic regression to determine independent risk factors. Preoperative factors that were significant or with a P value <0.3 were retained in the analysis. Survival was examined by the Kaplan–Meier product limit method and p values for difference between survival were obtained by the log-rank test. A value of P<0.05 was considered statistically significant.
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3. Results |
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TopAbstract1. Introduction2. Patients and methods3. Results4. Discussion5. ConclusionAppendix A. The variables...Appendix B. Conference...References |
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Concomitant CABG was associated with a lower risk of hospital mortality (33±14 versus 51±14%), but did not reach a significant level (P=0.1). Other factors with a p value at less than 0.3 included proximal coronary lesion, previous myocardium infarction and older age. No significant factors was found in the remaining 35 variables studied (Appendix 1). Especially, it concerns localization of the VSD, sex of the patient, pre and postoperative coronary score and all hemodynamic variables.
Concerning long term survival, Kaplan–Meier survival curves of patients related to the type of closure, and related to associated CABG are presented in Figs. 2 and 3 . No significant difference has been found in the long-term survival rate in both cases. Similarly, none of the others variables studied were significant.
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4. Discussion |
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TopAbstract1. Introduction2. Patients and methods3. Results4. Discussion5. ConclusionAppendix A. The variables...Appendix B. Conference...References |
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Hospital mortality in our series is similar to that reported by others groups since 1990, especially results of the last 10 years [2–4,15]. However, comparison of mortality between different institutions remains unreliable. Indeed, patients are usually first referral to cardiologist centers, and a part of the patients (depending of cardiologist habit) might be considered not suitable and then not referred to surgery. So, a part of the discrepancy in operative results between institutions might be attributed to variable recruitment. As in our series, the improvement of hospital mortality in the last years is usually found in other studies [3,4].
Risk factors for early death have been determined in our previous series [8], and confirmed in others [3–7,13,16,17]. Concerning clinical status, all authors found a higher mortality rate in patients with preoperative cardiogenic shock. However, we have to consider not only the cardiogenic shock itself, but also its intensity and its evolution under medical therapy. Worst results were observed in patients with lack of improvement hemodynamic status in spite the use of an IABP. This last point is likely the reflect of a large amount of infarcted left myocardium, which will have to switch patients to circulatory assist devices as a bridge to heart transplantation if patient's conditions allow it. Right ventricular function, important risk factor in our study, was not detected again in a recent publication [16]. Right ventricular dysfunction is related to several factors: left ventricular dysfunction, right ventricular infarction or ischaemia and right ventricle volume overload. Only the last is reversible. Analysis of the part of these three components is not easy, and as sample size of VSD series is small, analysis and conclusions are likely not very reliable, and would need much larger samples to determine exact predictors of outcome.
About surgical technique, few technical aspects need to be pointed. The double patch technique with glue used since 1986 is done without infartectomy at all. So, it avoids additional detrimental damages on the septum. Moreover, as the right ventriculotomy is achieved through an infarcted area, any detrimental effect of its function remains hypothetical, and identical long term follow-up preclude for that on long term. As each patch is used as a support for the suture on the other, they make the suture easier and less prone to tear than pledgets. Another role of the second patch is to contain the glue. By that way, the glue homogenize, reinforce and maintain the friable septal tissue which become dense and solid. In literature, VSD recurrences are not infrequent [2–4]. In a recent series [2] a residual shunt was found in 40% of patients with reoperation in a third of them and subsequent mortality. The absence of recurrence in patients treated with the double patch and glue technique could be an explanation for a part of the decrease of mortality since this technique was used. Moreover, a recent publication [5] mentions perioperative failure of the repair and the need of a re-repair with long time of cardiopulmonary bypass. Such pejorative complication does not occur in our experience with the double patch technique. So the double patch appears more reliable than the one patch technique. Posterior VSD has been traditionally associated with increased operative mortality. Difficulties in operative exposition and repair are usually advanced to explain that result [5,12]. In our series, there is no significant difference in operative mortality according to the localization of the VSD when the repair is performed with the double patch technique (Table 4). However, our sample is not big enough to totally ensure that. As for classic repair, and even if surgical exposure is improved by the double ventriculotomy, the repair is usually more demanding than in anterior localization. And the absence of recurrence of the VSD even in this localization confirms that the double patch technique allows a perfect and reliable repair.
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About preoperative coronarography, as other authors [4,14,18,19], we systematically performed it as soon as the patient is admitted. It allows in the same time the systematic insertion of an IABP, and concomitant CABG are achieved if necessary. No detrimental effect has been found with that policy. Especially, no mortality or morbidity has been found to be related to coronarography. Moreover, associated CABG did not appeared as a risk factor for early and late death. Recently report from Zûrich [18] has highlighted the interest of concomitant CABG. Our results confirm its conclusions. As long term follow-up of patients with associated coronary lesions is similar to those without coronary lesion, and as no complications can be related to concomitant CABG, preoperative coronarography had to be recommended and CABG performed if necessary to eliminated a potential ischemic added risk due to other coronary arteries lesions.
Some limitations of this study need to be noted. We have to point to the known disadvantages of a retrospective study, which covers 30 years. Especially, the quality of operative (cardioplegia, etc.) and intensive care management has dramatically changed and improved over this period. That makes any analysis of early mortality partially inaccurate. So, our results of the impact of the double patch and glue technique on early mortality have mainly to be analyzed in the lack of early recurrence of the VSD and subsequent mortality. However, this study reflects the intake of patients from a particular institution, and thus reflects similar patterns of patients’ recruitment and surgical indications.
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5. Conclusion |
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TopAbstract1. Introduction2. Patients and methods3. Results4. Discussion5. ConclusionAppendix A. The variables...Appendix B. Conference...References |
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Footnotes |
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Appendix A. The variables entered into the univariate analysis included: |
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TopAbstract1. Introduction2. Patients and methods3. Results4. Discussion5. ConclusionAppendix A. The variables...Appendix B. Conference...References |
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– Medical history variables: hypertension, diabetes mellitus, nicotinism, angina, previous myocardial infarction, dyslipidemia.
– Clinical variables: preoperative status (group), supraventricular or ventricular arrhythmia, atrio-ventricular conduction failure, preoperative intra-aortic balloon pump, evolution (impairment, stabilization, improvement) under intra-aortic balloon pump.
– Ventricular septal defect variables: myocardial infarction, site of myocardial infarction, delay infarction-ventricular septal defect.
– Angiographic variables: site of ventricular septal defect, left ventricular ejection fraction, right ventricular function, left ventricular aneurysm, mitral insufficiency, delay infarction-angiography.
– Coronarography variables: preoperative coronary score, post-operative estimated coronary score, site of the coronary lesion related to myocardial infarction.
– Catheterization data variables: pulmonary artery pressure (systolic, mean, diastolic), right ventricular pressure (systolic, diastolic), pulmonary capillary pressure, left ventricular pressure (systolic, diastolic), cardiac index, corrected cardiac index, enrichment in O2 in volumes, pulmonary to systemic flow ratio, left ventricular work index.
– Operative variables: operative myocardial ischemic time, extra corporeal circulation time, type of repair, year of operation, associated coronary bypass graft, associated left ventricular aneurysmectomy.
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Appendix B. Conference discussion |
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TopAbstract1. Introduction2. Patients and methods3. Results4. Discussion5. ConclusionAppendix A. The variables...Appendix B. Conference...References |
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Dr Deville: Now our policy is systematic coronarography in our patients. We have not noted detrimental effect of this procedure. The time required for the coronarography is short. All the patients with a significant coronary lesion (more than 70%) underwent a coronary bypass. It is generally not on the infarcted coronary artery but on a collateral of this artery. The discussion could concern patients with very poor hemodynamic condition with persistent cardiogenic shock. In such cases could be discussed the possibility of a perioperative coronarography, but in some patients there is no associated lesion. I think Prof. Turina brings a good clarification of this problem in a recent publication.
Mr A. Ritchie (Cambridge, UK): Thank you very much for your interesting and very long study, and your results are much more experienced than my personal limited clinical experience, but can I ask you a question that is very important to me. Is the improvement in both the short-term and long-term outcome more related to your management of patients when they present to you? And what I am really trying to get at here is has your policy of treating these patients before you actually take them to the operating theater changed?
In my institution, for example, I would put a balloon pump into the patient for 3, 4, maybe even 5 days and then take them to the operating theater, and that I have found has decreased the mortality for the procedure but also reduced the number of post repair leaks that subsequently come, and I think that more than any other factor, along with warm blood cardioplegia, which I routinely use, has changed the scenario for these patients. Is that clear in the way you treat your patients or do you take these patients immediately to the operating theater?
Dr Deville: Yes, our policy is to take these patients very quickly. If the patient is in stable condition, I think it is important to operate him urgently, but if he is in persistent shock, it is immediately, as soon as an operating room is available. Of course, the in-hospital mortality would be poor, but if you delayed patients, some of them would be dead before the surgery, and even if you have better short-term results, it is not ethical.
Dr P. Skillington (Melbourne, Australia): Thank you for your presentation. Most studies have shown an increased mortality with inferior VSD. Did you look at that risk factor?
Dr Deville: Yes. In our experience, the early results are not different according to the location of the VSD, and personally I think that the technical management is very important. Most of the problems were related to VSD recurrence. In literature, VSD recurrence appeared between 10 and 40%, and some publications mentioned peri-operative failure of the repair, especially in the posterior localization. We do not observe such complication with the double patch technique and the use of glue, and in our experience the difference was not significant between the early deaths in the two groups of patients. But of course, the technical aspect is more difficult in posterior localization; the exposure is more difficult and the lesion is, most often, more sophisticated.
Dr M. Irarrazaval (Santiago, Chile): Two short technical questions. Do you recommend this double patch for all of the VSDs or you are more selective in anterior or posterior?
And the second question is, in this 30-year period of time, there have been changes in the decision of where do you put the patch. We have gone more and more suturing the patch very far away from the necrosis, as far as possible. Would that be possibly another reason for the improvement of the results?
Dr Deville: To the first question, since 1992, I have systematically used the double patch technique with a double ventriculotomy. The role of the second patch is to constitute a support for the running suture but also to contain the biological glue between the two patches.
To your second question, of course we attempt to suture the patch very large away from the border of the lesions and sometimes very close to the mitral annulus. I think it is very important to exclude the most part of the infarcted septum.
Dr M. Turina (Zurich, Switzerland): Claude, congratulations on a very interesting paper. I was very surprised to find the right ventricular dysfunction as the independent predictor. In my experience, every patient who comes on the operating table has a major right ventricular dysfunction because of the shunt. So the next question is a logical one. Do you have a level of left to right shunt when you intervene? Some of these patients will have a very minor left to right shunt, something like 20, 25%, and in some of them it will progress quickly. In others, they can be managed with a balloon pump for a longer period of time, as suggested. But every patient who is operated upon has a right ventricular dysfunction.
Dr Deville: Yes. In the first part of our study we determined right ventricular dysfunction as a very important risk factor. It is always significant in the second part, and we believe have identified two groups of patients: patients who have a right ventricular dysfunction compared to 10% who have no survival, and between 10 and 20% who have a high risk of mortality but some survival. I think the problem is related to the fact that right dysfunction is related to three components: the left ventricular dysfunction, the right ventricular infarct, and the overload due to shunt. Only the last component is reversible. So sometimes patients with very poor right ventricular function because of an important shunt have a good outcome. I am not sure that this right ventricular function is a very good factor. I think it is an intricacy of the three components.
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TopAbstract1. Introduction2. Patients and methods3. Results4. Discussion5. ConclusionAppendix A. The variables...Appendix B. Conference...References |
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