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Eur J Cardiothorac Surg 2003;24:940-946
© 2003 Elsevier Science NL

Repair of post-infarct ventricular septal defect with or without coronary artery bypass grafting in the northwest of England: a 5-year multi-institutional experience

^a Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Manchester, UK
^b Department of Cardiothoracic Surgery, The Cardiothoracic Centre-Liverpool, Thomas Drive, Liverpool, L14 3PE, UK
^c Department of Clinical Governance, The Cardiothoracic Centre-Liverpool, Thomas Drive, Liverpool, L14 3PE, UK
^d Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool, UK
^e Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, UK

Received 1 May 2003; received in revised form 17 July 2003; accepted 18 July 2003.

^* Corresponding author. The Cardiothoracic Centre-Liverpool, Thomas Drive, Liverpool, L14 3PE, UK. Tel.: +44-151-293-2336; fax: +44-151-288-2371
e-mail: tony.grayson{at}ctc.nhs.uk

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
Objective: To present the 5-year experience of the northwest of England's surgical repair of post myocardial infarction (MI) ventricular septal defects (VSD). Our primary aim was to evaluate the effect of concomitant coronary artery bypass grafting (CABG) on mid-term survival and also to identify prognostic indicators. Methods: A multi-centre regional observational study involving clinical data from 65 consecutive patients who underwent post MI VSD repair in the northwest of England between April 1997 and March 2002. Both prospective and retrospective collection of preoperative, operative and postoperative information was performed. Patient follow-up was performed by linking their records to the National Strategic Tracing Service database. Multivariate logistic regression and Cox proportional hazards analyses were used to identify independent risk factors for poor prognosis. Results: Of the 65 patients included in the study, 42 (64.6%) underwent concomitant CABG with a median of two grafts. The majority of patients who had their coronary arteries grafted had multivessel disease (92.9%). Overall 30-day mortality was 23.1%. Predictors of poor prognosis included preoperative inotropes (P<0.001) and total occlusion of infarct related artery (P=0.03). The crude hazard ratio (HR) of mid-term mortality for concomitant CABG patients was 0.82 [95% confidence interval (CI) 0.38–1.78; P=0.62]. After adjustment for differences in patient and disease characteristics, the adjusted HR of mid-term mortality for concomitant CABG patients was 0.17 (95% CI 0.04–0.74; P=0.019). The adjusted freedom from death in the concomitant CABG patients at 30 days, 1, 2, and 4 years was 96.2%, 91.6%, 88.8%, and 82.8%, respectively, compared with 79.1%, 58.8%, 49.1%, and 32.2% for the non-concomitant CABG patients. Conclusion: These data provide evidence that concomitant CABG is significantly beneficial to mid-term mortality rates. We recommend that patients who present with post MI VSD who have multivessel disease should be routinely revascularised.

Key Words: Myocardial infarction • Ventricular septal defect • Coronary artery bypass grafting • Mid-term survival • Risk adjustment

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
Ventricular septal rupture is a rare, but fatal sequelae of a myocardial infarction (MI). Despite reports of spontaneous closure [1] and of transcatheter closure of ventricular septal defects (VSD) [2], non-surgical treatment is generally accepted to be inadequate [3,4]. Progressive deterioration in haemodynamic status makes surgical intervention often the only realistic option.

There are several large series in the literature attempting to identify risk factors for poor outcome [5–12]. Outcomes vary from 21 to 42% (30-day mortality). Although the associated mortality for surgical repair of post-infarct VSD is universally poor, successful results have been reported even at the extremes of age [13]. Functional results can be excellent with several reports showing that patients who survive long term generally have a New York Heart Association score of 1 or 2 [14–16].

Debate as to whether coronary artery bypass grafting (CABG) should be undertaken along with closure of the VSD has been ongoing. Evidence exists showing that CABG in this situation is beneficial [8,9,12]. However, results from other authors show this not to be the case [4–7]. The complex interaction of multiple factors including the patients preoperative haemodynamic status, site of VSD and different operative techniques used, are all confounding variables when trying to identify the usefulness of concomitant CABG.

In our series we report on the experience of the cardiac surgeons in the northwest of England, with a multi-centre regional cohort study, giving an account of the risk factors leading to poor prognosis. In particular we examine the effect of concomitant CABG on mid-term survival.

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
2.1. Patient population and data
The northwest quality improvement programme in cardiac interventions is a regional consortium involving all four centres (Blackpool Victoria Hospital, Blackpool; The Cardiothoracic Centre, Liverpool; Manchester Royal Infirmary, Manchester, Wythenshawe Hospital, Manchester) performing adult cardiac surgery and percutaneous coronary interventions in the northwest of England. The aim of the group is to continuously improve the quality of care for patients receiving cardiac interventions using a regionally based systems approach.

Data were collected on a total of 65 consecutive patients undergoing surgical repair of a post-infarct VSD between 1 April 1997 and 31 March 2002 in the northwest of England. Data collection methods and definitions have been described in detail previously [17] and are available from http://www.nwheartaudit.nhs.uk

Data on the following variables: age, sex, body mass index, urgency of operation, prior cardiac surgery, Canadian Cardiovascular Society (CCS) angina class, history of myocardial infarction (MI), smoking, diabetes, hypercholesterolaemia, hypertension, respiratory disease, renal dysfunction, congestive cardiac failure, cardiogenic shock, intra-aortic balloon pump (IABP), inotrope and ventilation support as well as the extent of coronary disease, and left ventricular ejection fraction were collected prospectively in our Cardiac Surgery Registry as part of routine clinical practice. The duration of cardiopulmonary bypass and cross-clamp times were also collected. The outcome measures for our study were in-hospital mortality, length of intensive care unit (ICU) and post-operative hospital stay, stroke, peri-operative myocardial infarction, re-operation for bleeding, renal failure, tracheostomy, atrial arrhythmia, pacemaker implantation, and post-operative requirement for inotrope and IABP support.

In-hospital mortality was defined as death within the same hospital admission regardless of cause. All patients transferred from the base hospital to another hospital were followed up to confirm their status at discharge. Post-operative stroke was defined as a new focal neurological deficit and/or comatose states occurring post-operatively that persisted for >24 h after its onset. We excluded confused states, transient events and intellectual impairment from our study to avoid any subjective bias. Post-operative myocardial infarction was defined as a new Q-wave post-operatively in two or more contiguous leads on an electrocardiogram or a significant rise in post-operative cardiac enzymes combined with haemodynamic and echocardiographic signs of myocardial infarction. Post-operative atrial arrhythmia (atrial fibrillation or flutter) was defined as the occurrence of new atrial arrhythmia in the absence of pre-operative persistent or paroxysmal atrial arrhythmias. Post-operative bleeding was defined as bleeding that required surgical re-exploration after initial departure from the operating theatre. Renal failure was defined as patients with a post-operative creatinine level greater than 200 µmol/l or patients requiring dialysis.

A retrospective case note review was carried out to collect additional information on infarct related arteries, total occlusion, location of MI and VSD, method of diagnosis, concomitant CABG, as well as heart rate on admission and recurrence of VSD.

2.2. Surgical technique
Following full cardiological assessment including echocardiography and coronary angiography patients were operated on through a median sternotomy. After cardiopulmonary bypass was established the septal rupture was approached through the infarcted area of myocardium. The VSD was then patched using various materials (Dacron, Teflon or bovine pericardium) or simply buttressed with sutures alone. The ventriculotomy was then closed using Teflon strips to support the suture line, with or without exclusion of the infarcted myocardium. Bypass was discontinued after which inotropes and IABP were used when indicated to stabilise the patient in the immediate postoperative period.

2.3. Patient follow-up
Patient records were linked to the National Strategic Tracing Service (NSTS), which records all deaths in the United Kingdom, to establish current vital status as from the 31st December 2002. Patients were matched to the NSTS based on patient name, National Health Service number, date of birth, gender, and postcode. This enabled us to assess 30-day mortality, defined as any death occurring within 30 days of surgery either in hospital or after hospital discharge.

2.4. Statistical methods
Due to the non-normality of continuous variables, data are shown as median with 25th and 75th percentiles. Categorical variables are shown as a percentage. Comparisons were made with Wilcoxon rank sum tests and Chi-square tests as appropriate. The Parsonnet risk stratification score (modified to a regional standard) and the European System for Cardiac Operative Risk Evaluation (EuroSCORE) were derived to assess differences in patient case-mix [17,18]. A multivariable logistic regression analysis was undertaken to identify independent risk factors for in-hospital mortality [19]. Variables listed in Table 1 and duration of cardiopulmonary bypass and cross-clamp times were offered to the model for consideration, using forward stepwise selection methods. The C statistic (equivalent to the area under the receiver operating characteristic curve) and the Hosmer–Lemeshow goodness-of-fit statistic were calculated to assess the performance and calibration of the model, respectively [19,20]. Events occurring as a function of time were described using the product limit methodology of Kaplan and Meier [21]. To control for differences in patient characteristics, we used forward stepwise Cox proportional hazards analysis to calculate hazard ratios (HR) and to risk adjust the Kaplan–Meier survival curves [22]. In all cases a P value <0.05 was considered significant. All statistical analysis was performed retrospectively with SAS for Windows Version 8.2.

	3. Results

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

A total of 42 patients (64.6%) underwent simultaneous CABG during the procedure, with a median of two grafts (25th and 75th percentiles: 1–3). The characteristics of patients depending on whether a concomitant CABG was performed or not is shown in Table 2.

3.2. In-hospital complications
The results of the logistic regression analysis found that the independent risk factors for in-hospital mortality were preoperative inotrope support [OR 8.8 (95% CI 2.5–31.4); P<0.001), and total occlusion of infarct related artery [OR 6.6 (95% CI 1.2–35.9; P=0.03]. The discriminatory ability of the logistic model, as measured by the C statistic, was 0.81. The Lemeshow–Hosmer goodness-of-fit statistic across deciles of risk was not statistically significant (P=0.85).

In-hospital complications and outcomes are shown in Table 3 depending on whether a concomitant CABG was performed or not.

Crude freedom from death figures at 4 years following VSD surgery, shown in Fig. 1 , was not significantly different between concomitant CABG and non-concomitant CABG patients [57.9% vs. 50.7%; HR 0.82 (95% CI 0.38–1.78); P=0.62). However, after performing forward stepwise Cox proportional hazards analysis, we found that concomitant CABG significantly improved mid-term survival with a hazard ratio of 0.17 (95% CI 0.04–0.74; P=0.019). Other variables found to be associated with mid-term mortality included unstable angina, smoking, and total occlusion of infarct related artery (Table 4). The adjusted Kaplan–Meier survival curves are shown in Fig. 2 . The adjusted freedom from death in the concomitant CABG patients at 30 days, 1, 2, and 4 years was 96.2%, 91.6%, 88.8%, and 82.8%, respectively, compared with 79.1%, 58.8%, 49.1%, and 32.2% for the non-concomitant CABG patients.

View larger version (20K): [in this window] [in a new window]   Fig. 1. Observed mid-term survival based on whether concomitant CABG performed.

View larger version (18K): [in this window] [in a new window]   Fig. 2. Mid-term survival based on whether concomitant CABG performed, adjusted for unstable angina, current smoking, and total occlusion of infarct related artery.

View larger version (10K): [in this window] [in a new window]   Fig. 3. Recurrence of ventricular septal defect following surgical repair.

	4. Discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

Previously reported 30-day mortality rates range from 21 to 42% [5,11]. Our 30-day mortality rate was comparable at 23%. Preoperative status of the patient has a bearing on prognosis. Poor ventricular function [5], deteriorating cardiovascular status [5,6], cardiogenic shock [4,5,11,12,23], inferior MI [11,12], increasing age [23] and inotrope requirements [12], have all been shown to be associated with a poor prognosis. Less evidence in the literature exists regarding how operative factors relate to mortality. One study did show that longer cardiopulmonary bypass time was a risk factor for higher mortality rates [7]. We have identified preoperative inotrope support and total occlusion of the infarct related artery as significant predictors of in-hospital mortality.

Angiographic results from our population differ from other studies. Previously reported single vessel disease was the most common finding, usually 56–63% [6,8,24] in patients presenting with VSD. In our cohort, only 29.2% of patients had single vessel disease with the majority having double or triple vessel disease. This difference could be explained by the high prevalence of ischaemic heart disease in the northwest of England. The higher incidence of multivessel disease allows more realistic assessment of the benefit of CABG than other studies where single vessel disease predominates.

The question of whether to perform bypass grafts at the same time as the VSD closure has remained largely unresolved over recent years. The safety of coronary angiography in these unstable patients has been a concern. It has been shown that up to 4.5% of these patients can deteriorate haemodynamically during catheterisation [8]. In contrast, Labrousse et al. [5] demonstrated angiography to be safe in their cohort. In our experience, coronary angiography did not adversely affect the clinical state of the patients in our population. Often, it was useful not only in providing information about the coronary arteries but also provided the opportunity to site an IABP. Davies et al. [15] from their retrospective series of long term follow up concluded that septal rupture from an anterior MI in patients with no previous history of ischaemic heart disease were unlikely to have multivessel disease and therefore angiography, along with its potential hazards could be avoided. Although this may largely be the case, there are always exceptions and as long as evidence suggests that angiography in this setting is safe, we recommend it should be performed routinely.

Several reports have shown concomitant CABG to be of no benefit in improving early and late outcomes [4–7]. These authors have questioned whether longer procedure, bypass and cross-clamp times are justified. There is evidence, however, that show CABG in this situation to be advantageous [8,9,12].

Labrousse [5], Deja [6] and Dalrymple-Hay [7] all showed no significant difference in mortality rates if CABG was undertaken or not. However, their papers make the point that this is a complex matter and these findings are not a reason to avoid revascularisation. None of these studies showed a detrimental effect, concluding that CABG is safe in this situation but not necessarily beneficial. In order to recommend routine CABG in post infarct VSDs, they recognise that further evidence is required to fill the deficiencies in the literature.

Anderson et al. [12] highlighted the beneficial effect of grafting the right coronary artery. However, it was argued that this improved prognosis was actually a consequence of all the VSDs being anterior [7]. This is commonly accepted to have favourable outcomes compared to posterior VSDs [7]. Interestingly though, other reports have found no significant difference between outcomes of anterior and posterior defects [6].

Two large studies have reported that concomitant CABG is beneficial. First, Muehrcke et al. [9] found that patients who had coronary artery disease outside of the infarcted region of myocardium fared significantly better, long term, if they were grafted. This conclusion may be limited in that only univariate analysis was performed on the data. Cox et al. [8] reports similar findings.

Pretre and colleagues, in a recent publication of 54 patients who underwent patch closure of the post-infarct VSD, showed that simultaneous myocardial revascularisation controlled the added risk of coronary artery disease [25].

In this multi-centre regional cohort study of patients who underwent surgical repair of post-infarct VSD, we have shown that patients who receive simultaneous CABG have a significantly reduced risk of mortality over a 4-year follow-up period. After multivariable adjustment for patient and disease characteristics, the 4-year post-VSD repair survival rate was 88.2% with CABG, and 32.2% without, and the adjusted HR for mortality during the entire follow-up period was 0.17 (P=0.019 ).

Recurrence of VSDs, after the initial emergency repair have been quoted at different rates ranging from 10 to 40% [6,11]. Deja reported that of the 44% of their series that had residual shunt, 30% required a further operation to correct the persistent VSD, of these 9% died. This highlights the importance of a sound closure in these compromised patients. Labrousse et al. [5] recently published their series comparing single patch to double patch VSD closure. Their single patch series had an 11% recurrence rate compared to no recurrence in the patients who received a double patch repair. The recurrence rate we report of 24% is similar to those of other authors. Possibly in the future, when there is more experience of the double patch technique, recurrence rates may be reduced.

There are some limitations, which may effect the conclusions drawn from this study. First, it is an observational report and therefore could be confounded by selection bias. However, we have used multivariate Cox proportional hazards analysis to adjust for differences in patient and disease characteristics. Although, the risk adjustment may not have taken into account variables that may affect the survival of our patients, but for this to have a dramatic effect on our conclusions, the variables used in the risk adjustment would have to be uncorrelated with the variables not adjusted for. Second, it is important to note that it would be virtually impossible to scientifically prove that CABG is beneficial in these patients. A randomised control trial of two groups of patients who both require CABG, which would involve a control group of patients who are refused myocardial revascularisation, would be unethical. Another limitation is the small sample size of 65 patients, which reduces the accuracy of our results leading to wide confidence limits. For example, the independent risk factors for in-hospital mortality have wide confidence limits around the odds ratio [preoperative inotrope support OR 8.8 (95% CI 2.5–31.4)]. However, the logistic model had a C statistic of 0.81 indicating a good ability to predict the number of observed deaths [20].

In conclusion, from the 5-year experience in the northwest of England, CABG performed with closure of post infarct VSDs is significantly beneficial to mid-term outcome compared to no revascularisation. This adds support to various other reports that advocate the use of routine CABG in this setting. Preoperative inotrope support and total occlusion of the infarct related arteries are significant predictors of in-hospital mortality.

	Acknowledgments

 
We would like to acknowledge the co-operation given to us by all the Consultant Cardiac Surgeons in the region. Blackpool Victoria Hospital: Mr Au, Mr Bhatnagar, Mr Duncan, Mr Fagan, Mr Millner, Mr Nkere, Mr Sharpe. The Cardiothoracic Centre-Liverpool: Mr Chalmers, Mr Dihmis, Mr Drakeley, Mr Fabri, Miss Griffiths, Mr Mediratta, Mr Page, Mr Pullan, Mr Rashid, Mr Weir. Manchester Royal Infirmary: Mr Grotte, Mr Hasan, Mr Keenan, Mr Odom, Mr Pendergast. Wythenshawe Hospital: Mr Bridgewater, Mr Campbell, Mr Carey, Mr Deiraniya, Mr Hooper, Mr Jones, Mr Lawson, Mr Rahman, Mr Waterworth, Mr Yonan. Special thanks to M.N. Bittar, J.B. Barnard, A. Jalal, J. Thekkudan, and K. Prasad for their assistance in data collection. We would also like to thank for their considerable efforts Stephen Bullough, Suzanne Chaisty, Janet Deane and Catherine Malpas, who maintain the quality and ensure completeness of data collected in our Cardiac Surgery Registry.

	Footnotes

 
On behalf of the North West Quality Improvement Programme in Cardiac Interventions.

	References

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 

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