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Eur J Cardiothorac Surg 2005;27:216-221
© 2005 Elsevier Science NL

Surgical repair of post infarction ventricular septal defects: a national experience

^a Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
^b Department of Cardiothoracic Surgery, University Hospital, Lund, Sweden
^c Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
^d Swedish Heart Surgery Registry, Stockholm, Sweden
^e Department of Thoracic Surgery, Karolinska Hospital, Stockholm, Sweden

Received 10 September 2004; received in revised form 12 October 2004; accepted 20 October 2004.

^* Corresponding author. Tel.: +46 31 3421000; fax: +46 31 41 79 91. (E-mail: anders.jeppsson{at}vgregion.se).

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Objectives: Ventricular septal rupture is a rare but feared complication after acute myocardial infarction. Most reports about outcome after surgical treatment are single center experiences. We investigated the results after surgical repair in all patients in Sweden during a 7-year period. Methods: All patients undergoing surgical repair 1992–1998 were identified with the aid of the Swedish Heart Surgery Registry. The patients (n=189, 63% men, mean age 69±8 years) were operated at 10 different centers. Pre-and peri-operative variables were collected from the Registry and individual patient charts. Mortality was calculated and a Cox proportional hazards regression model was used to identify independent predictors for early and late mortality. Mean follow-up was 2.4 years. Results: Seventy-seven of the 189 patients died within 30 days (41%). Urgent repair (Risk Ratio 4.2 (2.0–8.9), P<0.001) and posterior rupture (RR 2.1 (1.3–3.4), P=0.002) were independent predictors of 30-day mortality. Total cumulative survival (Kaplan–Meyer) was 38% at 5 years. For patients that survived the first 30 days (n=112), 5 year cumulative survival was 67%. Independent predictors for mortality after 30 days were number of concomitant coronary anastomoses (RR 1.5 (1.2–2.0), P=0.001), residual postoperative shunt (RR 2.7 (1.4–5.4), P=0.004) and postoperative dialysis (RR 3.4 (1.5–7.5), P=0.003). Conclusions: Early mortality after surgical repair of post infarction septal rupture is still considerable. Early repair and posterior rupture are predictors of early mortality. Long-term survival in patients surviving the immediate postoperative period is limited by pre-existing coronary artery disease, postoperative renal failure and the presence of a residual postoperative shunt.

Key Words: Post infarction ventricular septal rupture • Coronary artery bypass grafting • Mortality • Risk analysis

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Ventricular septal defect (VSD) is a rare but feared complication after acute myocardial infarction (MI). The incidence is low, approximately 0.2% of all patients with a MI develop post infarction-VSD [1]. Mortality with medical treatment only is extremely high, over 90% [1,2] whereas mortality after surgical repair varies between 19 and 60% in different studies [1,3–11].

Most reports about outcome after surgical repair of post infarction-VSD are single center experiences. Due to the low incidence, the studies contain either relatively few patients or more patients collected over a long period of time. Thus, the aim of the present investigation was to report outcome in a larger group of patients collected over a shorter period, i.e. all patients subjected to surgical repair for post infarction-VSD in Sweden during a 7-year period. Furthermore, we sought to identify risk factors for early and late mortality after surgery.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
2.1. Patients
All patients in Sweden subjected to surgical repair of a post infarction-VSD during the years 1992–1998 were identified with the aid of the Swedish Heart Surgery Registry. The patients (n=189, 63% men, mean age 69±8 years, range 47–83 years) were operated at ten different hospitals. The number of patients operated at each hospital during the inclusion period varied between 3 and 50. Patient selection and surgical methods were determined by local routines. The local research ethics committee at all participating hospitals approved the study. Patient characteristics are given in Table 1.

2.3. Definitions
Early mortality was defined as all deaths within the first 30 days and late mortality as all deaths after 30 days. Urgent repair was defined as surgery within three days after diagnosis. The calculation of perioperative complications is based on patients that survived the operation.

2.4. Follow-up
Follow-up is 100% complete. Mean follow-up time for the whole material is 2.4±2.8 years (range 0–8.9) and 4.0±2.5 years (range 0.1–8.9) in the patients who survived the first 30 days.

2.5. Statistical analyses
The data are generally presented as the means and standard deviations. For time from MI to VSD diagnosis, time from MI to surgical repair and time from VSD diagnosis to surgery, the median time and inter-quartile range is given. Student' t-test was used to compare continuous data and chi-square test was used to compare categorical data. Cumulative long-term survival was calculated according to the method of Kaplan and Meier and groups were compared with the log rank test. Cox's proportional hazard model was used for multivariate analysis of risk factors for early and late mortality. Only factors significant in univariate testing were included in the multivariate model. A P-value of <0.05 was considered significant.

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
3.1. Patient demography
Baseline characteristics and operative data for the 189 patients are given in Table 1. The median time from MI to VSD diagnosis was 4 days and the median time to repair from diagnosis was 1 day. Eighty-one percentage of the patients were operated within one week after diagnosis, 14% between one and three weeks and 5% after three weeks. In ten patients the exact time of MI and diagnosis was not available. A preoperative coronary angiogram was performed in 78% of the cases and 63% of the patients underwent concomitant CABG.

3.2. Early mortality
Overall postoperative mortality is given in Fig. 1. Seventy-seven of the 189 patients died within 30 days (41%), of which 38 patients (20%) died during operation. A comparison of pre-, peri- and post-operative variables between patients that died or survived the first 30 days are given in Table 2. Non-survivors were operated earlier after MI and VSD diagnosis, did less often undergo preoperative coronary angiography and had more often a posterior rupture. In addition, non-survivors had, as expected, a higher incidence of postoperative IABP, neurological complications, dialysis and re-exploration for bleeding than survivors, Table 2.

View larger version (30K): [in this window] [in a new window]   Fig. 1. Cumulative survival in all post infarction-VSD patients (n=189).

View larger version (10K): [in this window] [in a new window]   Fig. 2. Thirty-day mortality in patients operated at different time intervals after VSD diagnosis.

In large centers (30 patients during the study period) was early mortality 36%. In medium-sized centers (15–29 patients) was early mortality 39% (P=0.64 vs large centers) and in small centers (15 patients) was early mortality 54% (P=0.06 vs large centers, P=0.15 vs medium-sized centers).

3.3. Late mortality
One hundred-twelve patients (59%) survived the first 30 days. Thirty-eight of these patients (34%) died during the follow-up period. Cumulative survival for all 189 patients was 47% at 1 year, 39% at 3 years and 38% at 5 years, Fig. 1. In Fig. 3, cumulative survival for the patients that survived the first 30 days is given. Cumulative survival in this subgroup at one, three and 5 years were 83, 72 and 68%, respectively. In Fig. 4, cumulative survival in patients with concomitant CABG or not in patients that survived the first 30 days is depicted.

View larger version (30K): [in this window] [in a new window]   Fig. 3. Cumulative survival in post infarction-VSD patients that survived the first 30 days (n=112).

View larger version (32K): [in this window] [in a new window]   Fig. 4. Cumulative survival after 30 days in post infarction-VSD patients that underwent concomitant CABG (filled line) or not (semi-dotted line). There was a significant difference between the two groups, P=0.030.

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

4.1. Early mortality
Crenshaw recently reported data from the large GUSTO database and found a lower incidence of post infarction-VSD (0.2%) and a shorter time interval between MI and VSD (median time 1 day) than in the pre-thrombolythic era [1]. In the present study, performed during the same time period, a considerable longer interval between MI and VSD was noted (4 days). We cannot explain the diverging results but it must be considered that the patient material in both studies is limited.

Early mortality (30 day) in the present study was 41%, which appears to be comparable to other recent reports the subject (19–52%) [1,3–11]. Variations in patient selection, or definitions of early mortality (30 day vs hospital mortality), and whether or not patients operated late after diagnosis were excluded makes direct comparisons less meaningful. However, mortality in our and other multi-center studies appears to be somewhat higher than reported in single center studies. One may suspect that centers reporting their own results have better than average outcome due to better patient selection and/or more refined surgical techniques.

Need for urgent repair, i.e. surgery early after diagnosis is a consistent risk factor for early mortality in literature [4,7,10]. This was also confirmed in the present investigation, as urgent repair (within 3 days after diagnosis) was an independent predictor for 30-day mortality. This is further illustrated in Fig. 2 demonstrating an inverse relation between 30-day mortality and time between diagnosis and repair. However, the fast deterioration of many patients with post infarction-VSD makes it often impossible to delay surgery and thus, our finding that need for early repair is a predictor for early mortality should not be interpreted that surgery should be delayed to reduce operative mortality. Instead, in our opinion and in current cardiology guidelines [12] surgical treatment should be initiated without delay after diagnosis, despite the high risk.

The study also confirms the previous reports [2,6] indicating that posterior ruptures is associated with increased early mortality as compared to anterior ruptures (51 vs 30%, P=0.005). probably related a more complex rupture and thus a technically more demanding operation [2]. In accordance with previous reports is also the lack of correlation between survival, sex and age in our study.

Early mortality tended to be higher in patients operated at small centers (<15 patients during the study period) compared to mid-sized and large centres (54, 39 and 36%, respectively). This finding suggests that patients in a stable condition should be transferred to a centre with large experience. However, it should be noted that many patients with post infarction-VSD deteriorate fast and thus the transport may be hazardous. In addition, the difference was not statistically significant (P=0.06) and the analysis is univariate.

4.2. Late mortality
It is controversial whether concomitant CABG improves outcome after post infarction-VSD repair. Some studies showed no benefit of CABG [6–8] while others found evidence for concomitant CABG to be advantageous [3,5,9]. In the present investigation concomitant CABG tended to result in lower early mortality (38 vs 46%, P=0.29) while mid-term survival (after exclusion of patients who died within the first 30 days) was significantly lower in patients undergoing CABG, Fig. 4. When all postoperative deaths were included in the comparison, mid-term mortality did not differ between patients undergoing concomitant CABG or not (P=0.70). Thus, our study does not give a clear indication whether CABG should be performed or not although the tendency to improved survival in the immediate postoperative period favors CABG. However, concomitant CABG was associated with a worse mid-term survival in patients surviving the immediate postoperative period, Fig. 4. Furthermore, the number of anastomoses was an independent predictor of late mortality with a risk ratio of 1.5 for each additional anastomosis, Fig. 5. To our knowledge this has not been previously been reported. It is likely that the number of anastomoses reflect the extent of coronary artery disease (CAD) at the time of repair. That the extent of CAD predicts long-term survival appears logical since the extent of CAD predicts survival in other CAD populations [13].

View larger version (38K): [in this window] [in a new window]   Fig. 5. Cumulative survival after 30 days in patients with no anastomoses (filled line), 1–2 anastomoses (dotted line), or 3 or more anastomoses (semi-dotted line).

4.3. Limitations
Most reports about outcome after surgical repair of post infarction-VSD are single center experiences with few patients collected over a long period of time. The advantages of the present study are that it is a multicenter experience, including all patients operated in Sweden during a relative short period of time (7 years), a 100% complete follow-up and to our knowledge, the largest study on outcome after surgical repair after post infarction-VSD. However, there are important limitations to discuss. First, is the retrospective design, although partly based on prospectively collected data. Second, the multicenter design which necessitated a simplified data collection form with a limited number of variables to avoid missing data. Thus, it cannot be completely ruled out that non-registered variables could have influenced the results of the multivariate analyses.

In summary, the present large national study confirms the high perioperative mortality, the positive effect on long-term survival, and the identification of posterior rupture and urgent repair as independent risk factors of early mortality after surgery of post infarction-VSD. In addition, the extent of CAD at the time of repair was shown to limit long-term survival.

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Dr J. Pomar (Barcelona, Spain): May I ask you the impact of the right ventricular function on the outcomes?

Dr Jeppsson: We didn't measure right ventricular function. The retrospective multicenter study design necessitated a simple data collection form to avoid missing data and we did not include right ventricular functional data.

Dr F. Bouchart (Rouen, France): How do the cardiologists manage these types of patients, that is, do you think you included all patients with VSDs? Isn't there really a selection before the patient goes to the surgeon?

Dr Jeppsson: You are right, this is definitely not all patients with a post infarction-VSD in Sweden. We have made a preliminary study in another patient kohort, which indicates that about 50% of all patients with a post infarction-VSD come to surgery.

Dr P. Tossios (Cologne, Germany): Can you comment on the use of preoperative intra-aortic balloon pump and the impact that it has on outcome?

Dr Jeppsson: 19% of the patients had a preoperative intra-aortic balloon pump, and in univariate testing, this was a significant risk factor for early death. However, it was not a significant predictor in multivariate testing. In our opinion, the use of a preoperative balloon pump reflects the condition of the patient before surgery, more severely ill patients receive a pump and postoperative mortality is subsequently higher in this subgroup of patients.

Dr O. Simic (Rijeka, Croatia): Do you have data about mortality for the rupture of the anterior VSDs? You said that altogether it was 40%, but do you have data just for the anterior side?

Dr Jeppsson: Early mortality was 50% in the group of patients with a posterior rupture and 30% in the group with anterior rupture.

	Acknowledgments

 
The authors thank the chiefs of service at the ten Swedish centers that provided access to patient charts. The patients were operated at Lund University Hospital, Malmö General Hospital, Karlskrona Hospital, Sahlgrenska University Hospital, Linköping University Hospital, Örebro University Hospital, Uppsala Academic Hospital, Karolinska Hospital, Huddinge University Hospital and Umeå University Hospital.

	Footnotes

 
Presented at the joint 18th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 12th Annual Meeting of the European Society of Thoracic Surgeons, Leipzig, Germany, September 12–15, 2004.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 

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