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Eur J Cardiothorac Surg 2005;28:185-186
© 2005 Elsevier Science NL
Letter to the Editor |
a Department of Cardiothoracic Surgery, The Cardiothoracic Centre, Thomas Drive, Liverpool L14 3PE, UK
b Department of Research and Development, The Cardiothoracic Centre, Liverpool, UK
Received 1 March 2005; accepted 30 March 2005.
* Corresponding author. Tel.: +44 151 293 2336; fax: +44 151 288 2371. (Email: tony.grayson{at}ctc.nhs.uk).
Key Words: Myocardial infarction • Ventricular septal defect • Coronary artery bypass grafting • Mid-term survival
We enjoyed reading the recently published article by Jeppsson and colleagues [1], which examined the national results in Sweden for surgical repair of post-infarct ventricular septal defects (VSD). They correctly concluded that the long-term survival of these patients was limited by pre-existing coronary artery disease (CAD), post-operative renal failure, and the presence of a residual post-operative shunt. Interestingly, Jeppsson showed that the risk of death increased with the number of coronary anastomoses performed and concluded from this that this was a reflection of the extent of CAD. However, their conclusions on the potential benefits of performing concomitant coronary artery bypass grafting (CABG) were inconclusive.
In our own series of post-infarct VSD patients within the northwest of England [2], we concluded that concomitant CABG offered a significant benefit with respect to mid-term mortality. Although our series of 65 patients was smaller than the 189 patients in Jeppsson's series [1], we found that after adjusting for other risk factors for mid-term mortality (unstable angina (class IV), current smoking, and total occlusion of the infarct related artery), patients with concomitant CABG had a substantial reduced risk of death with a relative risk of 0.17 (95% confidence intervals 0.04–0.74; P=0.019) [2].
In our series [2], patients with concomitant CABG were more likely to have unstable angina than patients without concomitant CABG (50 versus 30%); and unstable angina was associated with the greatest risk of death during follow-up, with such patients being 12 times more likely to die than patients with stable angina. Jeppsson admits to limitations in their data collection, and may have missed variables related to mortality [1]. We note that angina status was not included, and we feel that this variable must be considered when balancing out differences between patients with and without concomitant CABG.
Two other large studies by Cox [3] and Muehrcke [4] have reported that concomitant CABG is beneficial. Muehrcke and associates [4] found that patients who had coronary artery disease outside of the infracted region fared significantly better, long term, if they were grafted. 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 [5].
From our own data and other published series, we would recommend that patients who present with post-infarct VSD who have multi-vessel disease should be routinely revascularised.
References
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