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Eur J Cardiothorac Surg 2005;28:186-187
© 2005 Elsevier Science NL

Letter to the Editor

Reply to Ramnarine and Grayson

Anders Jeppsson a , * , Per Johnsson b

a Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg 41 345, Sweden
b Department of Cardiothoracic Surgery, University Hospital, Lund, Sweden

Received 29 March 2005; accepted 30 March 2005.

* Corresponding author. Tel.: +46 31 3424988; fax: +46 31 417991. (Email: anders.jeppsson{at}vgregion.se).

Key Words: Post-infarction ventricular septal defect • Coronary artery disease • Survival

We thank Dr Ramnarine and Dr Grayson for their comments about our series of 189 patients surgically treated for post-infarction ventricular septal defects [1]. We share Ramnarine and Grayson's view that concomitant CABG should be performed in patients with post-infarction ventricular septal defect and significant coronary disease. However, from a scientific point of view, the support for this approach is weak. In their letter Ramnarine and Grayson refer to their own article [2] and to the works by Cox, Muehrcke and Pretre which indicates that concomitant CABG is beneficial, but do not mention the works by Labrousse, Deja and Dalrymple-Hay [3–5] that did not find any support for CABG. Interestingly, concomitant CABG was not a predictor of survival in the two largest series [1,3].

Ramnarine and Grayson also suggest that unstable angina should be included as a factor in multivariate analyses in post-infarction-VSD patients. Ramnarine and Grayson refer again to their own material of 65 patients [2]. First, it is not clear from the article when the period of unstable angina occurred. Was it before the myocardial infarction (MI), between MI and the development of VSD or after the VSD had been diagnosed and repaired? In addition, the imbalance between number of events and included factors in the analysis in Ramnarine and Grayson's study must be considered. In their study, 12 early and 16 late events (deaths) occurred during the follow-up period while over 30 different factors were included in the stepwise analysis. This disproportion generates a substantial risk for random significance, may imply that true predictors are missed and necessitates a critical assessment of the data before publication. Notably, recognized risk factors for death after post-infarction VSD, such as inferior infarction and repair early after diagnosis, which repeatedly has been shown to influence outcome after surgical repair were not identified in Ramnarine and Grayson's study. In contrast, their study identified smoking and unstable angina for the first time. The importance of these new potential predictors needs to be verified in larger studies with carefully selected variables.

References

  1. Jeppsson A, Liden H, Johnsson P, Hartford M, Radegran K. Surgical repair of post infarction ventricular septal defects: a national experience. Eur J Cardiothorac Surg 2005;27:216-221.[Abstract/Free Full Text]
  2. Barker TA, Ramnarine IR, Woo EB, Grayson AD, Au J, Fabri BM, Bridgewater B, Grotte GJ. 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. Eur J Cardiothorac Surg 2003;24:940-946.[Abstract/Free Full Text]
  3. Dalrymple-Hay MJ, Langley SM, Sami SA, Haw M, Allen SM, Livesey SA, Lamb RK, Monro JL. Should coronary artery bypass grafting be performed at the same time as repair of a post-infarct ventricular septal defect?. Eur J Cardiothorac Surg 1998;13:286-292.[Abstract/Free Full Text]
  4. Deja MA, Szostek J, Widenka K, Szafron B, Spyt TJ, Hickey MS, Sosnowski AW. Post infarction ventricular septal defect—can we do better?. Eur J Cardiothorac Surg 2000;18:194-201.[Abstract/Free Full Text]
  5. Labrousse L, Choukroun E, Chevalier JM, Madonna F, Robertie F, Merlico F, Coste P, Deville C. Surgery for post infarction ventricular septal defect (VSD): risk factors for hospital death and long term results. Eur J Cardiothorac Surg 2002;21:725-731.[Abstract/Free Full Text]




This Article
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