Post infarction ventricular septal defect – can we do better?✩

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Abstract
Objective: To identify predictors of early and late outcome among 117 consecutive patients who underwent postinfarction ventricular septal defect (VSD) repair over a period of 12 years. Methods: A retrospective analysis of clinical data was performed. Mean age was 65.5±7.8. There were 43 females. Full data were obtained in 110 patients. Of these, 76 patients presented with anterior and 34 with posterior VSD. Thirty-three patients were operated in cardiogenic shock. Mean time between myocardial infarction (MI) and VSD development was 5.6±7.8 days (median 4) and from VSD to surgery 9.0±28.1 (median 2). Sixty-six patients had intraaortic balloon pump (IABP) inserted, and 15 were ventilated preoperatively. Logistic regression and Cox regression were used for multivariate analysis. Results: Thirty days mortality was 37%. Among 110 patients, in whom complete analysis was possible, 38 died within 30 days (35%). Mortality in the posterior VSD group was 35% and in the anterior VSD group 34% (NS). In 44 patients (40%) a residual shunt was found on postoperative echocardiography. This required reoperation in 13 patients (four deaths). Cardiogenic shock prior to surgery adversely influenced early survival – odds ratio (OR) 5.7 (confidence interval (CI) 2.1–16.0) (P=0.0008). Deterioration of haemodynamic status in between admission and surgery was stronger predictor of mortality than shock on admission – OR 6.0 (CI 1.6–22.6) (P=0.008) vs. 3.1 (CI 1.0–9.3) (P=0.049). A longer time between MI and surgery favoured survival – OR 0.1 (CI 0.03–0.4) (P=0.002). The time period from the infarct to the septal rupture, but not from the rupture to surgery, appeared to be a significant predictor of survival – OR 0.2 (CI 0.05–0.6) (P=0.008). Five years survival was 46±5%. Preoperative cardiogenic shock affected late survival – OR 2.7 (CI 1.5–4.9) (P=0.001). Of 72 patients who survived 30 postoperative days, 12 (17%) were in New York Heart Association (NYHA) class III or IV and five (6.9%) in Canadian Cardiovascular Soceity (CCS) class III or IV at the last follow-up. Conclusions: Preoperative cardiogenic shock and early postinfarction septal rupture carry a grave prognosis. Achieving haemodynamic stability prior to surgery may be beneficial but prolonged attempts to improve patients’ cardiovascular state are hazardous.

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