Post infarction ventricular septal defect - can we do better?

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.

Role of transcutaneous ultrasound in evaluation of graft patency following minimally invasive coronary surgery.

OBJECTIVE: Recent development in minimally invasive coronary surgery prompted us to carry out prospective evaluation of patients undergoing coronary artery bypass grafting through left anterior small thoracotomy. METHODS: Between April 1996 and February 1997, 15 patients (age 32-70, 12 male) were operated on. The left internal thoracic artery (LITA) basal flow was assessed by means of transcutaneous Duplex ultrasound scanning with pulsed waved Doppler. Eight patients were studied in the immediate postoperative period (2-4 days) and seven patients (1-7 months) following revascularisation. In addition to that, nine patients underwent coronary angiography. RESULTS: LITA graft flows were quantifiable in all 15 patients. In two patients there was a significant reduction in both time-averaged velocity and total flow. The subsequent coronary angiogram revealed severe (>50%) stenosis of LITA graft in both patients. One of these patients had a reversible obstruction documented by Duplex scanning and coronary angiography. Systolic measures did not differ between normal (13) and stenosed grafts (2), but diastolic time-averaged velocity (indicating coronary run-off) and total flow appeared lower in the latter. CONCLUSIONS: LITA flow following left anterior small thoracotomy surgery can be evaluated non-invasively. Measurement of diastolic flow (i.e. coronary perfusion rather than internal thoracic branch run-off) and total flow is useful in estimating graft function.