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Interact CardioVasc Thorac Surg 2009;9:879-887. doi:10.1510/icvts.2009.210658 © 2009 European Association of Cardio-Thoracic Surgery
In patients undergoing surgical repair of post-infarction ventricular septal defect, does concomitant revascularization improve prognosis?
a Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden Received 28 April 2009; received in revised form 28 July 2009; accepted 3 August 2009
*Corresponding author. Tel.: +46737238120.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘In patients undergoing surgical repair of post-infarction ventricular septal defect (VSD), does concomitant revascularization improve prognosis?’. The scientific literature was reviewed by searching Medline, using Ovid interface, from 1950 to April 2009. Four hundred and five papers were found, of which 18 were deemed relevant to the topics. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, and results of these papers were tabulated. Seven out of 18 papers showed statistical evidence of benefit of concomitant coronary artery bypass grafting (CABG) in patients undergoing surgical repair of VSD. They showed a benefit especially with complete revascularization. Another five papers recommended CABG with VSD even in the absence of statistical evidence. The reported papers showed a mortality benefit from 26.3% without revascularization down to 21.2% with revascularization and an actuarial survival at five years from 29 up to 72%. However, six out of 18 papers did not find any difference. The largest study in this area was by Jeppsson et al. where 119 patients underwent VSD repair with revascularization and 70 underwent VSD repair only, the mortality was 38% vs. 46% (P=0.29). Barker et al. compared a group of 23 patients undergoing repair of VSD only and 42 patients undergoing concomitant CABG. The in-hospital mortality was 39.2% vs. 26.2%, and the four-year survival rate was 33.2% and 88.2%, respectively. Lundblad et al. found that in 66 patients undergoing concomitant CABG out of 102 undergoing repair of VSD, complete revascularization and revascularization of the culprit artery, both resulted in improved 30-day survival and long-term survival. Muehrcke et al. reported on 75 patients undergoing surgical repair of post-infarction VSD. Out of those, 33 (44%) had a concomitant CABG. The authors found that concomitant CABG increases long-term survival when compared with patients with unbypassed coronary artery disease (CAD) (P=0.0015). We conclude that patients undergoing concomitant CABG to all the stenotic coronary arteries, supplying the non-infarcted area, fare better both in improved 30-day survival and long-term survival. The improvement of the collateral flow to the myocardium contributes to its better recovery.
Key Words: Evidence based medicine; Ventricular septal defect; Coronary artery bypass; Myocardial infarction
A best evidence topic was constructed according to a structured protocol. This protocol is described in the ICVTS [1].
You are the cardiac surgeon called to attend the coronary care unit where a hypotensive 67-year-old gentleman has been diagnosed with a large anterior ventricular septal defect (VSD). His systolic blood pressure is 80 mmHg on 3 ml/h of dobutamine, and his electrocardiogram (ECG) on admission indicates an anterior myocardial infarction. The patient reports a 3-day history of pain. The cardiologist would like you to take him straight to theatre, but you would like him to have an angiogram first. He says that he could become unstable in the angiography suite and, besides, coronary revascularization makes no difference in this situation and he could stent any further disease at a later date. Your view is that revascularization of non-infarcted territories improves prognosis and improves intraoperative survival and that the cardiologist could place an intra-aortic balloon pump (IABP) for you. You both agree to look up the evidence on this topic.
In [patients undergoing surgical repair of post-infarct ventricular septal defect] does [a concomitant revascularization] improve [prognosis]?
Medline search 1950–April 2009 was performed using OVID interface. [exp Ventricular Septal Rupture/OR post-infarct$ ventricular septal rupture$.mp OR post-infarct$ventricular septal defect$.mp.] The ‘related article’ function was used to broaden the search and all the abstracts, studies, and citation scanned were reviewed.
Four hundred and five papers were found using the reported search; 18 papers represent the best evidence topic on the subject (Table 1).
Jeppsson et al. [2] found that early mortality was lower in patients that underwent preoperative angiography, whereas early mortality did not differ significantly between patients that underwent concomitant coronary artery bypass grafting (CABG) or not. Furthermore, the number of anastomoses was an independent predictor of late mortality with a risk ratio of 1.5 for each additional anastomosis; this indicating that the extent of coronary artery disease (CAD) at the time of repair limits the long-term survival. Barker et al. [3] found that performing the Cox proportional hazard analysis, concomitant CABG improves the mid-term survival with hazard ratio (HR) 0.17. With the adjusted Kaplan–Meier survival curve, the freedom from death in concomitant CABG vs. non-concomitant CABG patients at 30 days, 1, 2 and 4 years is: 96.2%, 91.6%, 88.8% and 82.8% compared with 79.1%, 58.8%, 49.1% and 32.2%. After multivariate adjustment for patient and disease characteristics, the 4-year post-VSD repair survival rate is 88.2% in patients with concomitant CABG and 33.2% in patients without. Mantovani et al. [4] did not report any difference regarding the benefit of associated CABG, but they expressed the opinion that all the stenotic vessels to non-infarcted areas should be grafted. Labrousse et al. [5] found that concomitant CABG was associated with a lower risk of hospital mortality (P=0.1). They assessed that associated CABG is not a risk factor for early and late death and that CABG should be performed in order to reduce a further ischemic risk. Prêtre et al. [6] found that an associated CABG had a marginally negative impact on postoperative deaths; the operative mortality was 19% vs. 32% (P=0.36), while it had no impact on late death. These authors encouraged performing revascularization on vessels with significant stenosis. Cox et al. [7] with a multivariate analysis showed that incomplete revascularization was found to be a major risk factor for late cardiac mortality. Although, it was assumed that revascularization was of secondary importance, compared to the impact of the closure of the ventricular septal rupture, optimal revascularization of the residual viable myocardium may contribute to better recovery. Muehrcke et al. [8] showed a benefit from CABG in patients with significant associated CAD on univariate analysis. Patients who had concomitant artery disease outside the infarcted region of myocardium fared better in long-term follow-up if they were grafted. This benefit was greater in patients with anterior compared to inferior infarcts. Deville et al. [9], in a univariate analysis, found that concomitant CABG is not a risk factor for early and late death. The association of CABG reduces the mortality. Concomitant CABG should be performed. Deja et al. [10] could not prove definitive influence of concomitant CABG on late survival of their patients using a Cox regression model. They did not express a firm conclusion on the utility of a concomitant CABG. Dalrymple-Hay et al. [11] could not demonstrate significant benefit with respect to operative mortality from concomitant CABG at the time of the repair. With Cox's proportional hazard method, they did not find benefit in long-term. Parry et al. [12] did not show any increased survival in patients with concomitant CABG. They assessed that although augmentation of the coronary flow may be important in selected patients with extensive CAD, the necessary increase in bypass time may in itself negate the benefit. Held et al. [13] found increased bypass time to be an independent predictor of surgical mortality in their patients. Anderson et al. [14] showed that a right coronary artery graft improved survival. A right coronary artery graft was performed only in patients with an anterior VSD. Patients with an anterior VSD had significantly better survival (64% at 1 year) compared to inferior defects (11% at 1 year). The perceived benefit of this graft is a reflection of the increased survival of patients with anterior defect and not to the true effect of CABG. Lundblad et al. [15] found that complete global revascularization and revascularization of the culprit artery both result in improved 30-day survival and long-term survival. Ozkara et al. [16] expressed the opinion that myocardial revascularization on patients operated without delay might have possible effects on early outcome. Coskun et al. [17] could not prove any influence of concomitant CABG on late survival of their patients, but patients who have multivessel disease should be routinely revascularized. Papadopoulos et al. [18] found that concomitant CABG was not a risk factor for in-hospital mortality. Cerin et al. [19] found that at univariate analysis, concomitant CABG and the extension of the CAD were not significantly associated with mortality. They assessed that concomitant CABG can be safely performed.
Data suggest that concomitant myocardial revascularization in patients with post-infarct VSD improves late survival [7, 8]. A key point is played by the revascularization of non-infarcted regions of the myocardium. Patients undergoing concomitant CABG to all the stenotic coronary arteries, supplying the non-infarcted area, fare significantly better in long-term follow-up. The improvement of the collateral flow to the myocardium contributes to its better recovery.
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Abstract
1. Introduction