Surgical Management of Postinfarction Ventricular Septal Defect

Accessible online at: www.karger.com/journals/hed In this issue of Heart Drug, Prêtre and Turina [1] present a retrospective study of 54 patients operated on for postinfarction ventricular septal defect (VSD) during the period 1979–1998. The treatment protocol applied was based on the principles of early closure, concomitant myocardial revascularization and ventricular remodeling. In the late 1970s, Daggett et al. [2] and Daggett [3, 4] outlined the principles for the surgical treatment of postinfarction VSDs. Although surgical results have improved over time, postinfarction VSD still represents a great challenge, as illustrated by the early mortality rate of over 20% in the paper in this issue [1] during the last decade. These patients often come out of the operating room on maximal support and have a long and difficult course in the intensive care unit. There are no randomized studies and no studies in which all patients with a postinfarction VSD from a given population have been entered to give a true picture of the spectrum of the problems and issues. We are limited to retrospective studies of patients who, for one reason or another, were operated on for their VSD. The patient selection is based on the biases of the involved cardiologists and surgeons. Important risk factors may be masked by selection criteria not accounted for. The development of treatment strategies and surgical techniques to deal with postinfarction VSDs is based on the application of experience and technologies which have been slowly developed over time. Some of them have been used and tested in other more prevalent patient groups (the ‘grounded theory’ approach to development). The numbers in all series are small (the Cleveland Clinic 1969–2000 series of postinfarction VSDs included 130 patients [5]) and the selection process and criteria as well as level of surgical experience are different in each series. Patient selection is of primary importance to the outcome: which patients with a postinfarction VSD should be operated on? The spectrum includes younger patients with limited myocardial damage and small VSDs as well as older patients in cardiogenic shock and renal and other organ failure. In a recent, not yet published analysis of 130 patients operated on for postinfarction VSD between 1969 and 2000 at the Cleveland Clinic, the risk factors for death included older age (p = 0.006), anuria (p = 0.02), shorter interval from myocardial infarction to surgery (p ! 0.0001), residual shunt (p ! 0.0001) and earlier era of surgery (p ! 0.0001) [5]. Using a multivariable hazard function equation, a subset of high-risk patients (short interval between infarct and surgery, anuria, severe right ventricular dysfunction) was identified for whom surgical therapy was associated with excessive hospital mortality (75%) and no survivors beyond 3 years. For these patients, surgery should not be offered as a therapeutic option. With the best constellation of risk factors, a moderate interval between myocardial infarction and surgery and the absence of other risk factors, 3-year survival was