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Ann Thorac Surg 2000;70:1444-1445
© 2000 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
Address reprint requests to Dr Blanche, Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Suite 6215, 8700 Beverly Blvd, Los Angeles, CA 90048
e-mail: carlos.blanche{at}cshs.org
Abstract
1Fifteen elderly patients (age more than 70 years) underwent surgical repair of postinfarction venricular septal defects during the years 1980 through 1992. The operative (to discharge or < 30 days) mortality rate was 47%, and the complication rate among survivors was 63%. The probability of survival at 1 year was 47% ± 13%. Because of the small sample size of our patient population, predictive preoperative risk factors associated with early mortality could not be identified with certainty. However, there is a trend suggesting that high right atrial pressures (p = 0.15) and the need of an intraaortic balloon pump preoperatively (p = 0.12) influence 30-day mortality, as previously described in larger series. Of 5 long-term survivors, 3 are in New York Heart Association functional class I and 2 are in class II. Our experience in this group of patients suggests that in the elderly, a very aggressive approach should be taken in recommending early surgical intervention for postinfarction ventricular septal defect before hemodynamic deterioration ensues and severely compromises chances for survival.
The development of a ventricular septal defect (VSD) complicating an acute myocardial infarction still remains an infrequent but catastrophic event, particularly in the elderly. When our experience in the management of postinfarction VSD in the elderly was published in 1992 [1], that cohort of patients represented 0.53% of the total population of patients older than 70 years of age undergoing coronary revascularization or valve procedures, or both, in our institution. Since 1993, we have operated on an additional 5 patients 70 years of age and older who presented with a VSD after an acute myocardial infarction. Such patients now represent only 0.20% of our elderly population undergoing similar cardiac surgical interventions. This significant decline in the incidence of postinfarction VSD in the last decade is perhaps due to a more aggressive prevention and treatment of coronary artery disease, including the widespread use of trombolytic therapy and angioplasty/intracoronary stent interventions.
Those 5 patients were all women aged between 70.9 and 79 years (mean 73.3 years). One patient was diabetic and all underwent closure of the postinfarction VSD emergently with a surgical technique described previously [2]. Two patients had associated coronary artery bypass grafting and none had concomitant valve repair/replacement. An intraaortic balloon pump (IABP) was inserted preoperatively in 2 patients and was precluded in the remainder because of severe peripheral vascular disease. The operative (less than 30 days or to discharge) mortality was 60% (3 of 5 patients) and all deaths were cardiac in origin (pump failure). Both surviving patients had an IABP placed preoperatively, associated coronary artery bypass grafting (one graft each), and prolonged intubation (more than 48 hours) for postoperative respiratory failure, but they both had no renal and neurologic complications postoperatively. These patients are alive and well in New York Heart Association Class II at 2.7 and 5.6 years after operation, respectively.
In contrast, 3 patients younger than 70 years of age (range 29 to 68.7 years, mean 52.6 ± 16.8 years) were operated on for postinfarction VSD in our institution during the same time interval (1993 to 1999). There was no operative mortality among them and 2 are alive and well 1.3 and 5.1 years after operation, respectively. The third patient underwent heart transplantation for intractable congestive heart failure due to a recurrent ventricular septal rupture 2 months after VSD repair and remains well 6 years after transplantation.
Based on these findings, although without statistical validation because of the small number of patients involved, we maintain that our conclusions have remained valid over time. That is, an aggressive approach that includes early placement of an IABP followed by urgent operative intervention gives the best chance for survival in this desperately ill group of patients. Our current 60% hospital mortality is still substantial despite all the advances in prevention and treatment of acute myocardial infarction and related complications, and cannot be ignored. This increased mortality has a multifactorial basis and is probably related to the marginal reserve of elderly patients with poor tolerance for postoperative complications and their propensity to develop multiple-organ failure. In addition, the elderly may have more advanced heart disease and comorbidity factors than younger patients. Even though few reports of surgical repair of postinfarction VSD in the elderly have appeared in the literature, a higher operative mortality in this group of patients has been noted and age older than 65 years has been proven to be an independent risk factor that adversely affects early survival [3, 4]. We continue to analyze our data to determine the preoperative predictive risk factors that might significantly affect early mortality and late prognosis, particularly in the elderly. Two such factors were observed in our previous report and they included high right atrial pressure (indicative of right ventricular dysfunction as a result of right ventricular infarct in association with a posteriorly located VSD) and the absence of an intraaortic balloon preoperatively. These two risk factors were identified previously in a larger series of younger patients [2, 5].
Although the surgical technique for repair of postinfarction VSD has not been modified over time, we have described a new surgical approach, namely cardiac transplantation, for selected patients [6]. Even though our experience with heart transplantation in patients 70 years of age and older has been satisfying [7], the elderly might represent a different group of patients in this regard, as the development of cardiogenic shock and multiple organ failure is poorly tolerated in the older patient, thus precluding consideration for transplantation. Heart transplantation would be an infrequent treatment option reserved perhaps for those patients with recurrent or residual defects after surgical repair with chronic congestive heart failure not amenable to further medical therapy or any other surgical intervention.
In summary, as the management of acute myocardial infarction continues to evolve toward an earlier and more aggressive pharmacologic and interventional approach, the incidence of ventricular septal rupture complicating an acute myocardial infarction may decline even further, which may result in fewer patients in need of surgical repair. Our experience with postinfarction VSD in the elderly justifies such an aggressive approach and the consideration for surgical intervention should be made independent of age, as age by itself should not be the deciding factor or form the basis for these complex decisions.
Footnotes
1 As Originally Published in 1994 by Carlos Blanche, MD, Steven S. Khan, MD, Aurelio Chaux, MD, and Jack M. Matloff, MD. Department of Cardiothoracis Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA 
References
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