title: Repair of post-infarct ventricular septal defect with or without coronary artery bypass grafting in the northwest of England: a 5-year multi-institutional experience.
abstract: OBJECTIVE
  To present the 5-year experience of the northwest of England's surgical repair of post myocardial infarction (MI) ventricular septal defects (VSD). Our primary aim was to evaluate the effect of concomitant coronary artery bypass grafting (CABG) on mid-term survival and also to identify prognostic indicators.
  
  
  METHODS
  A multi-centre regional observational study involving clinical data from 65 consecutive patients who underwent post MI VSD repair in the northwest of England between April 1997 and March 2002. Both prospective and retrospective collection of preoperative, operative and postoperative information was performed. Patient follow-up was performed by linking their records to the National Strategic Tracing Service database. Multivariate logistic regression and Cox proportional hazards analyses were used to identify independent risk factors for poor prognosis.
  
  
  RESULTS
  Of the 65 patients included in the study, 42 (64.6%) underwent concomitant CABG with a median of two grafts. The majority of patients who had their coronary arteries grafted had multivessel disease (92.9%). Overall 30-day mortality was 23.1%. Predictors of poor prognosis included preoperative inotropes (P<0.001) and total occlusion of infarct related artery (P=0.03). The crude hazard ratio (HR) of mid-term mortality for concomitant CABG patients was 0.82 [95% confidence interval (CI) 0.38-1.78; P=0.62]. After adjustment for differences in patient and disease characteristics, the adjusted HR of mid-term mortality for concomitant CABG patients was 0.17 (95% CI 0.04-0.74; P=0.019). The adjusted freedom from death in the concomitant CABG patients at 30 days, 1, 2, and 4 years was 96.2%, 91.6%, 88.8%, and 82.8%, respectively, compared with 79.1%, 58.8%, 49.1%, and 32.2% for the non-concomitant CABG patients.
  
  
  CONCLUSIONS
  These data provide evidence that concomitant CABG is significantly beneficial to mid-term mortality rates. We recommend that patients who present with post MI VSD who have multivessel disease should be routinely revascularised.
authors.affiliation: Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Manchester, UK.
authors.forename: T A
authors.initials: TA
authors.lastname: Barker
authors.forename: I R
authors.initials: IR
authors.lastname: Ramnarine
authors.forename: E B
authors.initials: EB
authors.lastname: Woo
authors.forename: A D
authors.initials: AD
authors.lastname: Grayson
authors.forename: J
authors.initials: J
authors.lastname: Au
authors.forename: B M
authors.initials: BM
authors.lastname: Fabri
authors.forename: B
authors.initials: B
authors.lastname: Bridgewater
authors.forename: G J
authors.initials: GJ
authors.lastname: Grotte
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass; D004739:England / Q000453:epidemiology; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012307:Risk Factors; D016896:Treatment Outcome; D018658:Ventricular Septal Rupture / Q000401:mortality / Q000601:surgery*