title: Outcome and survival analysis of surgical repair of post-infarction ventricular septal rupture.
abstract: BACKGROUND
  To review the experience of surgical repair of post-infarction ventricular septal rupture (VSR) and analyze the associated outcomes and prognostic factors.
  
  
  METHODS
  Following approval from the Singhealth Centralised Institutional Review Board (reference: 2011/881/C), a retrospective review was performed on 38 consecutive patients who had undergone surgical repair of post-infarction VSR between 1999 and 2011. Continuous variables were expressed as either mean ± standard deviation or median with 25th and 75th percentiles. These were compared using two-tailed t-test or Mann-Whitney U test respectively. Categorical variables were compared using chi-square or Fisher's exact test. To identify predictors of operative mortality, univariate analysis of perioperative variables followed by multivariate analysis of significant univariate risk factors was performed. A two-tailed p-value < 0.05 was used to indicate statistical significance.
  
  
  RESULTS
  Mean age was 65.7 ± 9.4 years with 52.6% males. The VSR was anterior in 28 (73.7%) and posterior in 10 patients. Median interval from myocardial infarction to VSR was 1 day (1, 4). Pre-operative intra-aortic balloon pump was inserted in 37 patients (97.8%). Thirty-six patients (94.7%) underwent coronary angiography.Thirty-five patients (92.1%) underwent patch repair. Mean aortic cross clamp time was 82 ± 40 minutes and mean cardiopulmonary bypass time was 152 ± 52 minutes. Coronary artery bypass grafting (CABG) was performed in 19 patients (50%), with a mean of 1.5 ± 0.7 distal anastomoses. Operative mortality within 30 days was 39.5%.Univariate analysis identified emergency surgery, New York Heart Association (NYHA) class, inotropic support, right ventricular dysfunction, EuroSCORE II, intra-operative red cell transfusion, post-operative renal failure and renal replacement therapy (RRT) as predictors of operative mortality. Multivariate analysis identified NYHA class and post-operative RRT as predictors of operative mortality.Ten year overall survival was 44.4 ± 8.4%. Right ventricular dysfunction, LVEF and NYHA class at presentation were independent factors affecting long-term survival. Concomitant CABG did not influence early or late survival.
  
  
  CONCLUSIONS
  Surgical repair of post-infarction VSR carries a high operative mortality. NYHA class at presentation and post-operative RRT are predictors of early mortality. Right ventricular dysfunction, LVEF and NYHA class at presentation affect long-term survival. Concomitant CABG does not improve survival.
authors.affiliation: Department of Cardiothoracic Surgery National Heart Centre, Mistri Wing 17 Third Hospital Avenue, Singapore 168752, Singapore. philip.pang.y.k@nhcs.com.sg
authors.forename: Philip Y K
authors.initials: PY
authors.lastname: Pang
authors.forename: Yoong Kong
authors.initials: YK
authors.lastname: Sin
authors.forename: Chong Hee
authors.initials: CH
authors.lastname: Lim
authors.forename: Teing Ee
authors.initials: TE
authors.lastname: Tan
authors.forename: See Lim
authors.initials: SL
authors.lastname: Lim
authors.forename: Victor T T
authors.initials: VT
authors.lastname: Chao
authors.forename: Jang Wen
authors.initials: JW
authors.lastname: Su
authors.forename: Yeow Leng
authors.initials: YL
authors.lastname: Chua
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D016896:Treatment Outcome; D018658:Ventricular Septal Rupture / Q000601:surgery*