Closure Of Residual Ventricular Septal Defect Research Articles

Percutaneous Closure of Hemodynamically Significant Postoperative Residual Ventricular Septal Defects.

The experience with percutaneous closure of postoperative residual ventricular septal defects (VSDs) is expanding with improved device technology and techniques. To report our experience with percutaneous closure of residual VSDs after cardiac surgeries. Retrospective clinical data review of patients who had percutaneous closure of postoperative residual VSDs at our institution between 2010 and 2022. Patients' demographics, procedural, and follow-up data were looked at. Twelve patients (50% males) with a median age of 9.2years (range 0.9-22) were identified. Baseline surgeries were 8 tetralogy of Fallot corrections, 2 pulmonary bandings for large muscular VSD (mVSD) including 1 coarctation repair, 1 atrioventricular septal defect repair, 1 sub-aortic membrane resection-induced iatrogenic VSD, 1 isolated VSD closure, and 1 additional mVSD. Median duration between baseline surgery and percutaneous VSD closure was 2.2years (range 0.2-8.3). Residual VSD shunting was secondary to surgical patch leakage in 8/12 patients. The median angiographic defect diameter was 6.8mm (range 4.8-14). The defect was balloon-calibrated in 3/12 patients. Defects were tackled retrogradely in 3/9 patients. Amplatzer Membranous VSD occluder (n = 1), Lifetech Multifunctional (n = 5), Membranous (n = 1) and muscular VSD occluders (n = 2) and Occlutech Membranous (n = 1) and Muscular (n = 2) VSD occluders were used. The procedure was successful in 10/12 patients. Two devices embolized to the pulmonary artery and were snare-retrieved. Both patients were referred for surgery. The median follow-up was 1.3years (range 0.1-12). Six-month ultrasound showed one trivial residual shunt and one mild right ventricular outflow obstruction. One patient is receiving targeted therapy for pulmonary hypertension at 2years of follow-up. Transcatheter closure of postoperative residual VSDs is a feasible yet challenging intervention. Procedural complications can be encountered.

Percutaneous closure of postoperative residual ventricular septal defects, including dehiscence of surgical patches.

Percutaneous closure of residual ventricular septal defects (VSDs) after congenital heart surgery may provide a safer and more efficient alternative to redo surgery. This study aimed to evaluate the outcome of transcatheter closure of residual postoperative VSD. This multicenter retrospective cohort study was conducted at the tertiary care institutions of King Faisal Specialist Hospital and King Abdulaziz University Hospital, Saudi Arabia, from March 2012 to March 2022. All patients who underwent transcatheter closure of postoperative residual VSD were included. As catheter closure of VSD related to surgical patches is challenging, patients were divided into two groups. Group 1 comprised patients with VSD related to the surgical patches, while Group 2 included residual muscular VSD. Various occluders and approaches were utilized based on the patient's weight and the VSD type, size, and proximity to the cardiac valves. Demographic, echocardiographic, catheterization, and outcome data were collected and analyzed using descriptive and comparative statistics. Thirty-three patients underwent 37 VSD catheter closure procedures. Twenty-two procedures were done to close residual VSD related to the surgical patch, while fifteen were done for additional muscular VSD. The median age of the patients was 3.3 years, and the interquartile range (IQR) ranged between 9 months and 7 years. The median weight was 13.1 kilograms, with an IQR of 5.1 to 16.8 kilograms. The median pulmonary to systemic flow ratio (QP/QS) was 1.6 with an IQR of 1.5 to 2.44; the median systolic pulmonary pressure was 46 mmHg with an IQR of 32 to 54 mmHg. The median procedure duration was 120 minutes, with an IQR of 90 to 160 minutes. Patients in Group 1 were older and had a lower mean pulmonary pressure than Group 2 (P=0.02, P=0.007, respectively). Of the 37 procedures, 35 (94.6%) were done successfully, while two patients had redo surgery due to failed procedures (one had device embolization). Ten successful catheterizations were performed for infants weighing ≤5 kilograms. The functional heart failure class improved significantly after the closure of the residual VSD. There were three documented mortalities, none related to the procedure. No significant difference between patient groups regarding hospital stay or survival (P=0.660, P=0.791, respectively). After congenital heart surgery, transcatheter closure of residual VSD may be a safe and effective alternative to surgical closure. It can be applied to various residual VSD using a variety of occluders with satisfactory results. Moreover, using specific approaches can close residual VSD, even in small infants.

A comparison of autologous pericardium with Dacron™ for closure of ventricular septal defect in infants.

Glutaraldehyde-treated autologous pericardium (GtAP) and Dacron™ are 2 patch materials commonly used to repair ventricular septal defects (VSDs) in children. The primary objective of this study was to test the hypothesis that GtAP is as effective as Dacron for the repair of isolated VSD in infants. Data were collected retrospectively from all infants who underwent repair of isolated VSD at our institution between January 2009 and April 2017. A total of 156 patients were divided into 2 groups: 99 underwent repair with Dacron patch and 57 with GtAP. The primary end point was the need for reintervention for significant residual VSD. Adjusted hospital charges were also compared. The 2 groups were comparable in their baseline characteristics. There was no significant difference in postoperative morbidity indicators. One patient in each group underwent reintervention for the closure of residual VSD. The GtAP group had a higher incidence trivial and small residual VSD at discharge than the Dacron group (65% vs 39%, P = 0.007). The median duration of follow-up was 37 (15-75) months with no difference between the 2 groups. Forty-five percentage of the residual VSDs in the Dacron group (19/42) and 54%in the GtAP group (21/39) had closed. There was no difference in hospital charges and clinical outcomes. GtAP for the closure of isolated VSD in infants is comparable to Dacron. Although the incidence of trivial or small residual VSD is higher with the use of pericardium immediately after surgery, this difference disappears over time.

Application value of echocardiography in transthoracic punctural closure of postoperative residual ventricular septal defect of congenital heart disease.

Residual ventricular septal defect (VSD) after congenital heart disease (CHD) is one of the major postoperative complications in cardiac surgery. At present, the commonly used clinical treatment methods for this complication are reoperation to redo surgical repair with cardiopulmonary bypass (CPB) and percutaneous transcatheter device closure, but these 2 methods have their own advantages and disadvantages. Transthoracic punctural closure of residual VSD is a feasible, safe, and novel technique for patients with residual VSD, which avoids not only the risk of difficulties in reoperation under another CPB due to thoracic adhesion, but also the risk of radiation exposure. Moreover, the operation is easier to handle due to short and direct operation path. This study aims to explore the role and value of echocardiography in transthoracic punctural closure of postoperative residual VSD of CHD. A total of 25 patients, who were admitted in the Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University and accepted transthoracic punctural closure of postoperative residual VSD, were collected. The morphology of the residual VSD and the distance from tricuspid valve and aortic valve were assessed by trans-esophageal echocardiography (TEE) preoperatively, and the location of the punctural point and the direction of puncture were determined. The establishment of delivery track and releasing of occluder device were accurately guided by TEE intraoperatively. The position and morphology of the occluder device, residual shunt, aortic regurgitaion, and outflow obstruction were required close attention in immediately postoperative evaluation. If any dislocation or residual shunt was found, adjustments were needed immediately. Follow-ups were performed at 3-5 days, 1 month, 3 months, 6 months, and 1 year after operation. Occluder location, residual shunt, valvular function, and other complications were observed by transthoracic echocardiography (TTE) to assess the effect of the closure by occluder. Ventricular size and cardiac function were determined to evaluate the state of ventricular remodeling. In addition, cardiac rhythm was monitored by ECG periodically. Of the 25 patients underwent transthoracic punctural closure of postoperative residual VSD, except 1 double outlet right ventricle (DORV) and 1 tetralogy of fallot (TOF) postoperative patients failured and immediately received a thoracotomy surgery with CPB due to excessive size of residual defect and the irregular morphology, the rest 23 patients were successfully closed by the occluders (92.0%). Among the 23 occluders (diameters range from 5 mm to 10 mm), membrane symmetrical VSD occluders were applied to 17 cases, small-waist-large-edge VSD occluder was applied to 1 case, and eccentric VSD occluders were applied to 5 cases. TEE, applied immediately after occlusion, showed the satisfactory position and the shaping of the occluders. There were no residual shunts, no cardiac tamponade, no thrombosis and outflow obstruction. Two patients had small amounts of pericardial effusion. No newly emerging valve reflux was observed. After 3-48 months of observation, there was no device displacement, newly emerging valve reflux, and residual shunt. One case had incomplete right bundle branch block. Guided by TEE, transthoracic punctural closure of postoperative residual ventricular septal defect of CHD is safe and effective. This procedure has broadened the indications for the minimally invasive treatment of CHD and improved the technical system of the minimally invasive treatment of CHD. TEE which can provide accurate diagnosis and guide the whole process plays a decisive role in this operation technique.

Revising ventricular septal defect residual shunts without aortic re-cross-clamping: a safe and effective surgical procedure.

BackgroundThe conventional approach to revising a residual shunt following ventricular septal defect (VSD) closure is to re-occlude the aorta and repair the residual shunt under cardioplegic arrest. The present study evaluated the safety and effectiveness of a new approach for revising residual shunts following VSD repair without re-occluding the aorta. This approach is known as on beating heart surgery.MethodsThis retrospective study included 80 pediatric patients who underwent surgical closure of a simple VSD. Residual shunts larger than 2 mm were intraoperatively detected by transesophageal echocardiography (TEE) and these patients received immediate reintervention. Of the patients, 37 received on beating heart surgery without aortic cross-clamping (Group A) and 43 patients were operated on with aortic cross-clamping and cardioplegia (Group B).ResultsResidual VSD closures were successfully performed in all patients. Group A had significantly shorter aortic cross-clamp times (P<0.0001), significantly shorter CPB times (P<0.01), a lower incidence of prolonged ventilation (>6 hours) (P=0.04), a lower incidence of prolonged intensive care unit (ICU) stay (ICU stay >1 day) (P=0.02), and reduced in-hospital expenses (P<0.0001) compared with Group B. There was no significant difference in the incidence of recurrent residual shunts (P=0.96), prolonged postoperative hospital stay (>5 days) (P=0.24), or the incidence of perioperative complications (P=0.81) between the groups.ConclusionsOn beating heart surgery is a safe and effective approach for the closure of residual VSDs and is significantly associated with a lower incidence of prolonged ventilation, a lower incidence of prolonged ICU stay, and reduced in-hospital expenses.

Severity Scoring System for Ventricular Septal Defect

Residual ventricular septal defect (RVSD) occurs in one-third of patients undergoing patch closure of congenital VSD. Indications for re-intervention are often based on either patient's symptoms or echocardiographic or hemodynamic studies. We report a novel scoring system for RVSD that takes into account all of the above criteria. RVSD size, Qp:Qs ratio, RV to LV pressure ratio, and heart failure symptoms are scored as follows: (A) RVSD size is subdivided into three categories: <3 mm, 3 to <4 mm, and >/=4 mm; (B) Qp:Qs ratio is also subdivided into three categories: <1.5, 1.5 to <2, and >/=2.0; (C) The right and left ventricular pressure ratio is subdivided into the following: <0.5, 0.5 to <0.75, and >/=0.75; (D) Heart failure symptoms are subdivided into three categories: NYHA class II/III, NYHA class IV, and pulmonary edema requiring assisted ventilation. Each of these categories is given a score value of one (less severe), two (intermediate severity), and three (severe). Intra-operative severity score of RVSD is calculated by adding the total score of A, B, and C. For post-operative RVSD severity, the score values of A, B, C, and D are added. According to the total score, the clinical significance of an intra-operative RVSD is then defined as mild, moderate, or severe for a score of </=3, 4-5, and >/=6, respectively. Similarly, post-operative RVSD is then labeled as mild, moderate, or severe for a score of </=4, 5-7, and >/=8, respectively. From our experience and review of literature, severe RVSD (and moderate VSD post Tetrology of Fallot (TOF) repair) require immediate closure of RVSD. Other patients with mild or moderate RVSD need close follow-up with a repeat of transesophageal echocardiography (TEE) before discharge, and six months after surgery. This scoring system, however, needs further prospective evaluation to assess its potential role in decision-making in the management of RVSD.

Outcome following single-stage repair of coarctation with ventricular septal defect.

A recent multi-institutional study suggested improved survival (97%) after staged repair of coarctation with ventricular septal defect (VSD) compared with single-stage repair. The current study was undertaken to determine outcome and need for reintervention following single-stage repair of coarctation and VSD at our institution. Retrospective review of patients undergoing single-stage repair of coarctation with VSD between October 1, 1994 and August 15, 1999. Single-stage repair of coarctation with VSD was performed in 25 infants (12 males, 13 females) at a median age of 12 days (range 1-87 days) and median weight of 3.3 kg (range 1.3-4.4 kg). The VSD was conoventricular in ten patients, malalignment type with posterior deviation of the infundibular septum in ten, muscular in four and conal septal hypoplasia in one. Arch hypoplasia was present in all patients and bicuspid aortic valve in 13. At least moderate subaortic narrowing was present in six patients (secondary to prolapse of tricuspid valve tissue across the VSD in four). Repairs were performed via a median sternotomy with a mean circulatory arrest time of 38+/-12 min. Overall patient survival was 96% with one operative death and no late deaths at a median follow-up of 16 months (range 1-50 months). Reinterventions included balloon dilatation of recurrent coarctation (five), closure of residual VSD (one) and Ross-Konno procedure (two). Actuarial freedom from reintervention for the hospital survivors was 81% (95% confidence limit (CL) 61%, 92%) at 6 months, 71% (95% CL 47%, 87%) at 1 year and 59% (95% CL 31%, 82%) at 2 years following surgery. Single-stage repair of coarctation with VSD can be performed with low operative mortality and good midterm survival equivalent to reported results for staged repair.