Postoperative Ventricular Septal Defects Research Articles

Conduction System Pacing in Pediatrics and Congenital Heart Disease: A Case Report and Literature Review.

Conduction system pacing involving either His bundle pacing (HBP) or left bundle branch pacing (LBBP) is a modality that has been introduced as a safe and effective alternative to right ventricular (RV) pacing to help prevent pacemaker-associated cardiomyopathy. While HBP has been employed in the pediatric and congenital populations, several small studies have shown LBBP to be safe and effective in the pediatric population. We present a patient with congenital atrioventricular block and postoperative ventricular septal defect repair cardiomyopathy with subsequent left ventricular function improvement following a transition from an RV epicardial pacemaker system to an LBBP system. This case report serves as a foundation for a review of the current state of LBBP in pediatrics and congenital heart disease.

Transaortic septal myectomy at the time of aortic valve replacement for severe aortic stenosis: a case series of 55 cases

Abstract Introduction Symptomatic aortic valve stenosis (AS) is associated with asymmetric basal septal hypertrophy (ABSH) in 10% of cases. In this cohort, it has been suggested that rectification of the left ventricular outflow tract obstruction (LVOTO) by concomitant septal myectomy (CSM) can improve the results of aortic valve replacement (AVR). Objective This study aims to present the technique of AVR with CSM for severe AS with ABSH and to determine the associated early and late post-operative outcomes. Methods Fifty-five patients were prospectively recruited to undergo AVR with CSM between 2011 and 2021 at two centres. The primary outcomes were mortality within 30 days, incidence of post-operative ventricular septal defects (VSD) and prosthetic valve sizing. The secondary outcomes were in-hospital complications, permanent pacemaker implantation (PPI), survival at 15 months and changes on transthoracic echocardiogram. Results Post-operative mortality was 1.8% and this figure was unchanged at 15-month follow-up. No patients developed a post-operative VSD. Intra-operatively, it was found that in 94.6% cases the direct valve sizing increased by one, when compared to the measurement made before CSM. The indexed effective orifice area (iEOA) was > 85 cm2/m2 in 96.4% and no patients had an iEOA ≤ 0.75 cm2/m2. Four patients (7.3%) required PPI due to complete atrioventricular block. Conclusion AVR with CSM is a simple technique that can be utilised in severe AS with ABSH. There does not appear to be an increase in mortality or incidence of iatrogenic VSDs. Importantly, CSM allows for the implantation of a larger aortic valve compared to measurements made before CSM.

Effect of Powerbreath Medic Plus versus Threshold IMT on maximal inspiratory pressure and functional capacity in post-operative ventricular septal defect closure: A protocol for a randomized controlled trial

Background: Congenital heart disease is a general phrase that refers to any heart conditions that exist at birth, the most prevalent of which being ventricular septal defects (VSD) and foetal congenital malformations. VSD refers to the presence of aperture between the ventricles which leads to mixing of oxygenated and de-oxygenated blood. Although many VSDs close on their own, failing to do so can result in a number of issues and typically necessitates open heart surgery for closure of the defect. According to various studies, there is reduced functioning of diaphragm post cardiac surgeries which leads to occurrences of pulmonary complications such as lung collapse, fluid accumulation in pleura, pneumonia, acute respiratory distress syndrome and pneumothorax which can be debilitating and jeopardize recovery as well as increase hospital stay. There are several devices which are proven to improve the strength of inspiratory musculature and hence improve maximal inspiratory pressure and functional capacity post cardiac surgeries. Method: In this study we aimed to assess and evaluate the effectiveness of Powerbreath Medic Plus and Threshold Inspiratory Muscle Trainer (IMT) adjunct to conservative physiotherapy management on subjects who underwent VSD closure in a two arm parallel superiority randomized control trial on improving maximal inspiratory pressure and functional capacity. 60 individuals in total will be allocated equally into two groups, and both groups will be receiving treatment for four weeks with five sessions per week. After four weeks of therapy and two weeks after the intervention is through, the results will be assessed for follow-up. Predicted results: By increasing maximal inspiratory pressure and functional capacity, this technique may be used to treat complications following heart surgery if our study's premise is found to be significant. CTRI registration: CTRI/2023/03/051090

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.

Left Ventricular Function Assessment of Patients with Postoperative Ventricular Septal Defect Closure by Longitudinal Strain on Two-Dimensional Echocardiography 1 Year after Surgery

Background: Patients with large perimembranous ventricular septal defects (pm-VSDs) undergo surgical repair with prosthetic material during infancy. However, the effect of the presence of akinetic patch in the ventricular septum on the left ventricular (LV) mechanical synchrony and ventricular function has not been studied. In our study, we assessed LV function in postoperative pm-VSD closure patients on two-dimensional (2D) echocardiography (echo) after 1 year of surgery using biplane Simspon's method, fractional shortening (FS), and global longitudinal strain (GLS) to assess the regional strain pattern. Methods: This was a a single-institution observational study. Patients following up 1 year after surgical ventricular septal defect closure at our institute were enrolled. On follow-up, detailed 2D echo was done with special emphasis on left atrial size, LV size (by M-mode), and presence of any residual shunt. LV function was assessed using biplane Simpson's method and longitudinal strain on 2D echo. GLS was measured in three standard apical views. Results: Of the 121 patients enrolled, 101 patients fulfilling the inclusion and exclusion criteria were analyzed. Of these 101 patients, 75.2% were males. The median age at follow-up after surgery was 3.67 ± 2.7 years. About 92.1% of patients did not have residual VSD lesion. No patient had pulmonary arterial hypertension. All except one patient had normal ventricular function. Patients with ventricular dysfunction had LV ejection fraction (LVEF) of 47%, GLS –17.4%, and FS −20.5%. The mean values of FS, LVEF, and GLS were 32.0 ± 5.28%, 62.2% ± 4.2%, and −26.53 ± 2.93%, respectively, in pm-VSD closure patients. Regional strain pattern analysis showed significantly lower strain values in basal anteroseptal segment with a mean of −21.4 ± 2.7%. FS and GLS were noted to have significant correlation with each other (P = 0.01) and LVEF by biplane Simpson's method and GLS had significant correlation with each other (P = 0.0001). Conclusions: GLS has strong correlation with LVEF by Simson's method and FS. Basal anteroseptal segment in pm-VSD patients had significantly lower strain values compared to other segments. There is no significant correlation between age at surgery and GLS in pm-VSD closure patients who were operated within 1 year of age. The type of VSD closure does not have significant influence on GLS.

The experience of transcatheter closure of postoperative ventricular septal defect after total correction

BackgroundThe purpose of this study was to describe our experience with patients who underwent transcatheter closure of a post-operative ventricular septal defect (VSD).MethodsAll patients who underwent transcatheter closure of a VSD after total correction of congenital heart disease since 2012 were enrolled. Medical records were retrospectively reviewed to determine the patients’ initial diagnosis, closure device used, and final outcome after device closure.ResultsSix patients with a median age of 17.7 years (range: 7 months–48 years) underwent transcatheter closure of an unresolved VSD. The median time interval from the initial corrective surgery to the percutaneous closure procedure was 10.4 years (range: 0.3–33.0 years). The initial diagnoses included tetralogy of Fallot (one patient), VSD (two patients), double outlet of the right ventricle (two patients), and aortic valve stenosis (one patient). The reasons for unresolved VSD (other than leakage) after corrective surgery included previous fenestration (in two patients), and iatrogenic Gerbode shunt (in one patient). Various devices were used, including the Amplatzer duct occluder I, Amplatzer duct occluder II, Amplatzer vascular plug II, and Cocoon membranous VSD occluder. Only one device was used in each patient. There were no major complications associated with the closure procedures. The immediate results were satisfactory. The median follow-up duration was 2.75 years. All cases were successful, with the exception of minimal leak in one patient.ConclusionsTranscatheter device closure of post-operative VSD can be performed using various device types of devices and is safe and effective. But more experiences are mandatory.

Association of aortic root dilatation with left ventricular function in patients with postoperative ventricular septal defect.

Proximal aortic enlargement is associated with an increased risk of heart failure and all-cause mortality. Recently, aortic root dilatation (ARD) was reported in postoperative patients with ventricular septal defects (VSDs). However, the impact of ARD on left ventricular (LV) function in postoperative VSD patients remains unclear. Thus, the aim of this study was to investigate the effect of ARD on LV function in patients with postoperative VSD. One hundred and thirty-five patients (> 15years of age) with surgically repaired isolated ventricular defects and who underwent transthoracic echocardiography in our institution between 2009 and 2013 were identified. ARD was defined as an observed aortic root diameter/body surface area > 2.1cm/m2. The propensity score estimating the probability of having ARD adjusted for anatomical and clinical characteristics was calculated. Forty-four patients (32.6%) had ARD. In unadjusted analyses, right ventricular systolic pressure, Tei index, and E/e' were significantly (p < 0.05) higher in patients with ARD than in those without ARD (31.3 ± 7.5 vs. 35.4 ± 13.7mmHg, 0.32 ± 0.10 vs. 0.44 ± 0.15, and 7.1 ± 1.7 vs. 9.5 ± 2.9, respectively). In the propensity score-adjusted analysis, significant differences in the Tei index and E/e' were confirmed between the two groups (Tei index difference: 0.11, 95% confidence interval 0.05-0.17; E/e' difference: 2.4, 95% confidence interval 1.3-3.5). However, there were no differences in the other echocardiographic measurements. The presence of ARD in patients with postoperative VSD was significantly associated with LV diastolic dysfunction. Thus, surgically repaired VSD patients require careful screening for aortic enlargement and LV function.

Surgical management of left ventricular outflow tract obstruction in a specialized hypertrophic obstructive cardiomyopathy center

ObjectivesThis study evaluates operative approach and contemporary surgical outcomes in the management of left ventricular outflow tract obstruction by a single surgeon at a high-volume, specialized hypertrophic cardiomyopathy center. MethodsThis is a retrospective review of 1559 consecutive operations for left ventricular outflow tract obstruction from 2005 to 2015. Demographic profiles, echocardiogram-derived ventricular morphology and hemodynamics, operative data, and in-hospital outcomes were analyzed. ResultsOf the 1559 operations, 586 were isolated septal myectomies, 522 were myectomies with mitral valve or subvalvular apparatus intervention, 422 were myectomies with another concomitant procedure, and 29 were isolated mitral valve interventions without myectomy. Common mitral valve interventions included anterior leaflet shortening (16%), chordae tendineae resection (9.8%), papillary muscle resection (7.2%), and papillary muscle reorientation (7.5%). Ninety-two patients underwent mitral valve replacement, 42 for left ventricular outflow tract obstruction and 50 for intrinsic mitral valve pathology. Patients undergoing mitral interventions had thinner septums (18 ± 0.4 mm vs 22 ± 0.5 mm, P < .001) and less myocardium removed (6.2 ± 3.5 g vs 8.8 ± 3.8 g, P < .001) than patients without a mitral intervention. Prevalence of in-hospital permanent pacemaker insertion was 4.2% (n = 1334) for complete heart block and 1.1% (n = 464) for isolated septal myectomy with normal preoperative conduction. Overall, there were 2 postoperative ventricular septal defects (0.13%) and none for isolated myectomies. Operative mortality was 0.38%. ConclusionsSeptal myectomy can be performed safely with excellent outcomes when the procedure is performed by a highly experienced surgeon in a high-volume, specialized center. A mitral valve intervention is a useful adjunct in patients with moderate hypertrophy.

Successful emergent coil embolization of an inferior epigastric artery perforation in a neonate

A 28-day-old neonate with a postoperative ventricular septal defect and coarctation of aorta suffered from a right inferior epigastric artery perforation at the time of a central venous catheter placement. It resulted in a rapid and extreme hemoglobin decrease and decrease in the systolic blood pressure. The contrast computed tomography scan revealed a large amount of retroperitoneal hemorrhaging and a hematoma. Pressure hemostasis was not effective in eliminating the extravasation and surgical hemostasis seemed uncertain to succeed, because the baby was too small and its condition was unstable. An emergent coil embolization using a Target® coil (Stryker Inc., Tokyo, Japan) was effective in completely eliminating the extravasation, resulting in saving its life. We speculated that a coil embolization was the only solution to rescue a neonate with a retroperitoneal hemorrhage due to an artery perforation.<Learning objective: Retroperitoneal hemorrhaging caused by an inferior epigastric artery perforation is a fatal condition in a neonate, because the neonate cannot express symptoms and this results in a delay in diagnosing it. Pressure hemostasis and surgical hemostasis are not effective in these cases. If a peritoneal hemorrhage is suspected, a coil embolization must be performed promptly as a sole solution to rescue the patient.>

Progression of aortic regurgitation after subpulmonic infundibular ventricular septal defect repair

ObjectiveIn patients with subpulmonic infundibular ventricular septal defect (VSD), postoperative progression of aortic regurgitation (AR) sometimes occurs despite early operation before the development of AR. The present study was aimed...

Clinical Experience of Transcatheter Closure for Residual Ventricular Septal Defect in Pediatric Patients.

Open cardiac surgery has traditionally been the gold standard for repair of ventricular septal defect (VSD). The inherent risks and complications associated with open surgery and the incidence of postoperative residual VSD are significant disadvantages of the open surgical approach. To evaluate the methodology and efficacy of transcatheter closure of postoperative residual VSD in children. Patients with postoperative VSD who underwent percutaneous device closure in the period from August 2010 and February 2014 in our center were analyzed retrospectively. Twelve children, including 8 males and 4 females, with mean age of 8.13 ± 5.39 years (range 0.67-17 years) and mean weight of 29.63 ± 20.86 kg (range 5.5-66 kg) were included in the study. Ten cases had residual shunts situated at the margin of the patches while the other two had residual shunts because of multiple muscular VSD. The mean VSD diameter was 3.84 ± 1.86 mm (range 2.3-8.7 mm). On cardiac catheterization, the reported mean pulmonary circulatory blood volume/systemic circulation volume (Qp/Qs) ratio was 1.86 ± 0.91 (range 1.1-4.25) and the mean pulmonary artery pressure was 25.92 ± 12.42 mm Hg (range 7-52 mm Hg). Successful transcatheter closure was obtained in all twelve patients with postsurgery residual VSD. Two cases with residual muscular VSD underwent retrograde catheterization via the femoral artery while one case with residual VSD located at the lower margin of the patch was accessed via the internal jugular vein. The mean procedure time was 81.25 ± 25.86 minutes (range 40-120 minutes). There was no evidence of residual VSD, and no instances of new-onset valvular regurgitation were reported, with the only two exceptions being patients who had multiple muscular VSDs where clinically insignificant residual shunts were detected. Our retrospective study highlights the potential safety and therapeutic efficacy of transcatheter approach for closing postoperative residual VSD in children. More robust studies with longer-term follow-up of outcomes are required to firmly establish the safety profile and respective indications for use of various occluder devices for treating different categories of residual VSD.

Transcatheter closure of postmyocardial infarction, iatrogenic, and postoperative ventricular septal defects: The Mayo Clinic experience.

To determine event-free survival after transcatheter closure of ventricular septal defect (VSD), and to identify predictors of adverse events (AE) in post myocardial infarction VSD (post-MI VSD) subgroup. There are limited data on mid-term follow-up after transcatheter VSD closure. Retrospective review of 27 cases of transcatheter VSD closure (post-MI = 18 and non-ischemic = 9) performed from 1999 to 2013. We defined AE as death, device embolization, hemolysis requiring blood transfusion, heart block and reintervention. In the post-MI VSD subgroup, mean age and follow-up was 69 ± 11 and 7.3 ± 7 years, respectively. AE occurred in 8 (44%) patients (death-3, device embolization-1, hemolysis-1, surgical VSD closure-2, reintervention-1). Event-free survival was 56% at 1 month and 5 years, and all AE occurred in the periprocedural period. Cardiogenic shock (HR: 3.21, CI: 1.82-5.41, P = 0.002), and VSD closure in acute phase (HR: 2.14, CI: 1.12-4.31, P = 0.004) were independent predictors of AE. In the non-ischemic VSD subgroup, mean age and follow-up was 49 ± 15 and 8.7 ± 8 years, respectively. AE occurred in 3 (33%) patients (late death-1, surgical VSD closure-2). For the entire cohort, freedom from death was 89% and 85% at 1 month and 5 years, and event-free survival was 70% and 61% at 1 month and 5 years. Transcatheter closure of post-MI VSD carries a moderate risk of periprocedural complications but low event rates afterwards. By comparison, device closure of non-ischemic VSD has lower periprocedural morbidity but some patients continued to experience AE during follow-up.

Congenital absence of the portal vein associated with focal nodular hyperplasia of the liver and congenital heart disease (Abernethy malformation): A case report and literature review.

Abernethy malformation is a rare congenital malformation defined by an extrahepatic portosystemic shunt. The majority of affected patients are young (<18 years of age) and experience various symptoms, including vomiting, jaundice, dyspnea and coma. The current study presents a case of Abernethy malformation in an asymptomatic adult male patient. The patient exhibited congenital absence of the portal vein, congenital heart disease (postoperative ventricular septal defect status), and multiple liver lesions, confirmed to be focal nodular hyperplasia by biopsy. Ultrasonography and magnetic resonance imaging findings revealing the liver lesions, type II congenital absence of the portal vein and the portosystemic shunt are presented. In addition, the common clinical presentations, associated anomalies, diagnostic workup and treatment options of this disorder are investigated by reviewing 101 previously reported cases.

Reply to Koestenberger and Ravekes

We would like to thank Koestenberger et al. [1] for their comments regarding our manuscript titled ‘Disparity in right vs left ventricular recovery during follow-up after ventricular septal defect correction in children’ [2]. We fully agree with Koestenberger et al. [1] that it would be interesting to gain further knowledge regarding ventricular performance in patients with different subtypes of ventricular septal defects (VSDs). The location of the VSD and implanted patch and its relation to the tricuspid valve ring may certainly influence right ventricular (RV) free wall motion. Both tricuspid annular plane systolic excursion (TAPSE) and RV peak systolic tissue Doppler imaging velocity (S0) are assessed at the base of the RV free wall, close to the tricuspid valve ring. Accordingly, both TAPSE and RV S0 could be different in patients with different subtypes of VSDs. Hence, we appreciate the suggestion made by Koestenberger et al. [1] to calculate the z scores of TAPSE and RV S0, as previously defined [3, 4], to shed further light on the subtype analysis. The calculation of preoperative z scores yielded a mean ± standard deviation of TAPSE of 0.9 ± 2.3 and a mean RV S0 z score of 0.6 ± 1.5. One day postoperatively, z scores significantly decreased, displaying a mean TAPSE z score of −5.7 ± 1.3 and a mean RV S0 z score of −4.5 ± 1.2. At medium-term follow-up, z scores were still low, with a mean TAPSE z score of −1.6 ± 1.4 and RV S0 z score of −1.5 ± 0.9. Similar to previous results, one-way analysis of variance of these z scores did not reveal significant differences between subtypes of VSD patients preoperatively or at medium-term follow-up. Yet, considering the small number of patients and relatively large standard deviations of z scores, a lack of statistical power could still be the cause of this absence. Accordingly, these additional analyses could not shed further light on the differences between subtypes. However, current z score calculations do further validate the conclusion of our manuscript, of a persistent impairment of RV performance after surgery for a VSD. In a previous study by our group, including patients with a variety of congenital heart defects, a similar decrease in RV performance following surgery was observed [5]. Furthermore, a longer aortic cross-clamp time was associated with a lower RV S0 in this study. These results emphasize the detrimental role of cardiopulmonary bypass in ventricular deterioration after surgery and highlight the importance of follow-up of RV performance after surgery. Hence, we join Koestenberger et al. [1] in their hope for routine RV function analysis in postoperative VSD patients.

Impairment of tricuspid annular plane systolic excursion and tricuspid annular peak systolic velocity after ventricular septal defect correction

We read with interest the article ‘Disparity in right vs left ventricular recovery during follow-up after ventricular septal defect correction in children’ by Klitsie et al. [1]. In our opinion, this is an interesting manuscript describing a possible long-term effect of open-heart surgery on the remodelling of the right ventricle (RV) in children with ventricular septal defect (VSD). The authors found a reduced tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular peak systolic velocity (S0) in their VSD patients compared with age-related normal values and that RV systolic performance, in contrast to LV systolic performance, remained significantly impaired up to 20 months postoperatively. We completely agree with the findings of Klitsie et al. [1] that this decrease of RV systolic performance after surgical correction of VSD may be due to the detrimental effects of open-heart surgery with cardiopulmonary bypass. We wish to mention that in children after open-heart surgery for tetralogy of Fallot, the TAPSE and S0 values are decreased and also worsen continuously over time [2]. Performing VSD subtype analyses, Klitsie et al. [1] found no significant difference in echocardiographic parameters, perhaps due to the small size of this subgroup. For the convenience of the readership of the European Journal of Cardiothoracic Surgery, we would like to mention that, in our opinion, if a comparison of TAPSE and S0 data from their VSD patients with available TAPSE and S0 paediatric normal values and Z-scores [3, 4] is made, this lack of statistical power in their subgroup analysis could be overcome. Klitsie et al. [1] also support the notion that the RV is highly susceptible to postoperative function impairment in paediatric patients with a VSD. We would like to thank the authors for addressing the need for careful and systematic evaluation of the RV in patients with congenital heart diseases before and after surgical correction. We hope that, with more interesting studies like this from Klitsie et al. [1], the quantification of systolic RV function will become a routine measurement in postoperative VSD patients.

A successful percutaneous closure of ventricular septal defect following septal myectomy in patients with hypertrophic obstructive cardiomyopathy

Postoperative ventricular septal defect (post-op VSD) after septal myectomy in patients with hypertrophic obstructive cardiomyopathy is a rare and unexpected complication. We report a case of successful percutaneous closure of VSD following septal myectomy and mitral valve replacement in a patient with intrinsic mitral valve disease and severe mitral valve regurgitation together with hypertrophic obstructive cardiomyopathy.

Percutaneous device closure of congenital and iatrogenic ventricular septal defects in adult patients

We report our 10-year experience with percutaneous closure of adult congenital and acquired (non-post-infarct) ventricular septal defects (VSDs) using different types of Amplatzer occluder devices. Adult congenital and acquired VSDs may produce significant morbidity and mortality. Furthermore, such VSDs pose a significant surgical challenge. Between February 2000 and August 2009, data were retrospectively reviewed from 28 patients who underwent 29 procedures for percutaneous device closure of hemodynamically significant VSDs. Seventeen had unrepaired congenital VSDs, 10 had post-operative VSDs (5 with residual patch-margin defects, 4 post-aortic valve replacement, 1 post-myomectomy), and one had an acquired traumatic VSD. INDICATIONS FOR CLOSURE INCLUDED: symptoms related to significant shunt (dyspnea on exertion); unexplained deterioration of LV function, and/or LV dilation; recurrent endocarditis, and pulmonary hypertension. Outcome parameters were procedural success, procedure-related complications, evidence of residual shunt by echocardiography, and improvement in the signs/symptoms for which the procedure was performed. The mean follow-up interval was 68 months. Of the 28 patients studied, a single VSD was present in 26 patients, while one patient had two defects, and one patient had one defect on the LV side with three openings at the RV side. The median size of the defects by echocardiography was 6 mm. A device was successfully implanted in 28 of 29 (97%) procedures and 28 of 28 (100%) patients. PROCEDURE-RELATED COMPLICATIONS OCCURRED IN TWO CASES: one involving an access site hematoma not requiring transfusion as well as nonsustained ventricular tachycardia that resolved spontaneously and the other involving acute mitral regurgitation due to inadvertent trapping of the anterior mitral valve leaflet between the left ventricular disk and the septum that was resolved by recapturing of the disk. There was immediate complete closure in 20 patients (71%). In six cases there was trivial residual shunt and in two patients the residual shunt was mild. At the latest follow-up, four of the eight with a residual shunt had no shunt and in the remaining four the residual shunt was trivial. Among symptomatic patients 18 (64%), there was marked improvement in symptoms and for those patients 17 (61%) for whom the procedure was performed to address left ventricular enlargement, there was reduction or stabilization in LV size on serial echoes. Percutaneous closure of VSDs in the adult patient appears to be safe and effective.

Percutaneous transthoracic ventricular puncture for diagnostic and interventional catheterization

To describe our experience in a case series of patients requiring percutaneous direct ventricular puncture and sheath placement for diagnosis or intervention. Access to the right or left ventricle for percutaneous interventions is limited in patients with mechanical prostheses in either the tricuspid, or mitral and aortic positions. After coronary angiography, direct ventricular puncture under ultrasound and fluoroscopic guidance was performed. At end of case, protamine was given to reverse the heparin, and sheaths were pulled with purse-string suture closure of the skin entrance. For right ventricular access, 8- to 9-F sheaths were placed from subxiphoid approach in 2 patients to allow conduit and pulmonary artery interventions. For left ventricular access in patients with mitral and aortic prostheses, 4- to 8-F sheaths were placed from apical approach to allow diagnostic evaluation in 1 and interventions in 5 to occlude perivalvular mitral leaks and postoperative ventricular septal defect. Complication in one consisted of intercostal vein injury resulting in hemothorax requiring chest tube drainage. In this small cases series, direct ventricular puncture allowed the intervention to proceed with up to 9-F sheath size. Attention to puncture site relative to intercostal vascular anatomy is warranted.

Percutaneous closure of postoperative ventricular septal defects with the amplatzer device

The objective of this study was to look at the procedure, the results, and the follow-up of patients who underwent percutaneous closure of a residual ventricular septal defect (VSD) following a surgical closure using the Amplatzer VSD device. Four patients had an original diagnosis of tetralogy of Fallot, two patients had a patch leak following a surgical repair of a VSD, and three patients had a VSD not repaired at the time of surgery. All patients fulfilled the currently accepted surgical criterion for reoperation (Qp/Qs>1.5). The mean Qp/Qs was 1.8+/-0.3 (1.5-2.3). Four patients underwent VSD closure using an Amplatzer perimembranous VSD device and in five patients an Amplatzer muscular VSD device was implanted. We performed percutaneous closure in nine patients. The size of the residual shunt ranged from 6 to 14 mm and the size of device used ranged from 8 to 16 mm. The arteriovenous loop needed to be recreated in two patients because of failure to advance the delivery sheath. There was complete closure of the defect in six cases, and a small residual shunt remained in three cases. Percutaneous closure of postoperative VSDs appears to be an effective way to resolve a hemodynamically significant residual shunt. There were no difficulties encountered with implantation of the devices. These promising short-term results need reinforcement with additional long-term data.

Ventricular arrhythmias after correction of ventricular septal defects: Importance of surgical approach

To compare the prevalence of conduction disturbances and ventricular arrhythmias in cases of postoperative ventricular septal defect, 100 patients (50 with repair by right atriotomy, group 1; and 50 with repair by right ventriculotomy, group 2) underwent complete evaluation including an electrocardiogram (ECG) and 24 h ambulatory ECG monitoring. The two groups were comparable except for a shorter follow-up duration (7 ± 3 versus 12.4 ± 7 years) and a younger age at evaluation (12.4 ± 5 versus 16.9 ± 7 years) in group 1.Complete right bundle branch block was less frequent in group 1 than in group 2 (20% versus 50%, p < 0.05) but three of the four patients with complete atrioventricular (AV) block detected on ambulatory monitoring were in group 1. Six patients had significant supraventricular arrhythmias, all well tolerated. Ambulatory monitoring revealed significant ventricular arrhythmias (modified town grade 2 or higher) in 39 patients, with a lower prevalence in group 1 (30% versus 48%, p = 0.05). No correlation was found between prevalence of ventricular arrhythmias and right ventricular systolic pressure, cardiopulmonary bypass duration, presence of a synthetic patch, previous pulmonary artery banding, presence of complete right bundle branch block and cardiomegaly on chest X-ray film. Prevalence of ventricular arrhythmias increased with follow-up duration, age at evaluation and age at surgery. These were always well tolerated and did not warrant treatment.Thus, right atriotomy reduces the prevalence of right bundle branch block but does not prevent late AV block. Ventricular arrhythmias are frequent after surgical closure of ventricular septal defect whatever the surgical approach and their prevalence is not statistically different from that in postoperative tetralogy of Fallot. Only studies with a longer follow-up period will be able to assess the true significance of these arrhythmias and the true benefit of the transatrial approach.