Recurrent Ventricular Septal Defect Research Articles

Percutaneus Transcatheter Closure: An Alternative Treatment for Recurrent Postmyocardial Ventricular Septal Defect After Surgery

Percutaneus Transcatheter Closure: An Alternative Treatment for Recurrent Postmyocardial Ventricular Septal Defect After Surgery

Role of Multidetector CT in Assessment of Repaired Tetralogy of Fallot

The population of adults with repaired tetralogy of Fallot (TOF) is growing, thanks to improvements in the surgical and medical management of this condition. Accordingly, late postrepair complications are important medical concerns in these individuals. Initial surgical repair of TOF typically occurs in infancy, consisting of patch repair of the ventricular septal defect (VSD) and relief of right ventricular outflow tract (RVOT) obstruction. Although patients may remain asymptomatic for several decades, the majority will have progressive pulmonic regurgitation that leads to right ventricular (RV) dilatation and functional deterioration. Other frequently seen complications include branch pulmonary artery stenosis, RVOT aneurysms, and recurrent VSDs. Cardiac computed tomography (CT) is widely available and, in some cases, is the imaging modality of choice for serial evaluation of TOF patients. CT is particularly useful when magnetic resonance (MR) imaging is contraindicated (eg, in patients with implantable cardiac devices). Unlike MR imaging, cardiac CT allows excellent visualization of endovascular stents and stent-mounted valves. Retrospective electrocardiographically gated cardiac CT can be used for accurate volumetric and functional analysis of the RV. Comprehensive serial evaluation will assist in determining the need for surgical pulmonary valve repair in the setting of progressive RV dysfunction. Three-dimensional volumetric images are useful for evaluation of stent integrity and aneurysm formation. The radiologist should be familiar with the anatomy of TOF, surgical interventions for repair, and postrepair complications encountered at follow-up imaging of these patients. By extracting the breadth of information obtained with cardiac multidetector CT, the radiologist can play an essential role in the management of adult patients with repaired TOF.

Cardiovascular MR Imaging after Surgical Correction of Tetralogy of Fallot: Approach Based on Understanding of Surgical Procedures

Tetralogy of Fallot (TOF) is one of the most common congenital heart diseases for which patients are referred for postoperative magnetic resonance (MR) imaging evaluation. The most common surgical procedures for TOF repair include infundibulectomy, transannular pulmonary artery patch repair, and right ventricle-pulmonary artery conduit placement. In the past few decades, surgery has proved successful, but most patients require repeat imaging throughout their lives. MR imaging is now frequently used for morphologic and functional evaluation after TOF repair. The most common late postoperative sequelae and residual lesions include right ventricular outflow tract aneurysm and dyskinesis, conduit failure, pulmonary regurgitation, tricuspid regurgitation, right ventricular failure, residual main and branch pulmonary artery stenosis, branch pulmonary artery aneurysm, left pulmonary artery kinking, and residual or recurrent ventricular septal defect. The imaging approach for the evaluation of patients with repaired TOF should be guided by the surgical procedure used and the complications that are expected. Knowledge of the most common postoperative problems and their cardiovascular MR imaging appearances is essential for good radiology practice in this clinical setting.

Management and midterm outcomes of post-infarction ventricular septal defect

We assessed midterm outcomes, predictors of mortality, and residual defects after repair of post-infarction ventricular septal defect in 10 patients (mean age, 65.3 years; range, 50-78 years) who were operated on between 2000 and 2008. Mean time from onset of symptoms of myocardial infarction to diagnosis of ventricular septal defect was 3.5 days. Time from diagnosis to surgery ranged from 6 h to 84 days. The defects were located anteriorly in 4 patients and posteriorly in 6. Patch reconstruction of the septum was used in 6 patients and the infarct exclusion technique in 4. Hospital mortality was 60%. The only predictor of mortality was tricuspid valve competence (p = 0.048). There was no correlation between location of the defect or type of repair and operative mortality. Residual or recurrent ventricular septal defect was noted in 6 patients. Location of the defect and type of repair were not predictors of residual or recurrent defects. Residual ventricular septal defect was not associated with increased short-term mortality or reduction of functional status. Early mortality associated with post-infarction ventricular septal defect repair is significant. Discharged patients continue to have good functional capacity and quality of life, as well as favorable midterm survival.

Extracorporeal Membrane Oxygenation as a Bridge to Definite Surgery in Recurrent Postinfarction Ventricular Septal Defect

A recurrent shunt after a postinfarction ventricular septal defect (PI-VSD) repair is common. We treated a case of cardiogenic shock caused by a large recurrent shunt after the patch repair of an apical PI-VSD with percutaneous extracorporeal membrane oxygenation (ECMO) for 4 days until a secondary definite repair. This suggests that percutaneous ECMO support is reliable before and after secondary definitive surgery in recurrent PI-VSD and may imply using a delayed surgical strategy with ECMO support to restore hemodynamic stability and avoid primary surgery on freshly fragile infarcted myocardium.

Transcatheter Closure of Recurrent Postmyocardial Infarction Ventricular Septal Defect Facilitated by Percutaneous Left Ventricle Access

We report a case of a 68-year-old woman with a basal postmyocardial infarction ventricular septal defect that recurred 4 months after initial surgical repair. Successful transcatheter closure using an Amplatzer Muscular VSD Occluder was facilitated by direct percutaneous left ventricular access.

Long-term follow-up and quality of life after closure of ventricular septal defect in adults

To study patients who underwent surgical closure of a congenital ventricular septal defect (VSD) and presenting at adult age. A retrospective study was carried out of 28 patients (15 male) operated upon between 1980 and 2004. Patients were investigated by echocardiography, ECG and assessed for quality of life by a questionnaire. The indication for surgery was volume overload in 11 patients, endocarditis in 8, aortic valve regurgitation in 8 and the combination of a VSD with subvalvular aortic stenosis in 1. Follow-up was complete with a mean duration of follow-up of 13 years. There was no early or late mortality. One patient was reoperated for recurrent VSD. Twenty-five patients underwent echocardiography, which revealed a trivial residual VSD in two and mild aortic regurgitation in 10 (40%) patients. One patient was in atrial fibrillation. Health related quality of life in the dimensions cognitive functioning and sleep differed significantly from that of the general population. With a relative difference in indications for closure of a VSD in adulthood, surgical closure of VSD at adult age is an adequate and safe procedure, with good results on long-term follow-up. Progression of aortic valve regurgitation is a matter of concern.

Transcatheter Repair of Recurrent Postinfarct Ventricular Septal Defects

Surgical repair of recurrent postmyocardial infarction septal defect is associated with a high mortality rate. We present 2 patients whose recurrent defects were closed percutaneously using an Amplatzer device.

Long-Term Outcome After Total Correction of Tetralogy of Fallot in Adolescent and Adult Age

Although most patients with tetralogy of Fallot (TOF) undergo radical repair during infancy and childhood, patients remaining undiagnosed and untreated until adulthood can still be treated. These patients have either a previous palliative or natural collateral circulation to the lung or a mild form of right ventricular outflow tract (RVOT) obstruction. The aim of this study is to analyze the perioperative and long-term results of radical corrective procedures in patients who reached adult ages. Two hundred and seven patients with TOF underwent complete correction between 1985-and 2002, 64 (30.9%) of whom were aged 14 years or more. The mean age at corrective repair for this group was 20.6 +/- 7.5 years (range 14 to 49 years). Only two patients had previous modified Blalock-Taussig shunts. In 44 patients (68.7%) besides infundibular resection, a transannular gluteraldehyde-treated pericardial patch was used to reconstruct right ventricular outflow tract (RVOT). Only infundibular patching was used in 15 patients (23.4%) and infundibular muscular resection with primary closure of right ventricle was performed in five patients (7.8%). Hospital mortality was 3.1% with two patients. Four patients (6.2%) underwent reoperation because of recurrent ventricular septal defect (VSD) with/without residual obstruction or pulmonary regurgitation. All survivors were in NYHA class I (42) or II (17). Late mortality was recorded in two patients and 16-year actuarial survival was 89.2%+/- 4.9%. The significant negative predictors of late survival determined by univariate analysis were reoperation <0.018) and associated cardiac anomalies <0.011). Multivariate analysis showed that there was no negative predictor of late-term mortality. Corrective procedures in adult patients with TOF can be performed successfully compared to patients who underwent operation during infancy and childhood.

A Retrospective Comparison of Bovine Pericardium and Polytetrafluoroethylene Patch for Closure of Ventricular Septal Defects

This retrospective study compared the immediate post-operative (first month) and mid-term (up to 5 years post-operation) results of 22 patients with isolated ventricular septal defects who underwent surgical correction with bovine pericardium with 57 similar patients who received a polytetrafluoroethylene (PTFE) patch. There were no cases of early (in the first month) mortality in either group and the 3-month post-operative echocardiographical studies showed no evidence of calcification or aneurysm formation around the patch. Recurrent ventricular septal defects due to dehiscence of the patch occurred in the early follow-up period in four patients who had the PTFE patch but this was not statistically significant. Annual echocardiographical examination revealed some calcification in both groups. We conclude that although there are no significant differences between the two materials in outcome after ventricular septal defects closure, we prefer bovine pericardium because of its handling characteristics, elasticity and the lower risk of endocarditis.

Outcome after repair of tetralogy of Fallot in the first year of life

Background. The purpose of this study was to evaluate the early and late outcome after repair of tetralogy of Fallot in the first year of life. Methods. Between 1974 and 2000, 89 consecutive infants with a mean age of 6.3 ± 2.6 months (range, 15 days to 12 months) underwent repair of tetralogy of Fallot (ventricular septal defect and pulmonary stenosis) by one surgeon (J.L.M.). Three infants had previous palliative operations. Sixty-seven procedures were urgent or emergency. A transannular patch was inserted in 69 patients (77.5%). Follow-up was complete, averaging 13.4 ± 5.6 years (range, 0 to 25.4 years). Results. There was one operative death (1.1%). Mean right ventricular to left ventricular pressure ratio postoperatively was 0.4 ± 1.1 (in 79 patients, < 0.5). Fourteen patients underwent reoperations or reinterventions. There were no reoperations for residual or recurrent ventricular septal defect. Kaplan-Meier freedom from reoperation or reintervention for any cause at 20 years was 85% ± 4.4%, for relief of right ventricular outflow tract obstruction it was 94% ± 3.1%, and for pulmonary valve replacement this was 95.4% ± 2.6%. Use of a transannular patch did not significantly affect the need for reoperation or reintervention. There was one late death (leukemia). Kaplan-Meier 20-year survival was 97.8% ± 1.9%. On latest echocardiography, 42 patients had moderate pulmonary regurgitation, 4 had a right ventricular outflow tract gradient more than 40 mm Hg, and 86 had good biventricular function. Twelve-lead electrocardiography was performed in all and 24-hour electrocardiography in 61 patients. One patient (1.1%) exhibited late recurrent ventricular tachycardia requiring implantation of a defibrillator. The remaining 86 patients are in New York Heart Association class I with none of them receiving antiarrhythmic medications. Conclusions. These data strongly support the concept of early repair of tetralogy of Fallot. It is associated with an acceptable operative risk and a low incidence of significant arrhythmias, and provides long-term survival similar to that observed in the general population. Late complications may, however, develop, and long-term follow-up for their early recognition is essential.

A Right Atrial Approach in Redo Postinfarction Ventricular Septal Defect

Despite improvements in surgical techniques, post-infarction ventricular septal defect remains a surgical challenge that is associated with significant early and late mortality. Furthermore, the recurrence of the defect after primary correction occurs in ∼10–25% of patients, and the operative risk increases because of a difficult dissection that is often complicated by previous patent grafts. The repair of recurrent ventricular septal defect has generally been performed by ventriculotomy in the infarcted zone. The authors propose an alternative approach that, when the rupture is posterior, allows its complete visualization, and avoids any further ventriculotomy in an already impaired ventricle.

A right atrial approach in re-do post-infarction ventricular septal defect

Despite improvements in surgical techniques, post-infarction ventricular septal defect remains a surgical challenge that is associated with significant early and late mortality. Furthermore, the recurrence of the defect after primary correction occurs in ~1O–25% of patients, and the operative risk increases because of a difficult dissection that is often complicated by previous patent grafts. The repair of recurrent ventricular septal defect has generally been performed by ventriculotomy in the infarcted zone. The authors propose an alternative approach that, when the rupture is posterior, allows its complete visualization, and avoids any further ventriculotomy in an already impaired ventricle.

Surgical repair of postinfarction ventricular septal defect by infarct exclusion.

Repair of postinfarction ventricular septal defect (VSD) by infarct exclusion has been used for a decade in our unit. It involves securing a glutaraldehyde-preserved bovine pericardial patch to the endocardium of the left ventricle all around the necrotic myocardium to exclude the VSD and the infarct from the left ventricular cavity. Fifty-two patients with postinfarction VSD underwent this type of repair from 1987 to 1996. Thirty-four patients were in shock when undergoing operation; 26 had anterior VSD and 26 had posterior. Ten patients died perioperatively, for surgical mortality of 19%. Three patients developed recurrent VSD; one died and two survived. Preoperative cardiogenic shock and age older than 70 years were associated with an increased operative mortality. Operative survivors were followed up from 6 to 135 months, mean of 65 months. The actuarial survival at 8 years was 59% +/- 6%. Repair of postinfarction VSD by infarct exclusion is a relatively simple operative procedure and seems to have improved the results of surgery in patients with posterior VSD.

Aortic valve replacement after repair of pulmonary atresia and ventricular septal defect or tetralogy of fallot

Objective: Little attention has been paid to the occurrence of aortic regurgitation after complete repair in patients with pulmonary atresia and ventricular septal defect or tetralogy of Fallot. To highlight the development of aortic regurgitation or aortic root dilation severe enough to necessitate aortic valve replacement with or without aortic aneurysmorrhaphy or aortic root replacement, we retrospectively reviewed the records of patients who underwent aortic valve operation at our institution subsequent to repair of pulmonary atresia and ventricular septal defect or tetralogy of Fallot. Methods: We searched the Mayo Clinic database for patients with pulmonary atresia and ventricular septal defect or tetralogy of Fallot who subsequently had aortic valve or aortic root operations. The degree of aortic regurgitation before operation was noted. Aortic sinus and root dimensions were measured. Results: Sixteen patients underwent complete repair at a median age of 17 years, followed by an aortic operation a median of 13.5 years later. All 16 patients had dilated aortic sinuses at the time of the aortic valve operation. These 16 patients had aortic valve replacement: 11 with mechanical prostheses and 5 with bioprostheses. Five of the 16 also had reduction of aortic dilation by lateral aneurysmorrhaphy, and 1 had graft replacement of the ascending aorta. Five patients had associated conditions (evidence of valvular damage, recurrent ventricular septal defect, or history of endocarditis) discovered at the aortic valve operation that have been reported to be related to the development of aortic regurgitation. The remaining 11 patients had progressive aortic regurgitation despite complete, uncomplicated repair. Conclusions: Progressive aortic regurgitation and aortic root dilation can occur despite complete repair of pulmonary atresia and ventricular septal defect or tetralogy of Fallot. (J Thorac Cardiovasc Surg 1997;113:736-41)

Transaortic Approach Has a Role in the Surgical Treatment of Ventricular Septal Defects

A transaortic approach was used for surgical closure of ventricular septal defects (VSDs), sometimes as first choice and otherwise as an alternative approach. This paper presents the experience in a group of 124 patients who underwent VSD closure by a transaortic approach in an 18-year-period, between 1974 and 1992. Patients were divided in three groups: (I) Isolated VSD, 89 patients (mean age 7.6 years); (II) VSD associated with other malformations, 27 patients (mean age 10.8 years); and (III) recurrent VSD, eight patients (mean age 15.6 years). Two deaths occurred in the postoperative period (2/124), one after closure of VSD in a patient with severe pulmonary hypertension; another death was observed after transaortic closure of the VSD as part of the repair of a complex heart malformation. There were no instances of new right bundle branch block (RBBB) in the group operated on for isolated VSDs. Three cases of left bundle branch block (LBBB) (3.4%) occurred in the isolated VSD group. There were no cases of complete aortic valve (AV) block in the whole series and no instances of AV dysfunction. The transaortic approach is an alternative for the surgical treatment of ventricular septal defects. The ease of exposure and closure of defects suggest this technique to be a particularly attractive approach in the treatment of small to moderate-sized VSDs and also in recurrent VSDs.

Transaortic approach has a role in the surgical treatment of ventricular septal defects

A transaortic approach was used for surgical closure of ventricular septal defects (VSDs), sometimes as first choice and otherwise as an alternative approach. This paper presents the experience in a group of 124 patients who underwent VSD closure by a transaortic approach in an 18-year-period, between 1974 and 1992. Patients were divided in three groups: (I) Isolated VSD, 89 patients (mean age 7.6 years); (II) VSD associated with other malformations, 27 patients (mean age 10.8 years); and (III) recurrent VSD, eight patients (mean age 15.6 years). Two deaths occurred in the postoperative period ( 2 124 ), one after closure of VSD in a patient with severe pulmonary hypertension; another death was observed after transaortic closure of the VSD as part of the repair of a complex heart malformation. There were no instances of new right bundle branch block (RBBB) in the group operated on for isolated VSDs. Three cases of left bundle branch block (LBBB) (3.4%) occurred in the isolated VSD group. There were no cases of complete aortic valve (AV) block in the whole series and no instances of AV dysfunction. The transaortic approach is an alternative for the surgical treatment of ventricular septal defects. The ease of exposure and closure of defects suggest this technique to be a particularly attractive approach in the treatment of small to moderate-sized VSDs and also in recurrent VSDs.

Salvage of infected truncus repair using rifampicin-impregnated gelatin-sealed graft

An infant suffered sternal infection and ventricular septal patch dehiscente after a truncus arteriosus repair. Successful reoperation used rifampicin-impregnated gelatin-sealed Dacron to repair the recurrent ventricular septal defect and replace the contaminated conduit. This was an effective solution to a potentially lethal surgical complication.

Temporary tricuspid valve detachment in closure of congenital ventricular septal defect.

In a consecutive series of 149 patients with congenital ventricular septal defect (VSD), temporary tricuspid valve detachment was applied in 39 (detached group) to facilitate the transatrial approach for closure of the defect. Baseline characteristics showed that, preoperatively, the detached group were younger (1.3 +/- 2.3 vs. 3.5 +/- 4.1 years, P = 0.002), shorter (0.67 +/- 0.20 vs 0.87 +/- 0.34 m, P = 0.001), lighter (6.9 +/- 5.4 vs 13.5 +/- 12.0 kg, P < 0.002), and had a higher mean right atrial pressure (6 +/- 2 vs 4 +/- 3 mm Hg, P < 0.003), mean end-diastolic right ventricular pressure (10 +/- 3 vs 8 +/- 3 mm Hg, P < 0.01) and mean pulmonary vascular resistance (267 +/- 202 vs 170 +/- 131 dyn s cm-5, P < 0.02) on cardiac catheterization. At surgery the aortic cross-clamp time was longer (48 +/- 17 vs 39 +/- 15 min, P = 0.003). Seven patients died (2 detached, 5 not-detached), from causes not related to either tricuspid detachment or VSD closure. Follow-up was complete with a mean duration of 2.0 years (range 0.1-5.5). All 142 survivors were investigated by echocardiography, which showed normal tricuspid valve function in all but 29 patients who had trivial regurgitation (6 detached, 23 not-detached). There was no tricuspid stenosis. In 30 patients (8 detached, 22 not-detached) a trivial residual VSD could be detected. One reoperation (not-detached) was performed 12.5 months after the initial surgery for recurrent VSD.(ABSTRACT TRUNCATED AT 250 WORDS)

Restrictive ventricular septal defect: How small is too small to close?

Historically, indications for ventricular septal defect closure have included congestive heart failure, pulmonary hypertension, aortic insufficiency with or without aortic valve prolapse, and prior bacterial endocarditis. However, controversy exists as to how the lifetime risk of an isolated, nonoperated restrictive ventricular septal defect compares with the risk of surgical closure in an asymptomatic child. Between 1980 and 1991, cardiac catheterization and elective ventricular septal defect closure (age > 1 year, pulmonary to systemic flow ratio < 2.0) were performed in 141 patients aged 1 to 23 years (mean age, 6.1 ± 4.7 years). Mean systolic pulmonary artery pressure was 26.9 ± 13.0 mm Hg, and mean pulmonary to systemic flow ratio was 1.6 ± 0.3. Aortic valve prolapse was present in 63 patients (45%), aortic insufficiency was present in 25 (18%), and 5 (3.5%) had prior bacterial endocarditis. There were no early or late deaths or major morbidity. No patient required a ventriculotomy to accomplish ventricular septal defect closure. Mean postoperative intensive care unit stay was 1.3 ± 0.9 days, and mean hospital stay was 5.5 ± 1.9 days. There were no instances of permanent complete atrioventricular dissociation, reoperations for bleeding, postoperative wound infections, or roperations for residual or recurrent ventricular septal defect. These improved results justify a reevaluation of historic indications for ventricular septal defect closure. Surgical closure of a restrictive ventricular septal defect removes the socioeconomic stigma associated with living with an uncorrected cardiac defect, and the surgical risk as defined by this experience when compared with known natural history studies is less than the lifetime risks of development of bacterial endocarditis or progressive aortic valve prolapse leading to aortic insufficiency.