Residual VSD Research Articles

Surgical Closure of Ventricular Septal Defect: Contemporary Results and Risk Factors for Electrophysiological Changes

Abstract Background The surgical closure of a ventricular septal defect is a commonly performed procedure. Postoperative ECG changes are common findings that needs a proper assessment to provide valuable insights into the outcomes of the patients. In this study, we investigate the potential risk factors associated with electrophysiological changes following surgical closure of ventricular septal defects. Methodology A Prospective, non-randomized study was conducted from October 2020 to December 2022 on patients scheduled for VSD closure. Patients with prior abnormal Congenital electrophysiological disturbances, Internal pacemaker, Ebstein's anomaly, associated sub-aortic membrane or Hypertrophic obstructive cardiomyopathy, Iatrogenic VSD, need Aortic root dilatation with VSD closure were excluded. 12-lead ECG was reported on ICU admission and daily thereafter till discharge. Various demographic and peri-operative data were recorded and its correlation to the presence of electrophysiological changes and final outcomes were analyzed. Results 200 patients who underwent surgical VSD closure were included. Arrhythmias occurred in 41 patients (20,5%). The encountered arrhythmias were sinus bradycardia with junctional escape in 24 patients, junctional ectopic tachycardia in 10 patients, supraventricular tachycardia in 2 patients, premature complex in 2 patients, 2nd degree heart block in 4 patients and 3rd degree block in 2 patients. Mother's hypertension, preoperative mechanical ventilation, Associated cardiac anomalies, Down syndrome, size of VSD, type of VSD, Total bypass time, Aortic cross clamp time, Concomitant procedures, Intra operative pacing, and residual VSD, were identified in a univariate analysis as Risk factors for occurrence of arrhythmias. The multivariate logistic regression analysis shows that the most significant risk factors for the occurrence of ECG changes were outlet VSD type, mitral valve repair as a concomitant procedure and aortic cross clamp time >45 minutes. Conclusion Surgical VSD closure is a safe procedure with low mortality and morbidity rates. Younger age and lower body weight are risk factors for prolonged hospitalization, intensive care unit stay and mechanical ventilation. Longer crossclamp and CPB times were significant predictors of post Op ECG changes and associated complications with prolonged ICU and hospital stay.

Mid-Term Outcome of the Hybrid Method of Ventricular Septal Defect Closure in Children.

<b>Objective: </b>To describe the clinical experiences and mid-term follow-up results of the hybrid method of ventricular septal defect closure in children.<br /> <b>Methods: </b>This study was a combined - multidirectional cohort. Between May 2016 and December 2020, 250 patients with isolated VSD (or residual VSD after a previous repair) underwent surgery by the hybrid method at the pediatric cardiac surgery department in the National Scientific Medical Center. This study adopted a combined and multidirectional cohort approach, initially starting as a retrospective cohort and later transitioning into a prospective cohort.<br /> <b>Results: </b>A total of 250 patients in this cohort underwent hybrid VSD closure, of which 233 (93.2%) patients were successful, 16 (6.4%) patients were converted to the traditional method and 1 (0.4%) death occurred. New trivial or mild tricuspid regurgitation was detected in 35 patients (15%) and aortic regurgitation in 9 patients (3.9%) by intraoperative TEE. For the remaining 10 patients with incomplete right bundle branch blocks the sinus rhythm was restored in follow-up. In addition, the left ventricular ejection fraction improved over time. One of the important points after surgery is the deformation of the chest. In 122 (91%) patients, there is no deformation; unfortunately, in 12 (9%) patients, there is deformation. <br /> <b>Conclusions: </b>The hybrid method is a rapidly developing technique that has been safe and effective in a selected group of patients in recent years. The advantages of this method are minimum incision namely the size and length of the postoperative scar from 2 to 4 cm. Also, no myocardial injury, and reduces operation time, intensive care unit stay, and hospital stays.

Hybrid versus traditional method closure of ventricular septal defects in children

ObjectiveThe aim of our study was to evaluate the safety and effectiveness of the hybrid method off-pump for closure of isolated ventricular septal defect (VSD) compared with the traditional method of on-pump of children. MethodsThis research was a retrospective cohort study. Data were collected from 500 patients with isolated VSD (or residual VSD after a previous repair) who underwent surgery at the National Scientific Medical Center from May 2016 to December 2020. Patients were operated with 1 of 2 methods of surgery: the traditional method of on-pump or the hybrid method of off-pump. This study assessed the safety and efficacy of the hybrid method by comparing it with the traditional method for the treatment of patients with isolated VSD. ResultsThe procedural success rate reached 93.2% in the hybrid method, with a 6.4% conversion rate to the traditional method and 0.4% hospital mortality. The mean operation time was 84 minutes (31; 160 minutes) in the hybrid group (n = 250) and 168 minutes (70; 300 minutes) in the traditional group (n = 250) (P = .000). Hospital mortality was 0.43% in the first group and 1.5% in the second group (P = .000). ConclusionsThe hybrid method of VSD closure is safe and effective in a selected group of patients. The advantages of the hybrid method are improved cosmetics and shorter operation time and overall hospital stay.

Predictors Of Residual VSD After Surgical Versus Transcatheter Closure

Predictors Of Residual VSD After Surgical Versus Transcatheter Closure

Catheter closure of residual muscular VSD after VSD, interrupted aortic arch repair using Amplatzer muscular occluder (patient number 2 in Table S1). VSD, ventricular septal defect.

Catheter closure of residual muscular VSD after VSD, interrupted aortic arch repair using Amplatzer muscular occluder (patient number 2 in Table S1). VSD, ventricular septal defect.

Catheter closure of residual muscular VSD after common arterial trunk repair using Amplatzer muscular occluder (patient number 3 in Table S1). VSD, ventricular septal defect.

Catheter closure of residual muscular VSD after common arterial trunk repair using Amplatzer muscular occluder (patient number 3 in Table S1). VSD, ventricular septal defect.

Transcatheter closure of residual Gerbode VSD using ADO II after Rastelli operation (patient number 21 in Table S1). VSD, ventricular septal defect; ADO, Amplatzer duct occluder.

Transcatheter closure of residual Gerbode VSD using ADO II after Rastelli operation (patient number 21 in Table S1). VSD, ventricular septal defect; ADO, Amplatzer duct occluder.

Catheter closure for residual VSD after AVSD-TOF repair using ADO II (patient number 12 in Table S1). AVSD, atrioventricular septal defect; TOF, tetralogy of Fallot; ADO, Amplatzer duct occluder.

Catheter closure for residual VSD after AVSD-TOF repair using ADO II (patient number 12 in Table S1). AVSD, atrioventricular septal defect; TOF, tetralogy of Fallot; ADO, Amplatzer duct occluder.

Transcatheter closure of residual VSD related to surgical patch after Fallot pulmonary atresia repair using Amplatzer septal occluder (patient number 11 in Table S1). VSD, ventricular septal defect.

Transcatheter closure of residual VSD related to surgical patch after Fallot pulmonary atresia repair using Amplatzer septal occluder (patient number 11 in Table S1). VSD, ventricular septal defect.

Transcatheter closure of residual VSD in a small infant (3.8 kg) using ADO II (patient number 17 in Table S1). VSD, ventricular septal defect; ADO, Amplatzer duct occluder.

Transcatheter closure of residual VSD in a small infant (3.8 kg) using ADO II (patient number 17 in Table S1). VSD, ventricular septal defect; ADO, Amplatzer duct occluder.

Usefulness of perioperative transesophageal echocardiography during pediatric cardiac surgery

Pediatric transesophageal echocardiography (TEE) probes allow perioperative evaluation during pediatric congenital heart disease (CHD) surgery. To determine the usefulness of perioperative TEE for evaluation of residual lesions severity according to the type of repaired CHD. Retrospective review of patients who underwent a perioperative TEE study during open-heart surgery (excluding ostium secundum atrial septal defect closure) over 4 consecutive years in our center. Residual lesions were rated as mild, moderate or severe. Among 291 interventions (which may include multiple gestures) in 280 patients (pts), no complications related to TEE study occurred. Median weight was 8,1 kg (range 2–96) and size of probe (micro 2D TEE, mini-multi 2D TEE or 3D TEE) adapted to the weight. Twenty-one (7.2%) severe residual lesions required immediate reintervention. Eleven pts (9.7%) had severe residual stenosis and required immediate reintervention out of 113 right ventricular outflow tract obstruction (RVOTO) surgeries. Three pts (3.5%) required immediate reintervention for aortic regurgitation and two (2.3%) for mitral residual lesions out of 86 left heart surgeries. Two pts (1.1%) required immediate reintervention for severe residual VSD out of 188 ventricular shunt surgeries. Two pts (4.2%) required immediate reintervention for superior vena cava stenosis following Warden procedure out of 47 pretricuspid shunt surgeries. One immediate reintervention occurred after a “Cone surgery” for severe right ventricle dysfunction. Use of perioperative TEE is safe and provides accurate information of residual lesions leading to several immediate intervention. RVOTO, left valvular and shunt closure surgeries could most likely benefit of its use.

Predictors of major adverse events and complications after ventricular septal defects surgical closure in children less than 10 kg

BackgroundVentricular septal defect (VSD) is the most common congenital cardiac defect for which outcomes are not uniform. There is a lack of consensus on the risk factors for the unfavorable outcomes following surgical VSD closure.AimThe aim of this study was to determine the risk factors and the predictors of major adverse events (MAEs) and complications following surgical closure of VSD in children weighing less than 10 kg.MethodsThis retrospective cohort study included children less than 10 kg who underwent surgical closure of congenital VSD of any type with or without associated congenital heart diseases. Patients with associated major cardiac anomalies were excluded. Preoperative, operative and postoperative data were collected from medical records.ResultsThis study included 127 patients 52.8% were males, the median age was 8.0 months (IQR = 6.0–11.0 months), and their median weight was 5.7 kg (IQR = 4.8–7.0). Mortality was in one patient (0.8%) Multivariable logistic regression analysis revealed that male sex group (observational data), previous pulmonary artery banding (PAB), and significant intraoperative residual VSD were significant risk factors for the development of MAEs (odds ratios were 3.398, 14.282, and 8.634, respectively). Trisomy 21 syndrome (odds ratio: 5.678) contributed significantly to prolonged ventilation. Pulmonary artery banding (odds ratio: 14.415), significant intraoperative (3 mm) residual VSD (odds ratio: 11.262), and long cross-clamp time (odds ratio: 1.064) were significant predictors of prolonged ICU stay, whereas prolonged hospital stay was observed significantly in male sex group (odds ratio: 12.8281), PAB (odds ratio: 2.669), and significant intraoperative (3 mm) residual VSD (odds ratio: 19.551).ConclusionsSurgical VSD repair is considered a safe procedure with very low mortality. Trisomy 21 was a significant risk factor for prolonged ventilation. Further, PAB, significant intraoperative residual of 3 mm or more that required a second pulmonary bypass, and a greater cross-clamp time were significant predictors of MAE and associated complications with prolonged ICU and hospital stay.

Usefulness of perioperative transesophageal echocardiography during pediatric cardiac surgery

Pediatric transesophageal echocardiography (TEE) probes allow perioperative evaluation during pediatric congenital heart disease (CHD) surgery. The aim of the study was to determine the usefulness of perioperative TEE for evaluation of residual lesions severity according to the type of repaired CHD. Retrospective review of patients who underwent a perioperative TEE study during open-heart surgery (excluding ostium secundum atrial septal defect closure) over 4 consecutive years in our center. Residual lesions were rated as mild, moderate or severe. Among 291 interventions (which may include multiple gestures) in 280 patients (pts), no complications related to TEE study occurred. Median weight was 8.1 kg (range 2–96) and size of probe (micro 2D TEE, mini-multi 2D TEE or 3D TEE) adapted to the weight. Twenty-one (7.2%) severe residual lesions required immediate reintervention. Eleven pts (9.7%) had severe residual stenosis and required immediate reintervention out of 113 right ventricular outflow tract obstruction (RVOTO) surgeries. Three pts (3.5%) required immediate reintervention for aortic regurgitation and two (2.3%) for mitral residual lesions out of 86 left heart surgeries. Two pts (1.1%) required immediate reintervention for severe residual VSD out of 188 ventricular shunt surgeries. Two pts (4.2%) required immediate reintervention for superior vena cava stenosis following Warden procedure out of 47 pretricuspid shunt surgeries. One immediate reintervention occurred after a “Cone surgery” for severe right ventricle dysfunction. Use of perioperative TEE is safe and provides accurate information of residual lesions leading to several immediate intervention. RVOTO, left valvular and shunt closure surgeries could most likely benefit of its use.

Endotracheal bleed after intra cardiac repair in tetralogy of fallot patients: a diagnostic challenge

Background: Tetralogy of Fallot (TOF) is the most common congenital cyanotic heart disease (CCHD) in children. With the development and advancement of paediatric cardiac surgery and intensive care units, a large number of TOF are presenting for cardiac surgery. Operated TOF may suffer from endotracheal (ET) bleeding in postoperative period which results in delayed extubation of patients. ET bleeding is multifactorial with MAPCAs, coagulopathy residual VSD, and high LA pressure being usual causes. The objective of this study was to evaluate those children of TOF who suffered from ET bleeding, their causes and management after intracardiac repair.Methods: This was a single center retrospective study that included patients with a diagnosis of TOF. Total of 27 patients were operated at GB Pant Hospital, Department of CTVS from February 2021 to November 2021. After taking ethical approval we conducted a retrospective study to analyse the cause of endotracheal bleed. Statistical analyses were performed using STATA software version (16.0). Continuous variables were presented as mean±standard deviation (SD) or median (interquartile range [IQR]. Inclusion criteria was- all diagnosed case of tetralogy of fallot patient with age –1.5-8 years, both male and female. Exclusion criteria was- patients having co-morbidities, like juvenile diabetes, hypothyroidism, syndromic patients.Results: Endotracheal bleed noted in majority of patient in those MAPCAs were not coiled, not able to be ligated intaoperatively, they bleed in postoperative period which further delayed extubation of patients. Of the patients with Endotracheal bleed none had a residual cardiac defect. Post-operative mortality was 1/27.Conclusions: We hereby conclude that cause of endotracheal bleed after intracardiac repair of tetralogy of fallot patients can be due to left uncoiled, non- ligated major aorto-pulmonary collateral arteries (MAPCAs).

Transcatheter Closure of Postoperative Residual VSD and Acquired Left Ventricle-to-Right Atrium Shunt with Using Two Different Devices.

Transcatheter Closure of Postoperative Residual VSD and Acquired Left Ventricle-to-Right Atrium Shunt with Using Two Different Devices.

Individualized strategy of minimally invasive cardiac surgery in congenital cardiac septal defects

BackgroundIntracardiac septal defect is repaired using median sternotomy in most centers; however, there are several reports using minimally invasive surgery in both children and adults. This study summarized our strategy of minimally invasive therapy using various lateral mini-thoracotomies in patients with congenital septal defect.MethodsIn this study, 472 patients who underwent minimally invasive repair of intracardiac septal defects (atrial septal defect, (ASD), ventricular septal defect, (VSD), and atrioventricular septal defect, (AVSD)) from January 2012 to June 2020 were retrospectively reviewed. Those who underwent device closure were excluded. The minimally invasive strategy included three groups: the right sub-axillary vertical incision (RSAVI) group (N = 335, including192 ASDs, 135 VSDs and 8 AVSDs); the right anterolateral thoracotomy (RALT) group (N = 132, including 77 ASDs, 51 VSDs and 4 AVSDs); and the left anterolateral thoracotomy (LALT) group (N = 5, all subpulmonary VSDs).ResultsConcomitant surgeries included nine cases of right ventricular outflow tract obstruction relief, nine cases of mitral repairs and 37 cases of tricuspid repairs. There was one transition from thoracotomy to sternotomy. Three patients required second pump run for residual lesions (two residual VSD shunts and one mitral regurgitation). The age and body weight of the RSAVI group were significantly lower than those of the RALT and LALT groups (all P < 0.01). No postoperative death was observed. Postoperative complications included one case of chest exploration for bleeding, one case of reoperation due to patch dehiscence during the same admission, one case of transient neural dysfunction, three cases of diaphragmatic paresis and 13 cases of atelectasis. The median stay in the intensive care unit was two days, while the median postoperative hospitalization duration was six days. The echocardiography results before discharge indicated no significant residual lesions. No reoperation, no new onset of chest deformities and no sclerosis were observed during the follow-up.ConclusionsIntracardiac septal defects can be safely and effectively repaired by minimally invasive surgery with good cosmetic results. RSAVI is suitable in infants and children, while RALT is more commonly used in adolescents and adults. LALT is an alternative incision to repair subpulmonary VSD.

COMPLETE REPAIR OF TETRALOGY OF FALLOT (TOF) ON BEATING HEART SURGERY WITHOUT AORTIC CROSS CLAMPING : REPORT OF A CASE

Introduction: Reperfusion injury is a well-known phenomenon that occurred in cardioplegic techniques with cardiopulmonary bypass. Therefore great effort is made to prevent reperfusion injury. Beating Heart Continuous Coronary Perfusion (BHCCP) surgery is one of the alternative techniques to improve an ischemic reperfusion injury in open-heart surgery, either in pediatric or in adult. This technique can be done in complete repair of tetralogy of Fallot (TOF). Purpose: To report our first experience in doing complete repair of TOF using beating heart technique without aortic cross-clamping Case Report: A five-year-old boy came on to ER on January 6th, 2012, with a history of cyanotic since birth. His echocardiography and catheterization concluded a tetralogy of Fallot with a McGoon ratio of 1.95 (the diameter of RPA and LPA were 9.14 mm and 8.79 mm, respectively). A complete repair of TOF was done using beating heart surgery without aortic cross-clamping technique. One month post-surgery evaluation, there weren't any neurological or motor disorders. Echocardiography results showed no residual pulmonary stenosis, but 0.2 mm residual VSD was found. Conclusion: This heart rate technique is an alternative method of myocardial protection in cardiac surgery. In several cardiac centres globally, this technique is relatively safe and can be used during surgery, especially in the total correction of TOF.

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.

Management of Iatrogenic VSD during Systemic RVAD Implantation: Case Report

<h3>Introduction</h3> This is a case of a 16-year-old male with ccTGA who underwent systemic RVAD (HeartMate III) implantation for severe systemic RV dysfunction. <h3>Case Report</h3> Based on suboptimal transesophageal (TEE) and epicardial ECHO imaging, the inflow cannula was to be placed anterior and lateral to the true apex of the systemic RV. The ventriculotomy created by a coring device overrode into the ventricular septum and was hidden underneath the inflow cannula ring (<b>Fig 1A</b>). After VAD support was initiated, patient became severely hypoxic with a PO₂ of 45-50 mmHg. CPB was re-initiated and the inflow cannula was removed, revealing a large iatrogenic VSD at the cannula insertion point. VSD was closed by bovine pericardial patch and the ventriculotomy was extended laterally to relocate the VAD sewing ring (<b>Fig 1B</b>). After CPB was weaned again, patient initially remained cyanotic and imaging identified possible tiny VSD patch leak with right to left shunting as a potential cause of hypoxia. Pursuing residual VSD closure was deemed unsafe. Rescue nitric oxide (NO) infusion dramatically corrected the desaturation. <h3>Summary</h3> Iatrogenic VSD in the setting of systemic RVAD causes significant hypoxia but can be effectively repaired by patch closure. Determining the favourable positioning of the inflow cannula in ccTGA is a technical challenge. Using a combination of TEE and epicardial ECHO offers superior guidance for cannula insertion, but can still be inadequate in preventing iatrogenic injury. Furthermore, even small residual VSDs or septal suture holes can be a source of hemodynamically significant right to left shunting due to the high negative pressure from the inflow cannula. In these situations, medical optimization may be the solution. Rationale for the remarkable effect of NO in our case is somewhat unclear, but perhaps explained by improved ventricular ejection and decompression from the subpulmonary LV. <b>Figure 1.</b> ECHO of <b>A)</b> iatrogenic VSD hidden by sewing ring and <b>B)</b> RV after VSD patch closure and lateral repositioning of inflow cannula.=

Efficacy and Safety of Transcatheter Ventricular Septal Defect Closure Using Nit-Occlud Le VSD coil in Short-term Observation

Nit-Occlud Le VSD coil, an alternative device for closing VSD transcatheter, started to be used in dr. Soetomo Hosptal in 2017, but no research has been done on the results of closure with this device. This study aims to evaluate the efficacy and safety of the Nit-Occlud Le VSD coil. Descriptive observational method was used. The results are as follow: Of the 17 patients who underwent transcatheter closure during January to December 2018, 10 (58, 8%) cases were closed with Nit- Occlud Le VSD coil. The success of implantation is 100%, 8 cases were closed with Nit-Occlud Le VSD coil, 2 plus an amplatzer (ADO 1 and AVSO). Type of VSD: perimembranaous 7 (70%), subaortic 2 (20%) and mid muscularis 1 (10%). Immediate complete closure in 7/10 (70%), while 3 (30%) obtained residual DSV. The closure rate at the first month of follow up becomes 80%. Median length of post-catheterization was 2 days (2 - 3 days). Complications: 1 (10%) mild aortic regurgitation, 1 (10%) hemolysis and 2 (20%) with additional second device (ADO 1 and AVSO): first case: moderate residual VSD and severe aortic regurgitation; second case: severe tricuspid regurgitation and residual VSD that disappeared in first month. The residual VSD altered from 30% to 10%, and closure rate was 80% at the first month of observation. VSD closure with Nit-Occlud Le VSD coil provides good efficacy and safety for patients.&#x0D; Keywords: VSD, Nit-Occlud Le VSD coil.