Surgical Closure Of Ventricular Septal Defect Research Articles

Late surgical ventricular septal defect closure in a low middle-income country setting: a case series

BackgroundVentricular septal defect (VSD) is the commonest type of congenital heart lesion accounting for up to 40% of congenital heart defects. Well timed VSD closures are reported to yield excellent long-term outcomes. Late surgical VSD closures, particularly from the developing countries, are infrequently reported.Case presentationWe report three cases of African children aged between 13 and 14 years who had late VSD presentations. They reported complaints of growth failure and recurrent respiratory infections since early infancy which necessitated frequent visits to primary health care facilities. They were found to have large ventricular septal defects by thoracic echocardiography. Diagnostic cardiac catheterization was done to all three patients to rule out irreversible pulmonary hypertension. After promising cardiac catheterization findings, they all underwent successful surgical VSD repair with good early outcomes.ConclusionVSD surgical closure is ideal in children below 2 years, however, it can be done in children who present at advanced age despite being considered high risk patients. All three of our patients who presented late had successful surgical VSD repairs with promising immediate outcome. The role of genetics in the protection against developing irreversible pulmonary vascular disease in these patients is a possible area for future studies.

Tran Catheter Closure of Ventricular Septal Defects (VSD): Preliminary Results in Children Weighing 5kg or Less

<i>Aim: </i>This study aims to evaluate feasibility and complications of device closure of ventricular septal defect (VSD) in children weighing 5kg. <i>Methods:</i> Between March 2018 and March 2021, total 15 patients with Ventricular Septal Defect (VSD) weighing 5Kg or less were taken to Cath lab for percutaneous VSD closure out of which 13 (86%) had successful transcatheter closure and 2 (14%) cases were unsuccessful and subsequently send for surgical closure. All of these13 patients under went transcatheter closure of VSD using either a Amplatzer duct occluder1, Amplatzer duct Occluder 2 or Amplatzer Muscular VSD Occluder. A retrospective review of the results and related complications was done. <i>Results:</i> Among these 15 patients, 7 were females, 6 were male and the mean age was 8.5 (4-16month. The mean weight in this study was 4.46Kg (2.3-5Kg). Mean VSD size was 4.5 (3-10mm), 9 patients had VSD sizes between 3to5mm, 3 had between5-10 mm and 1 with more than 10mm. Among types of VSD, 9 cases were having Perimembranous, 1 was upper muscular, 1was mid while 1was lower muscular and only 1 had outlet muscular VSD. Amplatzer Duct Occluder (ADOI) was used in 2 cases, 9 were closed with Amplatzer Duct Occluder (ADO2) and 2 were selected for closure with Amplatzer Muscular VSD Occluder. Transthoracic Echocardiography (TTE) in immediate post intervention period revealed all these devices in situ with no or minimal residual flow which subsided within 24 hours period. As far as complications are concerned, we had one device embolization noted in our study. Tricuspid regurgitation (TR) was noted at the time of discharge in 4 patients but subsided after 48 hours while trivial aortic regurgitation was noted (AR) only in one case which is under close follow up and not increasing in severity after 6 months follow-up. <i>Conclusions</i>: Transcatheter closure of VSD in children 5kg or less is feasible and safe alternative to surgical VSD closure.

Fibronectin enhances attachment of human adipose-derived mesenchymal stem cells into polytetrafluoroethylene patch during surgical closure of the atrial and ventricular septal defect.

Polytetrafluoroethylene (PTFE) patch is commonly used during surgical closure for atrial septal defect (ASD) and ventricular septal defect (VSD). However, this patch has several limitations such as its inability to grow or remodel, especially in children and young adults. To tackle these limitations, we have tried to use fibronectin and human adipose-derived mesenchymal stem cells (hAMSCs) in the PTFE patch. To understand the impact of fibronectin to enhance hAMSCs cell-to-cell adherence and cell-to-patch surface attachment into PTFE patches used in the surgical closure of ASD or VSD. The hAMSCs were plated and fixated with 15 mL methanol and cluster of differentiation (CD) 90+, CD105+, and CD45 - antibodies were labeled with fluorescein isothiocyanate, rinsed with phosphate-buffered saline, and analyzed under a fluorescence microscope. Fibronectin solution (0.1%) was used to soak patch scaffolds for approximately 2-h duration and then dried for 20 min in the treatment group. The samples were examined with a scanning electron microscope (SEM). SEM examination showed incomplete attachment of the cells even after 10 days in the control group at 1.14 ± 1.13. In contrast, the treatment group showed more cells attached to the patch surface at 31.25 ± 13.28 (P ≤ 0.0001). The observation at 5 days was 17.67 ± 20.21, at 7 days was 12.11 ± 10.94, and at 10 days was 18.83 ± 23.25. There was no significant statistical difference in mean cell per view among each treatment group (P = 0.802). Our work demonstrates that fibronectin has a positive impact on hAMSC attachment seeded onto the PTFE patch. These properties, in combination with their developmental plasticity, have generated tremendous interest in regenerative medicine.

876 VENTRICULAR SEPTAL DEFECT AND RIGHT-SIDED INFECTIVE ENDOCARDITIS

Abstract Introduction Right-sided infective endocarditis (IE) accounts for 5-10% of IE cases; it is most frequently associated with intravenous drug abuse but can also be observed in patients with cardiac implantable electronic devices, central venous catheters or congenital heart diseases. Case report A 34-year-old female, with unrepaired perimembranous ventricular septal defect (VSD) and right ventricle and tricuspid valve (TV) IE with lung septic embolism treated conservatively with antibiotic therapy 16 years ago, was admitted to our hospital for persistent fever and cough unsuccessfully treated with empiric antibiotic therapy. She denied intravenous drug abuse and recent surgical or dental procedures. Blood cultures resulted positive for multi sensitive Staphylococcus lugdunensis, so antibiotic therapy with Oxacillin and Gentamicin was started. Suspecting IE, transesophageal echo (TEE) was performed and showed, inside VSD, a small fluctuating vegetation and, along the right side of the interventricular septum, next to the VSD, a voluminous hypomobile vegetation; septal and anterolateral TV leaflets appeared thickened and infiltrated by vegetations floating into the right atrium; at color-Doppler moderate TV regurgitation. A whole-body computed tomography showed right lung abscess and right kidney septic infarct. Endocarditis Team, considering hemodynamic stability and inflammatory biomarkers and surveillance blood cultures negativization, decided for medical therapy with echocardiographic follow-up. TEE performed at the end of antibiotic therapy demonstrated complete disappearance of the above described vegetations and surgical VSD closure was scheduled. Discussion Patients with unoperated small VSDs and without volume overload signs usually remain asymptomatic and do not require surgery; nevertheless, a small percentage of them develops problems later in life and IE represents one of the main concerns. Even if unrepaired VSD is associated with increased risk of IE compared with the general population, antibiotic prophylaxis is still recommended only for high-risk patients undergoing at-risk dental procedures, while non-specific oral and cutaneous hygiene measures should always be applied. Latest ESC Guidelines for the management of adult congenital heart disease state that in patients with no significant left to right shunt, but a history of repeated episodes of IE, VSD closure should be considered (IIa, C); it's still matter of debate whether closure should be performed after the first episode of IE. Conclusion IE should always be suspected in patients with VSD and persistent fever. Optimal oral and skin hygiene are effective prevention measures, while prophylactic antibiotic therapy is indicated only in selected cases. Surgery should be considered after repeated episodes of IE.

Comparative study between results of using synthetic versus pericardial patches for VSD closure in infants and children

Background: Generally ventricular septal defects (VSDs) are repaired with synthetic material: either Dacron (polyethylene terephthalate) or Goretex (expanded polytetrafluoroethylene) depending on surgeons preference. Aim of the work: To compare between the outcome of VSD closure by synthetic patches versus pericardial patches. Patients and methods: This study was conducted on 60 patients with surgical VSD closure. They were divided into 2 groups each included 30 patients. In group I synthetic patch (Dacron or Gortex) was used. In group II pericardial patch (fresh or treated or bovine) was used. The patients were evaluated at 3m and 6m after operation for: residual defects, endocarditis, heart block, AR, TR, LV dimensions and function and any other complications. Results: Ventilation time, was statistically significant shorter in group II (8.53 ± 6.37h) compared with Group I (30.60 ± 20.84h) p value 0.001*. Statistically significant shorter ICU time was found in group II (2.53 ± 0.90d) compared with group I (3.70 ± 1.62d). Twenty (66.7%) patients and 28(93.3%) patients in group I and II respectively had sinus rhythm. While 10 (33.3%) patients and 2 (6.7%) patients in group I and II respectively had temporary heart block.

Transcatheter closure of ventricular septal defects: preliminary results in children weighing 10 kg or less.

Ventricular septal defect is one of the commonest heart defect in children and closure of this defect with devices has seen a rapid progression over a period of time. The availability of new and safer devices has made the transcatheter closure of ventricular septal defect a suitable option even in young children. The study was done to evaluate the feasibility and complications of device closure of ventricular septal defect in children weighing 10 kg or less with different types of devices. The present study was undertaken in a newly established dedicated Paediatric Cardiac Unit at a Tertiary Care Hospital. Relevant data were obtained retrospectively from the case files and the catheterisation records and data were analysed for first 50 patients with ventricular septal defect weighing 10 kg or less between March 2018 and March 2021. Among these 50 patients selected, device closure was successfully done in 45 (90%) cases while 5 (10%) attempts were unsuccessful for various reasons. The mean weight in this study was 7.46 ± 1.89 kg (2.3-10 kg), 21 (42%) cases were females while 29 (58%) were males; mean age was 19.4 ± 11.88 months (4-48 months). Right heart catheterisation study showed 21 (42%) patients with normal pulmonary artery pressures (no pulmonary artery hypertension). Among 29 patients with pulmonary arterial hypertension, 13 patients (22%) were having mild pulmonary arterial hypertension, 4 (8%) were with moderate pulmonary arterial hypertension, and 12 (24%) were with severe pulmonary arterial hypertension. Mean Qp/Qs was 2.73 ± 0.72 (2.5-4.5) and mean pulmonary vascular resistance was 1.5 ± 1.04 (0.6-4.6 WU). Amplatzer Duct Occluder (ADOI) was used in 15 (30%) cases, 27 (52%) cases were closed with Amplatzer Duct Occluder (ADOII), and the 3 (6%) cases closure was done with Amplatzer muscular ventricular septal defect occluder. Transcatheter closure of ventricular septal defect in children 10 kg or less is feasible and safe alternative to surgical ventricular septal defect closure. The immediate and short-term outcomes have proven this method to be safe and valid.

Long-Term Outcomes of Surgical Repair for Ventricular Septal Defect in Adults.

Data of the outcomes of ventricular septal defect (VSD) closure in adults are limited to establish recommendations. Therefore, we reviewed our experience with surgical VSD closure in adult patients. We retrospectively reviewed 152 patients who underwent surgical VSD closure between January 1996 and April 2020. The median age of the patients was 30.5 [interquartile range (IQR) 23.1-42.7] years. The median follow-up duration was 10.9 (IQR 4.8-16.1) years. VSDs were classified according to the Society of Thoracic Surgeons classification as type 2 (n = 66, 43.4%), type 1 (n = 59, 38.8%), and type 4 (n = 27, 17.8%). Aortic cusp prolapse (n = 86, 56.6%) and aortic valve regurgitation (AR, n = 75, 49.3%) were the most common indications for surgical closure. Four patients underwent late reoperation (2.6%) due to AR, infective endocarditis and residual VSD. In the log-rank test, preoperative trivial or more degree of AR (P = 0.004) and coronary cusp deformity (P = 0.031) was associated with late moderate or greater degree of AR. Preoperative moderate or greater AR was associated with reoperation (P = 0.047). Only concomitant aortic valve (AV) repair at the time of VSD closure was a significant risk factor for late significant AR progression in the multivariable analysis. VSD closure in adults can be performed with low mortality and morbidity rates. AR can progress after VSD closure because the aortic cusp may have irreversible damage from long-standing shunt flow exposure. We conclude that VSD with AV deformity or AR in adults should be treated aggressively before disease progression with irreversible damage occurs.

Radiofrequency catheter ablation for ventricular tachycardia using robotic magnetic navigation technology in a teenager after surgery of congenital heart disease and transcatheter closure of ventricular septal defect using an occluder: a case report

Introduction. The case report describes radiofrequency ablation of ventricular tachycardia (VT) using robotic magnetic navigation (RMN) in a teenager after surgery of congenital heart disease (CHD) and transcatheter closure of ventricular septal defect (VSD) using an occluder.Short description. The 16-year-old female patient was operated on in 2005 for CHD. In 2018, the patient underwent resection of ascending aortic sub-valvular membrane, followed by transcatheter closure of VSD with an occluder. After surgery, VT of 294 bpm was documented, which required an emergency hospitalization. Decision was taken to perform a radiofrequency ablation (RFA) using RMN. RFA was performed from the pulmonary artery valve through the scar to upper occluder edge spreading to tricuspid valve. After procedure, VT paroxysms were not induced with all pacing types. According to ECG series and 24-hour Holter monitoring on the 2nd day after surgery, VT episodes were not recorded. During the 6-month follow-up period, VT episodes were not registered without taking antiarrhythmic drugs.Discussion. This case report demonstrates the effectiveness of using RMN system for VT ablation in a teenager with CHD, who underwent open surgical interventions and transcatheter VSD closure using an occluder.

Interrupted versus Continuous Suture Technique for Ventricular Septal Defects Surgical Closure

Background: Ventricular septal defect (VSD) is the most frequent congenital cardiac defect. Conventionally, open-heart surgical repair through cardiopulmonary bypass (CPB) is the primary approach for many years. Objective: Given the absence of a reliable evidence on the optimal suture technique regarding the efficacy and morbidity, this study aimed to compare the postoperative complication rates and the outcomes of the interrupted and continuous suture techniques for the surgical VSD closure. Patients and Methods: This retrospective cohort study included 140 consecutive children 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 long-term outcomes data including VSD residual and heart block that needed permanent pacemaker (PPM) were collected from medical files. The closure was performed using interrupted sutures in 76 (54.3%, group 1), and by continuous sutures in 74 (45.7%, group 2) patients. Results: Three (3.9%) patients in group 1 and four (6.3%) patients in group 2 developed heart block that needed PPM, with no significant difference (p=0.702). Four (5.3%) patients in group 1 compared with two (3.1%) patients in group 2 had clinically and sizable (by echocardiography) significant residual, with no significant differences between both groups (p=0.688). Conclusion: The present study indicates that interrupted and continuous VSD closure techniques have comparable success and postoperative complication rates. Thus, the optimal suturing technique for VSD clo­sure cannot be standardized, and their predilection depends on the experience and the comfort of the surgeons.

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.

Effect of change in tidal volume on left to right shunt across ventricular septal defect in children - A pilot study.

Background :Pulmonary vascular resistance, an important determinant of shunting across ventricular septal defects (VSD), rises at both extremes of lung volume.Aims :We sought to determine the effect of changes in tidal volumes (VT) on pulmonary blood flow (Qp), systemic blood flow (Qs), and shunt (Qp/Qs) in children with VSD.Setting :Single-center teaching hospital.Design :Prospective observational study.Methods :Thirty children with a mean age of 11.8 ± 5 months undergoing surgical closure of VSD were studied. Hemodynamics and shunt-related parameters were assessed using transthoracic echocardiography measured at three different VT i.e. 10, 8, and 6-ml/kg keeping the minute ventilation constant.Results :Reduction in VT from 10 to 8 to 6 ml/kg led to a reduction in gradient across VSD measuring 23.5, 20 and 13 mmHg respectively (P < 0.001). Similarly, right ventricluar outflow tract (RVOT) diameter, RVOT velocity time integral, Qp (57.3 ± 18.1, 50.6 ± 16.9, 39.9 ± 14.7 mL; P < 0.001), Qs (24.1 ± 10.4, 20.0 ± 8.7, 15.3 ± 6.9 mL; P < 0.001) and peak airway pressure (17.2 ± 1.5, 15.8 ± 1.3, 14.5 ± 1.2 cmHg; P < 0.001) showed progressive decline with decreasing VT from 10 to 8 to 6 ml/kg, respectively. However, Qp/Qs (2.4 ± 0.4, 2.6 ± 0.4, 2.6 ± 0.4) demonstrated a minor increasing trend.Conclusion :Lower VT reduces the gradient across VSD, the pulmonary blood flow, and the peak airway pressure. Hence, ventilation with lower VT and higher respiratory rate maintaining adequate minute ventilation might be preferable in children with VSD. Further studies are required to confirm the findings of this pilot study.

Ventricular Septal Defect (VSD) Among Children Attending Three Health Institutions: Clinical Correlates and Patientsâ Characteristics

Background: Ventricular Septal Defect (VSD) is the commonest acyanotic congenital heart disease which presents with some clinical and post-operative characteristics. Objectives: This study is aimed at determining clinical and post-operative characteristics of children with VSD. Methods: An observational study, done in three institutions over a five-year period. Seven hundred and fifty-eight (758) echocardiography reports on children with cardiac defects were ascertained and a total of 151 children had VSD was extracted. Results: An observational study, done in three institutions over a five-year period. Seven hundred and fifty-eight (758) echocardiography reports on children with cardiac defects were ascertained and a total of 151 children with VSD were extracted, with a mean age of 3.3 ± 4.4 years.The patients’ characteristics evaluated in this study include clinical profile, surgical outcome and nutritional status of children with VSD. Fast breathingwas the commonest clinical findings in children with VSD70 (127); 55.1%, followed by cough 11 (68; 16.2%) and poor weight gain 55 (125); 44%.Thirty point nine (30.9%) were both wasted and stunted. 6.9% of the children were overweight (BMI+2SD) and 2.0% obese BMI+3SD). Aortic regurgitation was noted in (5/150) 3.3% of children with VSD, seen commonly in Peri-membranous VSD. Prevalence of pulmonary hypertension in this study was 47 (31.3%). Complications noted post-operation are aortic regurgitation 3.3%, and residual VSD. Seventeen point nine (17.9%) (27/151) of the patients had surgery for surgical closure of VSD. There were a total of 19 deaths of which 47.4% was before surgery and 52.6% among the females.There were a total of 19 deaths of which 47.4% were before surgery and 52.6% among the females. Majority of the deaths was in the infants (47.4%), the preschool and school age contribute 21.0% each and the adolescents, 10.5%. Among the 27 children that had surgery, 37.0% died post-surgery while 7.4% were lost to follow up. The remaining 56.0% are alive and being followed up with others who are yet to have surgery. Cause of death was documented in 13 of the 14 deaths, (10 post-surgery and 4 before surgery). Other causes of death included rheumatic heart disease (23.1%), heart failure (15.4%), and fall at home (15.4%), infective endocarditis (7.6%) and post-surgery achalasia (7.7%). Conclusion: The frequent symptom of VSD is fast breathing and Peri-membranous type is the commonest. Aortic regurgitation is the commonest post-surgical complication associated with VSD closure. The children present with various degrees of malnutrition. There was ahigh mortality noted before surgery.

Percutaneous closure of ventricular septal defect: Short and medium term results

Ventricular Septal Defect(VSD)is the most common congenital heart disease in children.A minority require closure to avoid complications. Surgical approach is the gold standard.Even if results of surgical closure of VSD are satisfactory, it is associated with complications and inherent risks of sternotomy. Today, Percutaneous Closure(PC)of VSD has become a valuable tool in place of surgery in some cases. This was a retrospective, mono-centric and descriptive study of patients with a VSD in whom a PCVSD was performed. Patients were collected from our Cardiology department over a period from2014 to 2018. Twelve PCVSD were performed. The median age of discovery of VSD was 4 months (2 months to 33 years).The average age of PC was 8 years(2 to 33 years), with a female predominance(8 girls).VSD were perimembranous in 6 cases, and trabecular in the others. The VSD was unique in all cases. The diameter of the VSD was on average 5.7 mm(4 to 13 mm). Left cavities were dilated in 9 patients. Pulmonary artery was dilated in 3 cases. The VSD was restrictive in 11cases.The prosthesis size was(on average 5/5 mm),the largest was 6/6 mm. The type of prosthesis used was ADO II in 11cases,and ADO I in 1case.The 12 VSD were successfully closed. A transient AVB occurred immediately after the closure of a trabecular VSD.A minimal residual shunt was present immediately after closure in 9 cases. After a month all patients were asymptomatic, a residual shunt persisted in 7 cases. SPAP remained stable in all cases and were reduced for the child who initially had PAH. Left cavities remained dilated in the 9patients.1 year after PC, all patients were asymptomatic. A residual shunt was noted in 4 cases. Only 5 patients retained moderate dilation of the left cavities.2patients were put on ACE inhibitor. The follow-up was 2.5 years. PCVSD is a promising alternative to surgery. The results of our study are encouraging despite the small sample size and the absence of a surgical control group

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.

Assessment of Tricuspid Valve Detachment Efficiency for Ventricular Septal Defect Closure: A Retrospective Comparative Study.

The aim of this study was to investigate the efficiency of tricuspid valve detachment (TVD) during the surgical treatment of perimembranous ventricular septal defects (VSDs) and to compare the early and mid-term results to patients without TVD in terms of tricuspid insufficiency. A total of 170 patients who had undergone surgical closure of perimembranous VSDs between November 2012 and January 2019 were included in this study, of whom 50 had an additional TVD procedure during the surgery. All patients were examined by transthoracic echocardiography before and after the operation with regular intervals, and the tricuspid valve function was then evaluated. There was no significant difference between subgroups with an unchanging degree of TVR, however, the result was also similar among those who had a decreased degree of TVR at any level (p = 0.271, p = 0.451). At the end of the study, all patients were in New York Heart Association class I. We suggest that, in appropriate patients, VSD closure can be safely performed with an additional TVD application through an incision of the septal leaflet of the tricuspid valve without impairing the valve function or reducing the growth potential of the valve at midterm follow-up.

Residual Shunts Following Isolated Surgical Ventricular Septal Defect Closure: Risk Factors and Spontaneous Closure.

Although isolated congenital ventricular septal defects (VSD) can be repaired with a high degree of success, residual shunts (RS) are commonplace postoperatively. Small RS are relatively innocuous and tend to spontaneously close with time, despite the emotional burden it poses for the patient and family. A large RS, however, needs ongoing surveillance and may necessitate reintervention. Factors influencing the incidence of RS as well as the likelihood and expected timing of its spontaneous closure are discussed in this study. The patient records and relevant data of 362 consecutive patients undergoing cardiac operation with isolated congenital VSD closure as primary procedure between January 2017 and December 2017 were included in the study. Postoperative transthoracic echocardiograms were performed at hospital discharge, and during follow-up, at 1 month, 3 months, 6months and 1year postoperatively. Residual defects were measured under echocardiogram at every follow-up. Factors expected to be associated with RS occurrence and spontaneous closure were included for logistic and Cox regression statistical analysis. There were 113 cases where RS occurred according to the first postoperative echocardiograms that were performed at discharge, of which 80 were confirmed closed during subsequent follow-up, with a median follow-up of 96days. A cutoff of 1.25mm for the initial RS was found to be the best predictor of spontaneous closure at 6-month follow-up. Small shunts had higher closure rate than larger ones by a follow-up duration of 300 days, at which the two groups tended to reach a similar spontaneous closure rate. Longer surgical bypass time distinguished small from larger residual shunts measured upon discharge. Following repair of isolated congenital VSDs, the incidence of a residual shunt is high. The majority spontaneously close within 300days following surgery. Longer bypass time predicted a larger residual shunt upon discharge. Larger than 1.25mm shunts had lower short-term closure rate but seemed not to differ from smaller shunts beyond 300days postoperatively.

Management of Congenital Heart Disease: State of the Art-Part II-Cyanotic Heart Defects.

In this review management of the most common cyanotic congenital heart defects (CHDs) was discussed; the management of acyanotic CHD was reviewed in Part I of this series. While the need for intervention in acyanotic CHD is by and large determined by the severity of the lesion, most cyanotic CHDs require intervention, mostly by surgery. Different types of tetralogy of Fallot require different types of total surgical corrective procedures, and some may require initial palliation, mainly by modified Blalock–Taussig shunts. Babies with transposition of the great arteries with an intact ventricular septum as well as those with ventricular septal defects (VSD) need an arterial switch (Jatene) procedure while those with both VSD and pulmonary stenosis should be addressed by Rastelli procedure. These procedures may need to be preceded by prostaglandin infusion and/or balloon atrial septostomy in some babies. Infants with tricuspid atresia require initial palliation either with a modified Blalock–Taussig shunt or banding of the pulmonary artery and subsequent staged Fontan (bidirectional Glenn and fenestrated Fontan with extra-cardiac conduit). Neonates with total anomalous pulmonary venous connection are managed by anastomosis of the common pulmonary vein with the left atrium either electively in non-obstructed types or as an emergency procedure in the obstructed types. Babies with truncus arteriosus are treated by surgical closure of VSD along with right ventricle to pulmonary artery conduit. The other defects, namely, hypoplastic left heart syndrome, pulmonary atresia with intact ventricular septum, double-outlet right ventricle, double-inlet left ventricle and univentricular hearts largely require multistage surgical correction. The currently existing medical, trans-catheter and surgical techniques to manage cyanotic CHD are safe and effective and can be performed at a relatively low risk.

Longitudinal mechanics as predictors of left ventricular systolic function in the early postoperative period after surgical perimembranous ventricular septal defect closure in children aged &lt;1 year

Aim. To evaluate left ventricular systolic function in the early postoperative period after surgical perimembranous ventricular septal defect (VSD) closure in children aged &lt;1 year using longitudinal mechanics.Methods. Between 2014 and 2017, we examined 65 children aged 2–11 months with perimembranous VSD (mean diameter = 8.6 ± 1.7 mm) and a pulmonary-to-systemic blood flow ratio of &gt;1.5/1. The longitudinal mechanics of the left ventricle (LV) were assessed using vector velocity imaging. All the children underwent surgical perimembranous VSD closure. Echocardiographic studies were performed preoperatively, immediately postoperatively, and 1 and 20 days postoperatively.Results. In all the children, significant decreases in the LV end-systolic volume index, end-diastolic volume index, stroke volume index (SVI), and ejection fraction (EF) were identified immediately postoperatively when compared with the preoperative findings. One day postoperatively, the LV volume data normalized; however, in 10.8% of the children, the SVI and EF remained impaired. The percentage EF reduction showed weak correlations with the childrens’ weights (Rs = 0.3; p = 0.039), aortic cross-clamping durations (Rs = 0.36; p = 0.03), and VSD sizes (Rs = 0.33; p = 0.006). Twenty days postoperatively, the LV volumetric parameters normalized; however, the EF did not reach the initial value. The longitudinal strain and strain rate were reduced preoperatively when compared with normal values. For the prediction of a postoperatively significant EF reduction (≤35%), the preoperative LV strain had a sensitivity of 88%, specificity of 98.2%, and cutoff value of –9.2%; the LV strain rate had a sensitivity of 87.8%, specificity of 94.7%, and cutoff value of –0.47 s−1.Conclusion. Children aged &lt;1 year with perimembranous VSD showed reductions in the longitudinal mechanics of the LV, reflecting subclinical systolic dysfunction. One day after surgical correction, a transient decrease in LV systolic function was noted in all the children; however, a significantly impaired LV systolic function was noted in 10.8% of the children. Our findings indicate that the longitudinal mechanics of the LV can predict LV systolic dysfunction in the early postoperative period with high sensitivity and specificity.Received 17 January 2019. Revised 18 April 2019. Accepted 25 April 2019.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

Risk Factors for Major Adverse Events after Surgical Closure of Ventricular Septal Defect in Patients Less than 1 Year of Age: A Single-Center Retrospective.

ObjectiveTo reveal the risk factors that can lead to a complicated course and an increased morbidity in patients < 1 year old after surgical ventricular septal defect (VSD) closure.MethodsWe reviewed a consecutive series of patients who were admitted to our institution for surgical VSD closure who were under one year of age, between 2015 and 2018. Mechanical ventilation (MV) time > 24 hours, intensive care unit (ICU) stay longer than three days, and hospital stay longer than seven days were defined as “prolonged”. Unplanned reoperation, complete heart block requiring a permanent pacemaker implantation, sudden circulatory arrest, and death were considered as significant major adverse events (MAE).ResultsVSD closure was performed in 185 patients. The median age was five (1-12) months. There was prolonged MV time in 54 (29.2%) patients. Four patients (2.2%) required permanent pacemaker implantation. Hemodynamically significant residual VSD was observed in six (3.2%) patients. Extracorporeal membrane oxygenation-cardiopulmonary resuscitation was performed in one (0.5%) patient. Small age (< 4 months) (P-value<0.001) and prolonged cardiopulmonary bypass time (P=0.03) were found to delay extubation and to prolong MV time. Low birth weight at the operation was associated with MAE (P=0.03).ConclusionHigher body weight during operation had a reducing effect on the MAE frequency and shortened the MV duration, ICU stay, and hospital stay. As a conclusion, for patients who are scheduled to undergo VSD closure, body weight should be taken into consideration.

The effect of body weight in infants undergoing ventricular septal defect closure: A report from the Nationwide Japanese Congenital Surgical Database

ObjectiveIn infants with ventricular septal defect (VSD) who undergo surgical intervention, body weight, along with age, is frequently thought to be the decisive predictor of morbidity and mortality after surgery; however, its information on quantitative risk assessment is limited. MethodsAll infants (<1 year old) with a fundamental diagnosis of VSD who underwent surgical VSD closure or pulmonary artery banding between 2012 and 2016 were identified from the Japan Cardiovascular Surgery Database Congenital Section. The outcome of interest was a composite end point of all-cause death and major complications within 30 days after surgery. We evaluated the association between body weight at surgery and composite end point using logistic regression models. ResultsA total of 4947 cases were analyzed (median age, 125; interquartile range [IQR], 79-193 days; median body weight, 4.94 [IQR, 4.00-6.00] kg), including 4310 cases (87.1%) treated with surgical VSD closure and 637 (12.9%) treated with pulmonary artery banding. The surgical course was uncomplicated in 94.2% of cases, 23 (0.5%) died, and 283 (5.7%) experienced major complications. The risk of the composite end point was higher along with lower body weight (adjusted odds ratio, 1.56 for every −1 kg; 95% confidence interval, 1.30-1.88; P < .001) and plateaued at body weight of approximately >4.5 kg via smoothing spline curve. Importantly, cases with approximately <4.5 kg of body weight had higher predicted risk regardless of age. ConclusionsSurgical intervention for infants with VSD was safely performed in contemporary practice; however, caution is warranted in lower body weight infants, particularly for infants with approximately <4.5 kg.