Uncomplicated Ventricular Septal Defect Research Articles

Frequency of Circumferential Pericardial Effusion by Echocardiography in Adults With Foramen Ovale Type Atrial Septal Defect Versus Ventricular Septal Defect

Many published reports have described pericardial effusions in patients with secundum atrial septal defects. This study investigated their associated prevalence echocardiographically using 40 patients with isolated ventricular septal defects as controls in an adult patient population. Pericardial effusions accompanied atrial septal defects in 13 patients and ventricular septal defects in only 3 patients (p <0.0001). In conclusion, pericardial effusions are much more common (p <0.005) with uncomplicated secundum atrial septal defects than with uncomplicated ventricular septal defects.

Spontaneous closure of ventricular septal defects followed up from

This study evaluates the incidence and timing of spontaneous closure (SC) of ventricular septal defect (VSD) using Doppler color flow mapping. A total of 225 infants (mean age 30 days) were diagnosed with uncomplicated VSD: 31 (14%) subpulmonary VSD, 159 (70%) perimembranous, and 35 (16%) muscular. The patients were divided into two groups according to the presence or absence of congestive heart failure (CHF). SC was confirmed with color Doppler. Surgical closure was performed in 59 patients (26%). SC occurred in 107 patients (48%); three (10%) of 31 with subpulmonary VSD, 75 (47%) of 159 with perimembranous VSD, and 29 (83%) of 35 with a muscular VSD. Average age at SC was 19 months. In three SC patients with a subpulmonary VSD, there was no aortic valve prolapse and no aortic regurgitation. SC occurred in 96% of SC patients with a perimembranous VSD by the age of 6 years, and in 93% of those with a muscular VSD by the age of 3 years. In patients without CHF, the rate of SC was 72%; 23% in subpulmonary VSD, 74% in perimembranous, and 85% in muscular. SC occurred in only 23% of patients with a perimembranous VSD with CHF. Mean age at the final examination was 6.9 years in 59 patients with a VSD remaining open, and 63% of patients with a perimembranous VSD remaining open had an aneurysm of the ventricular membranous septum. The SC rate of VSD by mean age of 6.9 years was 48%, but it was 72% in patients without CHF. In patients with CHF, SC was seen only in patients with a perimembranous VSD. The rate of SC was 10% in subpulmonary VSD. The authors contend that SC probably occurred by growth of muscular septum surrounding VSD. Muscular VSD spontaneously closed earlier than perimembranous VSD.

Cardiac surgery under perfusionless hypothermia: Siberian experience.

Between January 1995 and December 1999, 942 patients (452 males and 490 females) aged 1 to 51 years underwent definitive surgery under perfusionless hypothermia for correction of congenital heart defects, predominantly uncomplicated ventricular or atrial septal defects (80%). Hypothermia of 24 degrees C to 28 degrees C was achieved in 15 to 45 minutes (mean, 25.7 +/- 1.2 minutes) by application of crushed ice over the body and head. Aortic crossclamp time ranged from 10 to 76 minutes (mean, 26.1 +/- 0.25 minutes). Cardiac restoration time ranged from 1 to 10 minutes (mean, 2.1 +/- 0.08 minutes). Eight patients (0.85%) died postoperatively: 4 from acute cardiac insufficiency, 2 as a consequence of technical faults, 1 from persistent pulmonary hypertension, and 1 had sudden cardiac arrest. None of the surviving patients showed any gross neurological deficit. Perfusionless hypothermic cardiac surgery, when applied appropriately, is safe and simple, and might still have a place in treating a selected group of patients with uncomplicated congenital heart defects.

Primary Repair of Isolated Ventricular Septal Defect in Infancy Guided by Echocardiography

Between 1989 and 1995, 96 consecutive infants affected by isolated ventricular septal defect (VSD) were submitted for primary correction at a median age of 4 months. Of the 96, 60 (group I) underwent surgery on the base of a 2-dimensional Doppler echocardiographic (DD echo) test alone. The preoperative DD echo anatomic definition of the type of VSD was confirmed at surgery in all 60 patients without false-positive results in terms of additional cardiac anomalies. There were 2 false-negatives: in 2 patients an associated cardiac anomaly was not detected by DD echo and required a second surgical procedure after postoperative cardiac catheterization. During the same period 36 infants (group II) underwent surgical closure of isolated VSD on the basis of cardiac catheterization and angiocardiography in addition to DD echo. The retrospective comparison between the 2 groups revealed no significant difference in terms of sensitivity and specificity of the diagnostic tools, early and late mortality after surgical correction, postoperative hospital stay, and need for late cardiac catheterization and surgery. We conclude that after an accurate selection, most of the infants with uncomplicated VSD can safely undergo primary repair on the basis of DD echo alone.This retrospective analysis of a series of 96 consecutive infants who underwent operation for isolated ventricular septal defect on the basis of a 2-dimensional echocardiographic Doppler test alone or cardiac catheterization and angiocardiography revealed no significant difference between the 2 diagnostic tools. Most infants with uncomplicated ventricular septal defect can safely undergo primary repair based on the 2-dimensional echocardiographic Doppler test alone.

Diastolic Left‐to‐Right Shunting in Uncomplicated Ventricular Septal Defect

The systolic left‐to‐right shunt in patients with uncomplicated ventricular septal defect is associated with a classic loud murmur, and is well described. The additional diastolic left‐to‐right shunt, always silent, is less well recognized. Left‐to‐right diastolic shunt flow is directly related to the defect size, to the diastolic pressure gradient between the left and right ventricle, and to the duration of diastole. The purpose of this study was to evaluate by Doppler echocardiography the duration, magnitude, and flow velocity characteristics of the diastolic left‐to‐right shunt. There were 30 adult patients with uncomplicated ventricular septal defects studied by color, pulsed, and continuous wave Doppler echocardiography. In each patient, the uncomplicated ventricular septal defect was visualized by two‐dimensional echocardiography and/or Doppler echocardiography, and the systolic and diastolic left‐to‐right shunt flow was identified by Doppler echocardiography. Accurate Doppler flow velocity peaks twice, in beginning and again at end diastole. The mean diastolic flow velocity was 0.5–1.5 msec (average 0.83 ± .22 msec). This flow velocity was markedly lower than the mean systolic shunt flow velocity (2.4–5.3 msec, average 3.8 ± .7 msec). The Doppler flow velocity integral was 0.17–0.64 m (average 0.36 ± 0.14), markedly smaller than the systolic flow velocity integral (0.8–1.8 m, average 1.3 ± 0.3). The diastolic left‐to‐right shunt flow was 12–41% (average 21 ± 8) of total (systolic and diastolic) shunt flow. In conclusion: Diastolic left‐to‐right shunts can be identified in all patients with uncomplicated ventricular septal defects, and analyzed in the majority of patients. A significant degree of the left to right shunting in uncomplicated ventricular septal defects occur during diastole.

1002-88 Is Angiocardiography Necessary in the Preoperative Assessment of Uncomplicated Ventricular Septal Defect in Infancy?

With current 2-dimensional echocardiography (ECHO) and colour-flow Doppler it may no longer be necessary to perform preoperative angiocardiography (ANGlO) for patients with a primary diagnosis of uncomplicated unrestrictive ventricular septal defect (VSD). We compared the sensitivity and specificity of both techniques in the detection of additional VSD's and commonly associated lesions using as “gold standard” a combination of surgical findings plus postoperative ECHO's. A total of 130 consecutive patients undergoing VSD repair in infancy between January 1991 and March 1994 were studied. The mean age at repair was 0.48 ± 0.26 year and mean weight at repair was 5.0 ± 1.5 kg. All ECHO's were performed prior to ANGlO. Associated lesions included right ventricular muscle bundles (RVMB), sub-aortic stenosis (sub-AS), and persistent ductus arteriosus (PDA). No case of aortic valve prolapse causing aortic incompetence was identified, and aortic arch abnormalities were generally surgically addressed prior to ANGlO. The sensitivity and specificity of the two techniques in the detection of additional VSD's were: Sensitivity Specificity Echo 63% 99% Angio 63% 95% Out of a total of 8 cases with additional VSD's, 2 were small anterior muscular defects which were clinically insignificant, and only seen by colour-flow Doppler. The results for detection of associated lesions were: Sensitivity Specificity Echo Angio Echo Angio RVMB 73% 73% 93% 96% Sub-AS 63% 38% 96% 97% PDA 80% 80% 98% 99% Our results suggest that ECHO is comparable to ANGlO in the preoperative assessment of uncomplicated VSD in infancy. Therefore, ANGlO should no longer be necessary in the evaluation of these patients.

Spontaneous closure of uncomplicated ventricular septal defect

The charts of 222 patients with a diagnosis of ventricular septal defect (VSD) were reviewed to determine the overall incidence, the prevalence of membranous and muscular defects and the rates of spontaneous VSD closure. VSD diagnosis and location were determined primarily from reports of 2-dimensional and pulsed Doppler echocardiograms. In a 5-year period, VSDs occurred in 3.85 1,000 live full-term births and 7.06 1,000 live premature births. The VSD closed spontaneously in 20 of 44 patients (45%) followed from birth (University Hospital group) during a mean follow-up of 12 months. Of 165 patients not followed from birth (referred group), the VSD closed spontaneously in 37 (22%). Overall, VSD location was determined in 101 of 209 patients (48%) and was distributed as follows: membranous 66 (65%), muscular 32 (32%) and subpulmonic 3 (3%). Rates of spontaneous closure for membranous and muscular VSDs were 37% and 50%, respectively, for the University Hospital group and 9% and 9%, respectively, for the referred group (no significant difference in either case). Surgical closure was required in 30 of 165 referred patients (18%) and only 1 of 44 University Hospital patients (2%). There was no significant difference in rate of closure for premature vs fullterm infants or small vs larger defects. Data for patients followed from birth more likely reflect the true natural history of VSD.

Long term results after operative treatment of isolated ventricular septal defect in adolescents and adults.

A series of 125 consecutive patients with isolated ventricular septal defect (VSD) aged 10 or over, were followed until death or beyond the age of 30 (31-73) years. A prospective restudy was performed after a mean follow-up of 15 (3-21) years. Forty-one patients (group 1) were treated with surgical repair of VSD at a mean age of 23 (10-51) years, and early mortality was 10%, i.e. 3 with severe aortic insufficiency and one with systemic pulmonary artery pressure. Surgery was initially not regarded indicated in 70 patients with small defects (group 2). A further 14 patients were judged inoperable (group 3). Long-term mortality was 5% in group 1, 9% in group 2 and 71% in group 3. When restudied, group 2 patients had significantly higher (p less than 0.01) and group 1, lower (p less than 0.01) pulmonary artery pressures than initially. A moderate deterioration in NYHA-rating was noted in group 2 (p less than 0.05) vs. a slight improvement in group 1 (p less than 0.05). The non-operated patients had a higher incidence of valvular lesions (19% vs. 13%) and bacterial endocarditis (4.3% vs. 2.7%) than the operated but not to a statistically significant level. Spontaneous closure was 6% in group 2 whereas mostly small residual defects were found in 34% of the operated. Patients with uncomplicated VSDs (absence of valvular lesions or coronary heart disease) had subnormal exercise tolerance as judged from a standardized ergometer bicycle test. These patients also had impaired left ventricular function based upon haemodynamic studies during moderate supine exercise. No major differences were noted between groups 1 and 2, but operated patients with residual VSDs tended to have the poorest cardiac performance. Non-cardiac disease represented only a minor problem and no significant differences in psychosocial function were observed between groups 1 and 2. Only 50% in group 1 and 60% in group 2 attended a regular medical clinic. Antibiotic prophylaxis had only been practiced by 50% in both groups. Although small, but differences between groups 1 and 2 favour surgery. This must be regarded as a positive result of surgical treatment since those operated on had basically larger and thus more severe defects than the others. In view of the very low operative risk associated with modern surgical technique one should direct patients with significant shunts to operative treatment.

Significance of pulmonary valve prolapse. A cross sectional echocardiographic study.

Many patients with congenital heart disease now undergo cardiac surgery based solely on clinical and echocardiographic findings, but those with intracardiac shunts still frequently require cardiac catheterisation because there is no reliable non-invasive method of measuring the pulmonary artery pressure. Blinded to the haemodynamic results two independent observers retrospectively studied the cross sectional echocardiograms of 59 patients with uncomplicated ventricular septal defect to assess whether diastolic backward bowing of the pulmonary valve leaflets towards the right ventricular outflow tract (pulmonary valve prolapse) was associated with pulmonary hypertension. There was considerable interobserver variation in the diagnosis of pulmonary valve prolapse, but concordance was achieved in 27 cases. Mean pulmonary artery systolic and mean and diastolic pressures and the ratios of aortic to pulmonary artery mean pressures were all significantly higher for the group with pulmonary valve prolapse diagnosed by both observers than for the group without, thus showing an association between pulmonary valve prolapse and pulmonary hypertension. Further studies are warranted to determine the usefulness of this cross sectional echocardiographic sign in routine clinical practice.

Corrective cardiac surgery in infants

This is a review of 136 patients who have undergone corrective surgery for congenital heart disease with the aid of profound hypothermia in a 6-year period. Almost all patients were less than one year old and less than 10 kg. In 1979 the average age was 3.4 months and the average weight was 4.1 kg in 34 infants. The hypothermic technique consisted of surface cooling followed by cardiopulmonary bypass cooling and circulatory arrest during definitive surgery. The hospital mortality was 26% for the whole period, having decreased from 53% in 1974 to 15% in 1979. After operation 70% of patients with uncomplicated ventricular septal defect or the tetralogy of Fallot were extubated within 4 hours, 65% of all patients were extubated within 12 hours of operation.

Incidence of congenital heart disease in Blackpool 1957-1971.

In the 15 years from 1957 to 1971, there were 57 979 births in a circumscribed population in North-West England. The requirements for a valid survey of the incidence of congenital heart disease were largely met. The necropsy rate for all stillbirths and neonatal deaths in the population was 93 per cent. Diagnosis of the type of heart lesion was by necropsy in 50 per cent, cardiac catheterisation in 19 per cent, operation in 5 per cent, and clinical observations only in 26 per cent. The incidence of congenital heart disease was 6-8 per 1000 total births and 5-9 per 1000 live births. The overall incidence has remained unchanged over the 15 years, but there were trends suggesting an increase in the incidence of uncomplicated ventricular septal defect and of endocardial cushion defect and a decrease in the incidence of ventricular septal defect with right ventricular outflow obstruction and of hypoplastic left heart. We have observed seasonal variations in total incidence and in incidence of some common individual lesions.

Second heart sound after pulmonary arterial banding operation.

After a pulmonary arterial banding procedure the phonocardiograms of 38 patients were correlated with haemodynamic and angiographic findings. Twenty-four patients had uncomplicated ventricular septal defect, 2 had single ventricle, 5 had transposition of the great arteries, 5 had atrioventricular canal defects, and 2 had coarctation of the aorta and ventricular septal defect. P2 was separated from A2 by less than 40 ms in 10 of the 11 patients with high pulmonary vascular resistance. Of 27 patients with nearly normal pulmonary vascular resistances and distal pulmonary artery pressures less than 50/20 mmHg (6-7/2-7 kPa), 24 had A2-P2 intervals of over 40 ms. A narrow A2-P2 interval with a satisfactory band was found in 2 patients with large right-to-left shunts. A2-P2 interval did not change appreciably with age, and this measurement is a useful guide as to the effectiveness of pulmonary artery banding by one year after operation. If this interval is less than 40 ms, repeat catheterization should be carried out as such patients may have persisting pulmonary hypertension and an increased pulmonary vascular resistance.

Echocardiography of the tricuspid valve in congenital left ventricular-riht atrial communication.

Two patients, ages 14 and 18, with congenital left ventricular-right atrial communication through a defect in the tricuspid valve were studied by echocardiography. Proof was obtained by angiocardiography and surgery in one and ultrasonic contrast injection and angiocardiography in the other. Both presented clinically as uncomplicated ventricular septal defects. Echocardiography consistently demonstrated a high frequency, low amplitude flutter of the tricuspid valve in systole and none in diastole. Following surgical correction of the defect in one patient, there was complete disappearance of the systolic flutter. Systolic flutter has not been observed with tricuspid incompetence nor with other forms of ventricular septal defects. Fistulous communication from the aorta to the right atrium just above the tricuspid valve did not demonstrate systolic flutter in one patient studies. Tricuspid valve systolic flutter appears to be caused by the passage of the left ventricular jet blood into the right atrium through a defect in the tricuspid valve. Echocardiographic study of the tricuspid valve is of value in the recognition of the congenital left ventricular-right atrial communication.

Specialized cardiac conduction system. Improved electrophysiologic identification technique at surgery.

An electrophysiologic technique has been described to localize the atrioventricular (A-V) conduction system during cardiac surgery. The method utilizes atrial pacing with an electrode plaque to insure a supraventricular rhythm, and an electrode probe to localize the specialized A-V pathways. Atrial pacing assures unchanging antegrade conduction to the ventricles, which permits beat-to-beat observation of changes in the P-R interval or QRS configuration that might result from surgical manipulation. The anatomic course of the bundle and bundle branches is delineated by observing a typical His spike during the P-R interval in the electrogram. While heart block is uncommon following repair of uncomplicated ventricular septal defect, this technique has been a distinct aid in the repair of ostium primum atrial septal defects (four cases) and fourteen other complex congenital anomalies.

Effects of Chronic Hypoxemia on the Electrophysiological Properties of Right Atria Tissue in Children

The purpose of this study was to determine the electrophysiological properties of normal right atrial tissue in children and to evaluate the role of chronic hypoxemia in the genesis of atrial arrhythmias. Using standard mocroelectrode techniques we studied the electrophysiological properties of preparations of right atrial tissue obtained during open heart surgery in two groups of patients. Group A consisted of 6 patients with uncomplicated ventricular septal defects. Group B comprised 6 patients with tetralogy of Fallot with arterial O2 saturations of 80-84%. All patients underwent cardiovascular diagnostic studies and had normal right atrial pressures and no evidence of atrial shunting. In Group A mean resting potential (RP) was −86±5.7 mV, action potential duration was 210±8 msec at a cycle length of 1,000 msec and conduction velocity was 0.45±0.05 M/sec. The relationship between the rate of rise of phase 0 of the action potential (AP) and the membrane potential at which the AP was elicited (membrane responsiveness) was ‘S’ shaped. Cells were unresponsive at a mean RP of −56±1.6 mV and maximum rate of rise occured at a mean RP of −86±5.7 mV. An increase in extracellular [K+] above control caused a decrease in the RP which was linearly related to log [K+]. When [K+] was reduced below control levels, RP decreased slightly. There were no significant differences (p = >0.05) between Group A and Group B for all properties measured. Results from Group A can be used for ‘normal’ reference values. Chronic hypoxemia does not seem to alter the electrophysiological properties of right atrial tissue. This is consistent with the clinical observation of the lack of atrial arrhythmias in cyanotic congenital heart disease when there is no pressure or volume overloading of the right atrium.

Pulmonary artery banding in congenital heart disease associated with pulmonary hypertension

A report is presented of pulmonary artery banding in 45 children with congenital heart disease associated with severe pulmonary hypertension. The majority were in uncontrollable heart failure and were in the age group 3 to 18 months. Nine older children not in heart failure were operated on because of serious pulmonary hypertension associated with malformations considered unsuitable for complete repair (truncus arteriosus, single ventricle). The mortality in those with uncomplicated ventricular septal defect was low (5.5%), but was much higher in those with accompanying lesions or more complex abnormalities (63%). All have been under supervision since operation and most have improved with diminution in cardiac size and recession of pulmonary congestion. Two have been recatheterized and both have undergone successful closure of their ventricular septal defect. It is our intention to reinvestigate many of the others three to four years after banding to assess the size of the defect prior to further surgery.

The superior vena cava in the evaluation of atrial septal defect.

THE SUPERIOR VENA CAVA IN THE EVALUATION OF ATRIAL SEPTAL DEFECTARNOLD CHAIT, M.D. and MARSHALL ZUCKER, M.D.Audio Available | Share

Correlation of chest roentgenograms and hemodynamic findings following surgical repair of ventricular septal defects.

The diagnosis and hemodynamic evaluation of ventricular septal defect are made at cardiac catheterization. The present-day value of the plain chest roentgenogram, then, is in following the evolution of the defect, and it has proved especially useful in detecting Eisenmenger's reaction and its associated pulmonary hypertension. Little emphasis, however, has been placed on the changes seen following surgical closure of the defect. This study was undertaken to determine the roentgen changes in the chest following successful closure of the ventricular septal defects and the rate at which such changes evolve. Materials and Methods The chest films and catheterization data of all patients operated upon for the repair of uncomplicated ventricular septal defects from January 1959 to December 1965 and in whom preoperative and postoperative cardiac catheterizations were performed were analyzed independently. Patients with residual postoperative shunts were included in the original analysis, and the person evaluating the films was unaware of the catheterization data. Patients with residual shunts were subsequently excluded from the series. Plain chest roentgenograms, including barium swallows in all cases, were evaluated for the degree of cardiac chamber enlargement, the extent of main pulmonary artery enlargement, and the degree of pulmonary vascularity. Left atrial and main pulmonary artery size and peripheral pulmonary vasculature were judged as normal, slightly increased (1+), moderately increased (2+), or greatly increased (3+), using established criteria (1–4, 10, 15, 16). All available follow-up films up to one year after surgery were examined. Catheterization data utilized included the pulmonary artery pressure, the ratio of pulmonary-to-systemic flow (the degree of left-to-right shunting), and the ratio of pulmonary vascular resistance to systemic vascular resistance (8, 9). A ratio of pulmonary-to-systemic flow of less than 2:1 was considered to be a moderate left-to-right shunt, and those ratios greater than 2:1 were considered to indicate large shunts. Pulmonary vascular resistance less than 0.25 was considered normal, from 0.26 to 0.50 moderately elevated, and greater than 0.50 markedly elevated. There were 61 patients in the original analysis, with ages ranging from three to forty-eight years. Forty-nine showed no evidence of residual shunting at the time of postoperative cardiac catheterization, and the age distribution for the final group is as follows: one to five years, 13 patients; six to ten years, 14 patients; eleven to twenty years, 12 patients; twenty-one to thirty years, 6 patients; thirty-one to forty years, 2 patients, and forty-one years or more, 2 patients.

Angiocardiographic determination of the size of the left ventricle in congenital heart disease.

ANGIOCARDIOGRAPHIC DETERMINATION OF THE SIZE OF THE LEFT VENTRICLE IN CONGENITAL HEART DISEASEAGUSTIN CASTELLANOS, SR., M.D. and FRANCISCO A. HERNANDEZ, M.D.Audio Available | Share

Pattern of Infarction Produced by Sodium Iothalamate 80 Per Cent (Angioconray) Invasion of Myocardium

With the aid of a barium titanate microphone incorporated in the tip of a specially designed catheter, intracardiac phonocardiograms were recorded in 160 subjects, of whom 20 had normal hemodynamic findings, 97 had congenital heart disease, and the remainder had acquired heart disease.The normal intracardiac phonocardiographic patterns from both the right and left cavities of the heart are described. The diagnostic value of intracardiac phonocardiography in congenital and acquired heart disease is stressed.On intracardiac sound recordings, murmurs are sharply localized in that chamber or vessel which receives the blood flow responsible for their production. Therefore, in the presence of uncomplicated ventricular septal defect, a pansystolic murmur is recorded only within the right ventricle; in cases of patent ductus arteriosus a continuous murmur is recorded only within the pulmonary artery. Both these conditions could be diagnosed or excluded with certainty, even when oxygen studies and clinical signs were equivocal. In cases of pulmonary stenosis an ejection murmur was recorded only within the pulmonary artery and its branches. Infundibular and valvular pulmonary stenosis showed different patterns during withdrawal of the sound catheter into the ventricle. This allowed differentiation between the two types of lesion. In atrial septal defect it was confirmed that murmurs and sounds are produced by the increased flow across the tricuspid and pulmonary valves, rather than by the flow across the defect. In cases of Lutembacher's syndrome a mid-diastolic or presystolic murmur in the inflow tract of the left ventricle was a diagnostic sign.In cases of pure mitral stenosis with apical systolic murmur the tricuspid origin of the murmur could be established. Simultaneous chest and intracardiac phonocardiograms allowed differentiation between valve closure and early diastolic sounds and between intra- and extracardiac sounds.