Underwent Ventricular Septal Defect Closure Research Articles

Predictive Value of Post-operative Cardiac Troponin I and Lactate Levels After Ventricular Septal Defect Closure

Objectives: Although the mortality rate of primary ventricular septal defect (VSD) closure surgery has been reduced to <0.5% in many centers, low cardiac output syndrome and multi-organ failure syndrome development in the post-operative period are still the most common causes of mortality and morbidity. The use of biochemical markers in the early period can be used as effective predictors for reducing mortality and morbidity. In this study, the effect of post-operative serum lactate and cardiac troponin I (cTNI) levels on hospital mortality in patients who underwent primary closure of VSD was investigated retrospectively. Methods: The effect of lactate and cTNI values on hospital mortality in 52 patients who underwent surgical repair for VSD was investigated. Serum lactate levels of all patients in the first 6 h after the operation; on the first post-operative day, cTNI values were examined retrospectively. Serum lactate levels exceeding 3.5 mmol/ lt and cTNI values exceeding 35 ng/mL were determined as the cut-off points. Results: Serum lactate level and cTNI increase were found to be statistically different in the mortality group (p<0.05). It was shown that increased cTNI was associated with weight, left ventricular end-diastolic diameter, and cardiopulmonary bypass time (p<0.05). Serum lactate levels were 4.1±0.5 mmol/lt in the non-mortality group and 15.3±8.3 mmol/lt in the mortality group, and the difference was statistically significant (p<0.05). Hospital mortality was observed in 6 patients. Conclusion: In patients undergoing VSD closure surgery, serum lactate levels measured in the first 6 h postoperatively and cTNI levels measured on the first post-operative day are associated with hospital mortality. Concomitant elevations of lactate and cTNI values in patients after VSD closure should suggest to take caution and early supportive treatments to reduce mortality.

Mechanical support for bridge to transplant in an infant with post-cardiotomy end-stage heart failure and complete heart block: report of a case.

The patient was diagnosed with perimembranous ventricular septal defect (VSD). She underwent VSD closure and muscle bundle resection across right ventricular outflow tract at the age of 3 months. Since then, she had suffered from severe heart failure and complete heart block. Permanent pacemaker generator was implanted in the left hypochondrium. She was depended on continuous catecholamine administration, so transferred to our hospital for further management. On arrival, her body weight was 5686g (- 2.7 SD). She underwent Excor pediatric left ventricular assist device implantation at the age of 9 months. Because the position of the left ventricular assist device cannula interfered with the pacemaker, herein, the pacemaker pocket was newly created in the left thoracic cavity. An 1mm in thickness of expanded polytetrafluoroethylene sheet was trimmed and sutured under the anterolateral wall of left thoracic cavity as a pacemaker pocket. Bipolar ventricular lead was sutured on left ventricular apex and basal wall to face each other, mimicking cardiac regeneration therapy. Even though she unfortunately required right diaphragmatic plication for iatrogenic phrenic nerve palsy, her respiratory function was well maintained; therefore, secondary right heart failure was not observed. Her cardiopulmonary function was quite stable until post-operative day 275 when the patient was transferred to another hospital for heart transplantation.

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

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

Post-infarction ventricular septal defect surgery in Portugal

Introduction and ObjectiveWe performed a collective analysis of a dedicated national post-myocardial infarction ventricular septal defect (VSD) registry to further elucidate controversial areas of this clinical entity's surgical treatment. MethodsA descriptive statistical analysis was carried out and cumulative survival using the Kaplan-Meier method and multivariate logistic regression of risk factors for 30-day mortality are presented. ResultsMedian survival of the cohort (n=76) was 72 months (95% CI 4–144 months). Better cumulative survival was observed in patients who underwent VSD closure more than 10 days after myocardial infarction (log-rank p=0.036). Concomitant coronary artery bypass grafting (CABG), different closure techniques, location of the VSD, extracorporeal membrane oxygenation as bridge to closure, or intra-aortic balloon pump as bridge to closure showed no statistically significant differences at Kaplan-Meier analysis. Multivariate binary logistic regression for independent factors affecting status at 30 days showed a statistically significant effect of age (OR 1.08; 95% CI 1.01–1.15) and concomitant CABG (OR 0.23; 95% CI 0.06–0.90). ConclusionsOur results are comparable with previous reports regarding mortality, risk factors and concomitant procedures. Timing of surgery remains a controversial issue. Later closure seems to be advantageous, however, there is significant observational bias.

Abstract 11151: Pre-Operative Malnutrition Increases Risk of Major Infection and Death in Hospital After Ventricular Septal Defect Closure in Low-Resource Settings

Introduction: High energy requirements and poor feeding due to left-to-right shunting can lead to growth failure in patients with ventricular septal defect (VSD) but the effect of malnutrition on surgical outcomes is not well known, especially in low-resource settings. More data would inform decisions on whether nutritional repletion should occur pre-operatively or be deferred until after surgery. Methods: We analyzed cases of isolated VSD +/- ASD or PDA closure in children < 5 years old from 19 centers in 10 low- and middle-income countries with complete audited data collected as part of the International Quality Improvement Collaborative for Congenital Heart Disease from 2016 - 2020. Premature infants and those with known genetic/non-cardiac structural anomalies were excluded. We examined inter-center variation in weight-for-height z score (WHZ) and adjusted for age and major medical illness to calculate odds ratios (OR) of death and major infection (surgical site infection or bacterial sepsis) during hospitalization for changes in WHZ, and for patients with moderate acute malnutrition (-3 < WHZ ≤ -2; MAM) or severe acute malnutrition (WHZ ≤ -3; SAM) versus those without malnutrition (WHZ > -2). Results: Among 6441 VSD closures (5023 membranous, 160 muscular, 73 AV canal, 1046 infundibular, 139 DORV), median age was 8 months (1 day - 4.4 years). Median WHZ at time of surgery was -1.1 (-8.0 - 7.4); 949 patients (15%) had MAM and 1026 (16%) had SAM. Median WHZ (-3.52 - 0.35) and rates of MAM (19 - 80%) and SAM (6 - 63%) varied among centers. Overall, 0.5% died in hospital and 1.2% had major post-operative infection. Odds of major infection (OR 1.07, 95% CI 0.89-1.29) and mortality (OR 1.18, 0.93-1.49) increased for each one unit decrease in WHZ. For the MAM group, odds of major infection (OR 1.50, 0.67-3.37) and mortality (OR 1.32, 0.50-3.49) were increased compared to those without malnutrition. For SAM, odds were higher, and were significant for major infection (OR 2.15, 1.01-4.56) and nearly so for mortality (OR 1.93, 0.98-3.77). Conclusions: Malnutrition is common in children undergoing VSD closure in low-resource settings and increases risk of major infection and death, especially in cases of SAM. Pre-operative nutritional repletion may be considered to reduce risk.

Early and long-term results of ventricular septal defect repair in children with severe pulmonary hypertension and elevated pulmonary vascular resistance by the double or traditional patch technique.

In upper-income countries, infants undergo low-risk ventricular septal defect (VSD) repair. Children in low- and middle-income countries frequently present at older ages with elevated pulmonary vascular resistance (PVR) and pulmonary arterial hypertension (PAH). Expensive interventions for pulmonary hypertensive crisis are not available, and children are often denied an operation due to the mortality risk. We report our early and late experiences with these patients who underwent VSD closure by traditional patch (TP) or double patch (DP) techniques. We extracted data from patients with VSD and PAH who underwent VSD closure operations from 1996 to 2016. Information regarding cardiac catheterizations, operations, time in the intensive care unit and follow-up information was found. We identified 129 children and analysed the differences between the TP (89/129) and the DP (40/129) in unidirectional groups. After 2005, the patients were pretreated with sildenafil 3 months before catheterization. The TP group was younger (P < 0.001). Hospital mortality (2.5%, DP; 10.1%,TP) was not significantly different (P = 0.17) between the 2 groups despite significant differences in baseline PVR, PVR/systemic vascular resistance and the number of children with a saturation less than 90%. The long-term survival and regression of PAH were better in the DP group (survival over 97% vs 93% in the TP group). Moreover, 61% of children with DP and 75% of those with TP had normal to mild elevations in pulmonary artery pressures at the last follow-up examination (P = 0.046). The DP operation is a low-risk procedure. Moreover, the long-term outcome with the use of this technique in high-risk patients with VSD and high PVR and PAH is favourable with respect to survival and showed a decrease in PAH at the last follow-up.

Conduction disorders after perimembranous ventricular septal defect closure: continuous versus interrupted suturing techniques.

The aim of this study was to investigate postoperative conduction disorder differences between continuous and interrupted suturing techniques for the closure of perimembranous outlet-type ventricular septal defects (VSDs) in both tetralogy of Fallot (ToF) and isolated VSD cases. Patients aged 4 years or younger who underwent VSD closure for ToF (n = 112) or isolated perimembranous outlet-type VSD (n = 73) from April 2010 to December 2018 at 3 centres were reviewed. Patients either received continuous suturing for ToF (C-ToF, n = 58) or isolated VSD (C-VSD, n = 50), or interrupted suturing for ToF (I-ToF, n = 54) or isolated VSD (I-VSD, n = 23). Cohorts did not differ in preoperative characteristics. Postoperative conduction disorder differences upon discharge and postoperative year 1 (POY1) were evaluated by electrocardiography. The C-ToF group showed significantly shorter PQ intervals (124.0 vs 133.5 ms; P = 0.042 upon discharge, 125.3 vs 133.5 ms; P = 0.045 at POY1) and QRS durations (98.0 vs 106.2 ms; P = 0.031 upon discharge, 97.3 vs 102.5 ms; P = 0.040 at POY1) than the I-ToF group. Right bundle branch block incidence was significantly lower in the C-ToF versus I-ToF groups (56.8 vs 75.9; P = 0.045 upon discharge, 56.8 vs 75.9; P = 0.045 at POY1). Heart rates were significantly lower in the C-ToF versus I-ToF groups at POY1 (109.2 vs 119.3 bpm; P < 0.001). No parameters significantly differed between C-VSD and I-VSD groups. Multivariable analyses confirmed the group (C-ToF versus I-ToF) as a significant covariate in postoperative heart rate, PQ interval, QRS duration and right bundle branch block outcomes at POY1 (P = 0.013, 0.027, 0.013 and 0.014, respectively). A continuous suturing technique for the closure of outlet-type VSD in ToF could reduce the incidence of postoperative right bundle branch block, shorten the PQ interval and lower heart rate. 110, 138, 139.

Toward Routine Minimally Invasive Ventricular Septal Defect Closure Via Right Lateral Minithoracotomy.

Background: Improving the surgical results and recent advancement of transcatheter techniques for closure of ventricular septal defect (VSD) increased the demand for minimally invasive approaches. In this study, we analyzed the results of the patients who underwent VSD closure with right lateral minithoracotomy (RLMT).Methods: Between September 2014 and February 2021, 24 patients underwent minimally invasive VSD closure with RLMT. The median age of the patients was 16 months (range, 4-84 months). Fifteen patients (62.5%) were female. The median weight of the patients was 9.75 kg (range, 4.6-30 kg). The types of VSD were perimembranous in 19 patients, subaortic in three patients, inlet in one patient, and subpulmonic in one patient. Five patients had low-lying pulmonary stenosis in addition to VSD.Results: No perioperative death or major complication occurred during follow-up. All defects were repaired through RLMT. The median cardiopulmonary bypass time was 81 min (range, 44-163 min), and the aortic cross-clamp time was 65 min (range, 33-131 min). The median hospital stay was 6 days (range, 5-21 days). One patient had minimal (2 mm) residual left-to-right shunt. All families were satisfied with the cosmetic results during the follow-up.Conclusions: The RLMT method is a safe and effective alternative to standard median sternotomy for VSD closure and can be performed with favorable cosmetic and clinical results.

Verifying the Usefulness of Pulmonary Blood Flow Studies in the Correction of Pulmonary Atresia and Ventricular Septal Defect with Major Aortopulmonary Collateral Arteries.

Objective We retrospectively analyzed the surgical results of pulmonary blood flow studies to guide ventricular septal defect (VSD) closure in the correction of pulmonary atresia and ventricular septal defect with major aortopulmonary collateral arteries (PA/VSD/MAPCAs). Methods A total of 57 children who were diagnosed with PA/VSD/MAPCAs and who underwent intraoperative pulmonary blood flow studies at our hospital between August 2016 and June 2019 were included. Surgery and cardiopulmonary bypass records were collected. The receiver operating characteristic (ROC) curve was used to verify the accuracy of pulmonary blood flow studies to predict VSD closure. Results Complete VSD closure was achieved in 39 of 57 children (68.42%), with a median age of 2 years and 5 months (range: 7 months to 15 years and 9 months) and a median weight of 11.0 kg (5.7–36.5 kg). Partial VSD repair was recorded for 21 children (36.84%), including 4 children (19.05%) who underwent VSD closure in the later stages and 13 children (61.90%) who were under follow-up and waiting to undergo complete VSD closure. There was only one child (1.75%) with VSD left. After eliminating the data of four unqualified cases, the ROC curve for predicting VSD closure based on 53 pulmonary blood flow studies was obtained at a p value of <0.001, with an area under the curve of 0.922. The maximum Youden's index was 0.713, which corresponded to an optimal mean pulmonary artery pressure cutoff value of 24.5 mmHg. Conclusion The functional evaluation provided by pulmonary blood flow studies is highly accurate to predict intraoperative VSD repair. We recommend using pulmonary blood flow studies with a mean pulmonary artery pressure of ≤25 mmHg during blood perfusion at 3.0 L/min/m2 as the standard to repair VSD.

Comparison of the clinical effect between the lower sternal incision and the left parasternal fourth intercostal incision in the transthoracic closure of ventricular septal defect

BackgroundTo analyze the clinical effect of two different ways of minimally invasive transthoracic closure in children with ventricular septal defect (VSD).MethodsFrom January 2015 to July 2019, 294 children with VSD were enrolled in the Fujian Medical University Union Hospital. Patients were divided into two groups – those who underwent VSD closure through the left sternal fourth intercostal incision (group A: n = 95) and the lower sternal incision (group B: n = 129).ResultsThe operation time, bleeding volume, postoperative mechanical ventilation time, postoperative intensive care unit (ICU) monitoring time, postoperative hospitalization time and complication rate in group A were significantly lower than those in group B (P < 0.05). There was no significant difference between the two groups in the operation success rate, mechanical ventilation time and total hospitalization cost (P > 0.05).ConclusionThe transthoracic closure of ventricular septal defect through the left sternal fourth intercostal incision is feasible, safe, cosmetic, and worth popularizing.

Early Ventricular Septal Defect Closure Prevents the Progression of Aortic Regurgitation: A Long-Term Follow-Up Study.

According to current short-term evidence, ventricular septal defect (VSD) closure should be performed as early as possible after aortic regurgitation (AR) diagnosis in pediatric patients to prevent AR progression. However, long-term follow-up data are lacking. Therefore, our aim was to evaluate the long-term follow-up (≥ 10years) of patients who underwent VSD closure as early as possible after AR diagnosis and to evaluate whether early VSD closure prevents progression of AR. This was a retrospective cohort study of 42 patients with VSD and AR who had undergone VSD closure at a median age of 2.9years, with a median waiting period from AR diagnosis to VSD closure of 3.4months and follow-up of a median 13.1years (interquartile range 10.0-15.8years). The preoperative degree of AR was trivial in 25 patients, mild in 15, and moderate in 2. Of the 33 patients followed up for ≥ 10years, none required aortic valve replacement and there was no incidence of mortality. The degree of AR improved or did not change, except in 1 patient. The size of the VSD (odds ratio [OR] 0.85; 95% confidence interval [CI] 0.62-1.18; p = 0.33), time from diagnosis to surgery (OR 1.00; 95% CI 1.000-1.001; p = 0.657), and age at the time of surgery (OR 1.00; 95% CI 0.998-1.004; p = 0.452) were not predictive of persistent postoperative AR. Therefore, VSD closure performed as early as possible after AR diagnosis could successfully prevent AR progression in patients with less than moderate preoperative AR, eliminating the need for aortic valve replacement and valvuloplasty.

Syndrome of Ventricular Septal Defect and Aortic Regurgitation - A 22-Year Review of its Management.

IntroductionThe presence of aortic regurgitation (AR) in the setting of ventricular septal defect (VSD) has always been a management challenge.MethodsThis is a retrospective study looking at patients who underwent VSD closure with or without aortic valve intervention between January 1st, 1992 and December 31st, 2014 at the Institute Jantung Negara. This study looked at all cases of VSD and AR, where AR was classified as mild, moderate, and severe, the intervention done in each of this grade, and the durability of that intervention. The interventions were classified as no intervention (NI), aortic valve repair (AVr), and aortic valve replacement (AVR).ResultsA total of 261 patients were recruited into this study. Based on the various grades of AR, 105 patients had intervention to their aortic valve during VSD closure. The rest 156 had NI. All patients were followed up for a mean time of 13.9±3.5 years. Overall freedom from reoperation at 15 years was 82.6% for AVr. Various factors were investigated to decide on intervening on the aortic valve during VSD closure. Among those that were statistically significant were the grade of AR, size of VSD, age at intervention, and number of cusp prolapse.ConclusionWe can conclude from our study that all moderate and severe AR with small VSD in older patients with more than one cusp prolapse will need intervention to their aortic valve during the closure of VSD.

Transcatheter Closure of Perimembranous Ventricular Septal Defects Using Different Generations of Amplatzer Devices: Multicenter Experience.

Objectives To demonstrate safety and efficacy of using different generations of softer Amplatzer™ devices for ventricular septal defect (VSD) closure to avoid serious complications at follow-up. Background Transcatheter closure of perimembranous ventricular septal defects (PmVSD) is a well-established procedure; however, it is associated with unacceptable incidence of complete heart block. Great advantages have been achieved by using softer devices for VSD transcatheter closure. The first and second generation of Amplatzer™ occluders (AVP II, ADO, and ADO II) seem to offer a safe and attractive alternative for this procedure. These devices can be delivered using either an arterial (retrograde) or venous (prograde) approach. Methods and Results Patients with congenital PmVSD who underwent transcatheter closure using ADO, ADO II, and AVP II devices were included. Primary end point was to determine efficacy and safety of these generations of devices and to determine the incidence of complications at follow-up (complete AV block and aortic/tricuspid/mitral regurgitation). One hundred and nineteen patients underwent VSD closure at a median age of 5 years (8 months–54 years). During the catheterization, there were only minor complications and at follow-up of 36 ± 25.7 months (up to 99 months), the closure rate was high of 98.3% and freedom from AV block was 100%. Conclusions The use of softer Amplatzer™ devices is a good alternative to achieve PmVSD closure safely with no risk of AVB during the procedure or at midterm follow-up.

Tricuspid Valve Detachment in Ventricular Septal Defect Closure Does Not Impact Valve Function

Although tricuspid valve detachment (TVD) facilitates improved exposure during transatrial ventricular septal defect (VSD) closure, few have analyzed the impact of TVD on long-term valve durability. Pediatric patients undergoing VSD closure at our institution from 1997 to 2013 were identified, and charts were retrospectively reviewed. Patients were separated into groups based on utilization of TVD. Propensity score matching was then performed using a nonparsimonious logistic regression model involving 7 variables. Primary outcome was residual TV dysfunction at long-term follow-up, defined as mild (2+) and moderate (3+) TV regurgitation (TR) on follow-up echocardiography. Secondary outcomes included postoperative atrioventricular dissociation, residual VSD, and reinterventions. A total of 247 patients underwent VSD closure; 164 (66.4%) without TVD and 83 (33.6%) with TVD. Median follow-up time was 2,343 days (interquartile range, 1,237 to 3,963.5 days) in the group without TVD versus 1,606 days (interquartile range, 826 to 3,017 days) in those with TVD. After successfully matching 83 patients, 29 of 83 (34.9%) patients in the non-TVD group had mild TR versus 28 of 83 (33.7%) patients in the TVD group (p= 0.87). 2 patients in the non-TVD group had moderate TR versus 1 patient in the TVD group at long-term follow-up. One patient in each group suffered transient atrioventricular block, but neither required pacemaker insertion. TVD did not compromise long-term valve durability and did not impose increased morbidity. Patients who underwent TVD had a similar prevalence of mild TR to patients without TVD. Moderate TR was exceptionally rare in both groups. When exposure is difficult, TVD is a safe and effective technical adjunct.

Early pulmonary arterial hypertension immediately after closure of a ventricular or complete atrioventricular septal defect beyond 6 months of age

BackgroundPulmonary arterial hypertension (PAH) is virtually absent after closure of ventricular septal defect (VSD) in the first six months of life. However the prevalence of PAH in patients, who underwent VSD closure later, is not clear. The aim of this study was to analyse the prevalence of PAH after a successful VSD closure after the age of 6months and whether there are risk factors for developing PAH. MethodsEchocardiographic and right heart catheter data of patients with VSD or complete atrioventricular septal defect, who underwent VSD closure after the age of 6months in our institution between 01/2005 and 06/2014, were retrospectively analyzed. PAH was defined as mean pulmonary arterial pressure (mPAP) of ≥25mmHg or tricuspid regurgitation jet velocity of ≥3.5m/s. ResultsIn 228 patients (median age at shunt closure 4.0years, range 0.5–69) and 174 complete follow-up data (median follow-up 3.7years, range 0.5–39.4), 9 patients needed pulmonary vasodilator therapy after shunt closure, 4 of them temporarily for up to 79months. Three patients are still on vasodilator treatment 1, 2.6 and 6years after surgery, other two were lost to follow-up. Another 6 patients with preoperatively borderline hemodynamics due to elevated mPAP and pulmonary vascular resistance, recovered well without signs of postoperative PAH. ConclusionWith the current practice for safe late VSD closure, PAH is very rare at least in the first years of follow-up. In most patients with perioperative PAH, this condition appears to be transient and shows good response on pulmonary vasodilator treatment.

Long-Term Outcome of Patients with Perimembranous Ventricular Septal Defect: Results from the Belgian Registry on Adult Congenital Heart Disease

Objectives: Studies evaluating the long-term outcome of adults with ventricular septal defect (VSD) are important to inform patients about prognosis. This study investigated the long-term outcome of patients with perimembranous VSD (pmVSD) followed in the Belgian Registry on Adult Congenital Heart Disease. Methods: All pmVSD patients in the registry were analyzed. Results: Two hundred and sixty-six patients were studied. Fifteen patients had Eisenmenger syndrome. One hundred and seventy-three had isolated pmVSD and 78 had pmVSD with concomitant lesions. Of the patients with isolated pmVSD, 52% were male, median age was 29 years (IQR 24-35 years) and median follow-up duration was 18 years (IQR 10-25 years). Fifty-three (31%) patients underwent VSD closure and 10 (19%) had a residual shunt. Most (93%) patients were in NYHA class I. No patients died. Two (4%) patients developed atrial arrhythmia and 2 (4%) required pacemaker implantation. Seven (14%) developed left ventricular outflow tract obstruction (LVOTO). In the unrepaired pmVSD group, 4 developed endocarditis. In the entire group, moderate or severe aortic regurgitation (AR) occurred in 9 (5%) patients. Conclusions: Long-term survival in patients with isolated pmVSD was not uneventful. Moderate or severe AR might develop and endocarditis occurred in patients without VSD repair. Complications after VSD closure included atrial arrhythmia, pacemaker implantation and LVOTO.

Detachment of the tricuspid valve for ventricular septal defect closure in infants younger than 3 months

ObjectivesAlthough several previous studies have reported that a ventricular septal defect (VSD) can be closed safely through the detached tricuspid valve (TV) without impairing TV function, this has not been demonstrated for infants younger than 3 months. MethodsWe enrolled 296 infants younger than 3 months who underwent VSD closure through the right atrium between January 2004 and December 2013. In the study group of 49 patients (16.6%), the TV was detached for better exposure of the defect. ResultsThe median age and weight were 63.5 days (14-90 days) and 4.4 kg (2.1-6.7 kg), without intergroup differences. Abnormal chordal attachment of the TV in preoperative echocardiography was associated with detachment of the TV during surgery (P = .001). Cardiopulmonary bypass (P = .001) and aortic crossclamp (P < .001) times were significantly longer in the study group. A permanent pacemaker was required for 2 patients in the control group. Follow-up echocardiography was available for 282 patients at a median of 21 months (1-108 months) after the operation. On final echocardiography, tricuspid regurgitation greater than grade 2 was observed in 1 patient in the study group and residual VSD existed in 4 patients (1 in the study group), without statistical significance. ConclusionsDetachment of the TV can be used safely for better exposure of the VSD without increased risk of tricuspid regurgitation in infants younger than 3 months. Preoperative echocardiography might be useful for predicting the possibility of detachment of the TV for enhancing exposure of the VSD.

Outcomes of Tricuspid Valve Incision for Ventricular Septal Defect Repair

Objectives: Incision of the septal leaflet of the tricuspid valve is a technique to obtain complete visualization in cases where a ventricular septal defect (VSD) is obscured by the tricuspid valve. However, tricuspid valve incision bears the potential risk of causing relevant postoperative tricuspid valve regurgitation and higher degree AV block. We therefore evaluated patients who underwent VSD closure at our institution.

Clinical analysis of 73 pediatric patients with completely atrioventricular conduction block

Objective To explore the causes, clinical characteristics and prognosis of children's completely atrioventricular block(CAVB). Methods The clinical data of 73 patients with CAVB were analyzed retrospectively from January 2004 to December 2013 at the Cardiology Department, Nanjing Children's Hospital Affiliated to Nanjing Medical University.Within those 73 patients, 34 patients were male and the others were female, from 3 months old to 12.5 years old, the mean age of 6 years. Results There were 21 congenital CAVB patients and 52 acquired CAVB patients with myocarditis undergoing ventricular septal defect (VSD) closure operation.All congenital CAVB patients were refractory to drug therapy.Electrocardiogram and echocardiogram were performed in 19 cases without clinical symptoms during follow-up, but 2 cases had permanent pacemaker implanted.Among 27 fulminant myocarditis, Adams-Stokes attacks were found in 15 cases, 3 cases had Adams-Stokes attack in 15 cases with sequelae of myocarditis, and 2 out of 6 cases undergoing VSD closure operation had Adams-Stokes attack, and other 4 cases without clinical symptoms were followed up periodically.The acquired CAVB patients were given energy composition and intravenous megavitamin C. The cases with fulminant myocarditis were given adrenal cortical hormone and intravenous gamma globulins simulta-neously.A total of 27 acquired CAVB patients were implanted temporary pacemaker and 5 with permanent pacemaker.Among 52 acquired CAVB patients, 31 cases were cured, 9 cases were improved, 11 cases were ineffective, and 1 case died. Conclusions Most congenital CAVB children without clinical symptoms need clinical follow-ups.Myocarditis is a major cause of acquired CAVB.The CAVB prognosis caused by fulminant myocarditis may be related to antimely implanting the temporary pacemaker timely.Permanent pacemaker should be implanted in patients who have no response to drug therapy with frequent Adams - Stokes or heart failure. Key words: Complete atrioventricular block; Pacemaker; Prognosis; Child

Preoperative Sildenafil administration in children undergoing cardiac surgery: a randomized controlled preconditioning study.

Sildenafil has strong cardiac preconditioning properties in animal studies and has a safe side-effect profile in children. Therefore, we evaluated the application of Sildenafil preconditioning to reduce myocardial ischaemia/reperfusion injury in children undergoing surgical ventricular septal defect (VSD) closure. This is a randomized, double-blind study. Children (1-17 years) undergoing VSD closure were randomized into three groups: placebo (Control group), preconditioning with 0.06 mg/kg (Sild-L group) and 0.6 mg/kg Sildenafil (Sild-H group). troponin release. CK-MB, Troponin I, inflammatory response (IL-6 and TNF-α), bypass and ventilation weaning times, inotropy score and echocardiographic function were assessed. Data expressed as median (range), and a value of P < 0.05 was considered significant. Thirty-nine patients were studied (13/group). Aortic cross-clamp time was similar [27 (18-85) and 27 (12-39) min] in the Control and Sild-L groups, respectively, but significantly longer [39 (20-96) min] in the Sild-H group when compared with the Control group. Area under the curve of CK-MB release was 1105 (620-1855) h ng/ml in the Control group, 1672 (564-2767) h ng/ml in the Sild-L group and was significantly higher in the Sild-H group [1695 (1252-3377) h ng/ml] when compared with the Control group. There were no significant differences in inflammatory response markers, cardiopulmonary bypass and ventilation weaning times, inotropy scores and echocardiographic function between the groups. In this small study, Sildenafil failed to reduce myocardial injury in children undergoing cardiac surgery, nor does it alter cardiac function, inotropic needs or postoperative course. A subclinical increase in cardiac enzyme release after Sildenafil preconditioning cannot be excluded. CTRI/2014/03/004468.