Transaortic repair of ventricular septal defect

A technique is described for repairing defects of the interventricular septum using an aortotomy incision. This approach allows excellent access to the membranous septum, where more than 80% of defects occur. While the standard transventricular or transatrial approach serves best in most instances, the transaortic exposure may be a useful alternative in the small defect, to avoid ventriculotomy, or in some complicated anomalies.     

Transaortic approach for a closure of a residual ventricular septal defect of the tetralogy of Fallot.

BACKGROUND: A residual ventricular septal defect as part of the tetralogy of Fallot (TOF) is often difficult to close when a long interval has elapsed after a radical operation or the position of the defect is problematic. METHODS: When an accurate diagnosis and closure of a residual ventricular septal defect (VSD) were not obtainable through right atriotomy and right ventriculotomy, the ascending aorta was opened. The smooth surface of the left ventricular septum makes it possible to find the position of the defect, and close it accurately and safely. RESULTS: Three consecutive patients were operated upon using this method. They had undergone repair of tetralogy of Fallot anomalies 8 years, 26 years, and 21 years prior to this surgery, respectively. All patients survived the operation and were discharged from the hospital. None of the patients had residual defects, aortic regurgitation, or new atrioventricular block. CONCLUSIONS: This transaortic approach for closing residual ventricular septal defects related to the tetralogy of Fallot offers an alternate method when either the right atrial or right ventricular approach cannot be performed successfully. This approach may make it possible to close such defects directly.     

膜周部室间隔缺损的微创封堵术

目的 探讨经胸壁微创室间隔缺损(VSD)封堵术对膜周部室间隔缺损(PVSD)的治疗效果及安全性.方法 2011年1月至12月,治疗129例PVSD患者(儿),男60例,女69例;年龄9个月～57岁.PVSD直径1.4～9.0 mm,均经胸骨中下1/3段3～5 cm正中小切口行微创VSD封堵术.术后密切随访观察,定期复查超声心动图和心电图.结果 114例封堵成功,15例术中转体外循环下行VSD修补术.其中应用等边封堵伞96枚,偏心封堵伞20枚.术后随访期间均无严重并发症发生.结论 经胸壁微创VSD封堵术治疗PVSD的近期治疗效果满意,具有良好的应用前景.目前尚缺乏长期的随访资料,有待进一步的随访观察.     

Interventricular septal hematoma in ventricular septal defect patch closure

We report a case of interventricular septal hematoma after patch closure of a perimembranous ventricular septal defect in a 4-month-old infant. On postoperative day 1, echocardiography showed a voluminous intramural hematoma causing severe thickening of the ventricular septum. Surgical revision was necessary immediately to drain the hematoma.     

Trans-pulmonary arterial closure of ventricular septal defect.

Fourteen patients ranging in age from 4 months to 28 years underwent closure of a ventricular septal defect (VSD) through the pulmonary valve after pulmonary arteriotomy. In 13 of these the VSD was of the supracristal type and in one patient it was of the bulboventricular type. In all patients, including two infants whose VSD was closed under circulatory arrest, the operative and postoperative courses were uneventful except in one, who needed prolonged respiratory care. Right bundle branch block (RBBB) resulted in four patients, one of whom had a bulboventricular defect. The procedure is technically feasible without difficulty when the VSD is of the supracristal type and when the patient is too small. Trans-pulmonary arterial closure is the method of choice for treating a supracristal VSD, as this procedure leaves no postoperative right ventricular scar. However, the advisability of continuing to use this procedure is to be decided after statistical analysis of the frequency of postoperative RBBB can be made with a larger series of patients.     

Combined perventricular closure of ventricular septal defect and atrial septal defect via lower ministernotomy

Background

Minimally invasive approaches such as perventricular closure of ventricular septal defects (VSD) have been applied for the surgical correction of congenital heart defects in order to avoid disadvantages related to median sternotomy with a cardiopulmonary bypass (CPB). However, reports remain scarce regarding combined perventricular closure of VSD and atrial septal defects (ASD) via minimally invasive approaches, such as lower ministernotomy.

Results

The authors have operated on 5 patients who were diagnosed with VSD in association with ASD, successfully realizing perventricular closure via lower ministernotomy.

Conclusion

The proposed technique proved to be safe and effective.

     

Surgical closure of an apical ventricular septal defect through a septal ventriculotomy

Here we report a 3-year and 7-month-old boy with a muscular ventricular septal defect at the apex. At age 7 months, pulmonary artery banding was performed. Surgical treatment consisted of double patch closure via septal ventriculotomy and a main pulmonary artery plasty by an end-to-end anastomosis with cardiopulmonary bypass. There was no residual leak of the ventricular septal defect or ventricular aneurysm and the postoperative course was good. This technique could be a useful surgical option for repair of apical muscular ventricular septal defects.     

Postinfarction ventricular septal defect closure with Amplatzer occluders.

OBJECTIVE: Postinfarction ventricular septal defect (PIVSD) is a rare and life-threatening complication with high risk of both surgical and medical treatment. Another option available now is transcatheter closure. The purpose of this paper is to report the results of such treatment with Amplatzer occluders. METHOD: Seven patients aged from 51 to 71 years were included. The procedure was performed between 2 and 10 weeks after myocardial infarction. One patient had double residual VSD (2 months after previous surgery) and another, coexisting critical stenosis of right coronary artery (RCA). All patients were in III/IV NYHA class, on intropes, one patient on aortic balloon counterpulsation. Venous jugular approach was used to close the VSD in six patients, venous transfemoral in one patient. Implantation of six Ampaltzer atrial septal occluders (ASO) and one muscular Amplatzer VSD occluder (VSO) were performed. RESULTS: All procedures but two were finished successfully. In one patient, the defect could not be entered neither from the venous nor the arterial side due to unusual oblique course (which was confirmed during subsequent operation). In the second patient (2 weeks after MI), the reason was unstable position of 24 mm ASO (probably due to necrotic borders of VSD). Immediate significant clinical improvement was achieved in all patients, in whom PIVSD was closed with Amplatzer occluders. In one postsurgical patient, two ASO were used; in another patient, prior to VSD closure, PTCA and stent implantation to RCA was performed. The stretched diameter of PIVSD ranged from 8 to 22 mm, the size of implanted Amplatzer occluders from 12 to 24 mm. Fluoroscopy time was 60 min (18-120). During the procedure, ventricular fibrillation requiring defibrillation was observed in three patients. One patient died 1 week after the procedure because of multiorgan failure and increasing mitral incompetence (MI). CONCLUSIONS: Despite some technical problems, implantation of Amplatzer occluders, is an attractive option of treatment of patients with subacute PIVSD.     

小婴儿巨大室间隔缺损的外科治疗

目的 报告３９例出生６个月以内小婴儿巨大型空间隔缺损的外科治疗经验。方法 体外循环下除４例经肺动脉切口外其余均经右房切口,行补片缝合修补空间隔缺损。其中合并动脉导管未闭５例、房间隔水平分流１２例和右室流出道狭窄２例均同期矫治。结果 ３９例病儿均痊愈出院。结论 巨大型空间隔缺损的小婴儿出现顽固性心力衰竭、药物治疗无明显效果或生长发育停滞及肺动脉高压时即应手术。尽可能完善的围术期处理是降低病死率的重要     

胸腔镜下室间隔缺损修补术

目的　探讨胸腔镜下室间隔缺损修补术。　方法　 16例先天性心脏病 (男 10例 ,女 6例 )。年龄 (6～ 2 7)岁。 (14± 7)岁 ,体重 (17～ 6 7)kg ,(38 5± 16 8)kg。采用股动静脉插管 ,在患者右侧第四肋间胸骨旁、第四肋间腋中线、第七肋间腋中线各打一个直径 1cm～ 3cm的孔 ,经第四肋间腋中线插入上腔静脉插管 ,建立体外循环 ,阻闭升主动脉 ,冠脉冷灌 ,心脏停搏 ,切开并悬吊右心房 ,显露三尖瓣及室间隔缺损 ,缝合室间隔缺损 ,缝合右心房切口 ,开放升主动脉。　结果　 16例手术均获成功 ,主动脉阻闭时间 (2 7～ 6 7)min ,(43± 13)min。体外循环时间 (6 6～ 16 8)min ,(95± 33)min。术后心脏杂音消失 ,心脏超声检查示无心内分流。　结论　胸腔镜下可完成室间隔缺损修补术的全部心内操作。也为室间隔缺损修补术提供了另一种选择。     

Transcatheter closure of residual atrial septal defect after cardiac transplantation.

A 55-year-old male patient experienced 2 acute neurologic events 3 weeks after orthotopic cardiac transplantation. Transesophageal echocardiography demonstrated a patent foramen ovale in the native portion of the interatrial septum with bidirectional shunting by Doppler and microbubble contrast. The defect was closed successfully with a CardioSeal transcatheter septal closure device. This case demonstrates the advantages of the percutaneous approach for closure of residual defects in the post-operative patient.     

Device closure of residual postsurgical atrial septal defect by transcatheter technique

Surgical closure of an Atrial Septal Defect (ASD) and transcatheter closure of ostium secundum ASD is an established form of therapy in selected patients. Only a few cases have been reported in literature when transcatheter closure of ASD was achieved successfully in a patient with residual postsurgical ASD. It is less invasive, avoids thoracotomy, requires short hospital stay, yet, hemodynamic benefits, similar to surgery, can be achieved. It may also be considered the procedure of first choice in postsurgical residual atrial septal defect. Present case report describes the technique in a 14 years old girl with residual ostium secundum ASD.     

Anesthesia for percutaneous transcatheter closure of perimembranous ventricular septal defect

OBJECTIVE: To review the anesthetic management for percutaneous transcatheter closure of perimembranous ventricular septal defect (VSD) with an Amplatzer asymmetric occluder device and to highlight the hemodynamic effects and potential complications associated with its delivery. DESIGN: Retrospective review of prospectively collected data. SETTING: University-affiliated teaching hospital. PARTICIPANTS: Nine consecutive children undergoing elective percutaneous transcatheter closure of perimembranous VSD. INTERVENTIONS: General anesthesia with sevoflurane for cardiac catheterization and percutaneous transcatheter device placement. MEASUREMENTS AND MAIN RESULTS: Ten anesthetics were delivered in 9 children ages 23 to 65 months with perimembranous VSD for attempted placement of an Amplatzer asymmetric device. The device was successfully placed in 7 patients. In 1 patient the device embolized to the right femoral artery, and was retrieved with a bioptome. Fluoroscopy time (59.8 +/- 17.24 min) was prolonged compared to that in other studies of placement of this device. All patients had episodes of arrhythmia and hemodynamic disturbance. Arrhythmias ranged from atrial or ventricular ectopic events to various degrees of atrioventricular block. Complete heart block occurred during the procedure in 1 patient and after the procedure in another patient. Hypotensive episodes occurred in 7 patients, and were attributed to arrhythmias in 5 patients and hypovolemia in 2 patients. Two patients were given blood transfusions after the procedure because they had signs of hypovolemia and a greater than 10% decrease in hemoglobin levels. CONCLUSIONS: Anesthesia for perimembranous VSD occluder placement is associated with hemodynamic instability, arrhythmias, prolonged procedure times, and inevitable and sometimes substantial blood loss.     

Follow-up after surgical closure of congenital ventricular septal defect.

OBJECTIVES: The purpose of this retrospective study was to assess long-term outcome of children after surgical closure of a ventricular septal defect (VSD). MATERIAL AND METHODS: Between January 1992 and December 2001 a consecutive series of 188 patients (100 females) were operated for closure of a VSD. Temporary tricuspid valve detachment (TVD) was applied in 46 patients (24%) to enhance exposure of the defect using transatrial approach. Pre-operative baseline characteristics showed that the detached group was younger (0.79+/-1.8 vs 2.1+/-3.5 years, p=0.002) and had a lower weight (6.5+/-6.4 vs 10.0+/-11.0 kg, p=0.009). RESULTS: There was no difference in cross-clamp time (temporary TVD 36.2+/-11.3 vs non-temporary TVD 33.6+/-13.1 min, p=0.228). Postoperative echocardiography showed that 67 patients (36%) had trivial/minimal regurgitation, 10 patients (22%) from the temporary TVD group vs 57 patients (40%) from the non-detached group (p=0.02). There was no tricuspid stenosis. Hospital mortality comprised two patients (1%). One patient died due to a pulmonary hypertensive crisis and one in relation to an acute patch dehiscence for which an emergency reoperation was necessary. At first postoperative echocardiography no shunting was detected in 113 patients, trivial shunting in 73 and significant shunting in none. Multivariate logistic regression analysis revealed that weight at operation was a predictive factor for the occurrence of residual shunting (OR 0.95, C.I. 0.91-0.99). One patient with conduction disturbances needed a permanent DDD-pacemaker. Three patients were lost to follow-up. Mean follow-up time was 2.6 years (range 0.1-9.4). During follow-up no reoperations were necessary for closing a residual VSD. One patient died 7 months postoperative due to a bronchopneumonia. During follow-up in 37 (51%) of the 73 patients the trivial shunting disappeared spontaneously at a median time of 3.9 years. According to actuarial analysis all trivial shunting had disappeared at 8.4 years. CONCLUSION: Trivial residual shunting disappeared spontaneously at a median follow-up time of 3.9 years. During follow-up no patient needed to be reoperated for residual VSD. TVD proved to be a safe method to enhance the exposure of a VSD.