Angiocardiographic diagnosis of ventricular septal defects in complete transposition of great vessels

The article analyses experience in angiocardiographic diagnosis of the localization of ventricular septal defects (VSD) in 47 patients with complete transposition of the great vessels (CTGV) and high pulmonary hypertension. Axial X-ray views ("4 chambers" and "long axis") were used in the examination. The work shows the angiographic signs of all types of VSD. It is concluded that at present there is no single X-ray view universal for all types of VSD. Two-dimensional echocardiography is important in the choice of the view in angiocardiography. The muscular type of VSD is encountered most frequently (40.5%) in CTGV. Absence of contact of the superior margin of the defect with the valve of the aorta and pulmonary artery is a characteristic angiocardiographic sign of the defect. Contact of the superior margin of the defect with the valve of the pulmonary artery and absence of contact with the aortic valve are characteristics of the perimembranous types of VSD. Subarterial types of VSD are characterized by contact of the upper margin of the defect both with the aortic valve and the valve of the pulmonary artery. In 11 patients the results of angiocardiography were compared with the findings of autopsy.     

Surgical management of transposition of great arteries associated with multiple ventricular septal defects.

OBJECTIVE: The presence of associated multiple ventricular septal defects (VSDs) increases the risk of the anatomic repair for transposition of the great arteries (TGA). The aim of this study was to define the optimal management of this complex anomaly. METHODS: Between January 1988 and December 1998, 45 patients underwent anatomic repair of TGA associated with multiple VSDs. The median age was 50 days and the median weight 4 kg. Eighteen (40%) had undergone previous palliation including 17 pulmonary artery banding procedure (PAB), seven associated with coarctation repair and one isolated coarctation repair. The perimembraneous septum was involved in 24 patients, the trabecular in 43, the inlet in seven and the infundibular in two. Closure of the VSDs included Dacron or pericardial patchs and matress sutures. The initial approach was through right atriotomy which was sufficient in 15 patients. VSDs were closed through right ventriculotomy in 13 patients, through pulmonary artery in six, through the aorta in one and in the remaining (n = 10) combined approaches were used. Only one patient required left apical ventriculotomy. RESULTS: There were five hospital deaths (11%; 70% CL: 6-18%) including the one early reoperation for residual VSD closure. Five patients had successful early reoperation for secondary PAB for residual VSD. Three late deaths occurred (7%; 70% CL: 3-13%). At the last visit, 95% of survivors were asymptomatic and without any cardiac medication. CONCLUSION: Mid-term survival with good quality of life can be achieved following either one or two-stage repair of this complex anomaly. In the presence of VSD closure failure a secondary PAB may be the procedure of choice.     

Surgical management of ventricular septal defects in infants

Infants with ventricular septal defect (VSD) who are symptomatic despite intensive medical therapy require surgical intervention. Choice of treatment depends upon the cumulative mortality and morbidity rates of the two-stage approach of initial pulmonary artery banding followed by debanding and VSD closure as compared to the risk of primary intracardiac repair in infancy. Sixteen infants underwent pulmonary artery banding at Columbia-Presbyterian Medical Center between 1967 and 1976, with one operative death but with a significant incidence of morbidity and late death. Forty patients underwent pulmonary artery debanding and closure of VSD with three operative deaths. This second-stage procedure was frequently complicated by repair of acquired lesions. During the same 10 year period 37 infants underwent primary closure of VSD with eight operative deaths. The morbidity related to this procedure is low. With the use of profound hypothermia and circulatory arrest, results have significantly improved and the risk of early correction now compares favorably with the cumulative mortality rate of the two-stage approach. Primary intracardiac repair is the procedure of choice.     

Surgical management of muscular trabecular ventricular septal defects

Despite recent advances in diagnosis, surgical techniques, and postoperative care of children with congenital cardiac defects, muscular trabecular ventricular septal defects (VSDs) are still a therapeutic challenge. Among these defects, it is more difficult to achieve secure and complete closure of low trabecular or apical VSDs because of the presence of numerous muscular trabeculations overlying the defect. When they are associated with “Swiss cheese”-type of VSDs, it is almost impossible to visualize the true edges of the defect through the transatrial approach. Consequently, there remains an unacceptable incidence of mortality and morbidity when compared to those that occur with closure of the usual perimembranous VSD. Although various techniques for closure of these difficult trabecular VSDs have been attempted, there is still a significant incidence of complications in the surgical management of trabecular VSDs, mostly significant residual shunts, a need for multiple reoperations, and severe left ventricular dysfunction. This article describes the anatomical details and classification of muscular trabecular VSDs. It also reviews several techniques currently utilized and their outcomes.     

Surgical management of ventricular septal defects complicating myocardial infarction

Ventricular septal rupture is an infrequent but often catastrophic complication of acute myocardial infarction. Occasional patients can be treated conservatively until an interval of 3–4 weeks postinfarct, a propitious time for surgical repair of the septal defect. However, the vast majority of patients who sustain interventricular septal rupture will not survive more than a few days unless the problem is dealt with promptly and definitively. The techniques for successfully closing postinfarct interventricular septal defects (VSD) are now at hand, and markedly improved results of emergency surgical closure have resulted from the application of these techniques. In anterior or apical defects secondary to acuteanterior myocardial infarction, the technique of closing the VSD by approximation of the septum to the right ventricular wall with Teflon^® felt buttressing, or the technique of apical amputation, has resulted in a high rate of success, even in patients requiring operation less than 3 weeks after infarction. However, only recently have techniques been developed which yield similarly successful results in patients after acuteinferior infarction with a posteriorly placed VSD. Recent experience has indicated that prosthetic fabric replacement of the septum, ventricular free wall, or both is necessary for permanent closure of posterior VSD's. The use of prosthetic fabric in this manner allows for maintenance of left ventricular volume but, most importantly, prevents tearing out of sutures used to close the defect or the ventriculotomy itself because of undue tension on the friable myocardium. One of the most gratifying aspects of the treatment of patients after septal rupture is the dramatic palliation which is achieved by successful closure of the VSD. Virtually all surviving patients achieve the status of New York Heart Association functional Class 1 or Class 2.

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Résumé La rupture du septum interventriculaire est une complication rare, mais souvent catastrophique, de l'infarctus du myocarde. Rares sont les malades qui peuvent être traités médicalement pendant 3–4 semaines après l'infarctus et attendre ainsi le moment favorable pour la réparation chirurgicale. La majorité des malades ne survivent que quelques jours s'ils ne sont pas rapidement opérés. Les techniques de réparation de rupture septale pour infarctus sont actuellement bien au point et leur application a nettement amélioré les résultats de ces interventions faites en urgence. Dans les ruptures antérieures ou apicales résultant d'un infarctus antérieur, la fermeture par apposition du septum à la paroi ventriculaire droite, avec points matelassés de feutre de Teflon^®, et l'amputation de l'apex ont donné des pourcentages élevés de succès, même chez les malades qui doivent être opérés moins de 3 semaines après l'infarctus. Mais ce n'est que récemment qu'ont été mises au point des techniques donnant d'aussi bons résultats dans les infarctus inférieurs avec rupture septale postérieure. L'expérience récente montre qu'il faut, pour fermer l'orifice, utiliser une prothèse remplaçant le septum, la paroi ventriculaire ou les deux. La prothèse conserve un volume ventriculaire adéquat et, surtout, elle évite la déchirure du myocarde friable au niveau des points de suture de la ventriculotomie. Un des aspects les plus encourageants du traitement des malades atteints de rupture septale est l'amélioration extraordinaire de leur état lorsque l'on réussit la réparation. Presque tous les survivants atteignent un stade fonctionnel 1 ou 2 de la classification de la New York Heart Association.

     

Surgical management of isolated multiple ventricular septal defects. Logical approach in 130 cases.

From January 1980 through September 1990, 130 children underwent surgical closure of isolated multiple ventricular septal defects (mean age 14 +/- 18 months, mean weight 7.0 +/- 4.4 kg). Sixty-one were less than 1 year of age. Sixty-one children had pulmonary protection, 51 had pulmonary artery banding, and 10 had pulmonary valve stenosis. All other patients had severe pulmonary hypertension (mean systolic pressure 75.7 +/- 20.5 mm Hg and already disabling heart failure (New York Heart Association classes III and IV). The surgical management was based on the location of the defects and the ventricular dominance that were assessed preoperatively and intraoperatively. Midtrabecular ventricular septal defects were always centered by the moderator band and were therefore divided into low trabecular, midtrabecular, and high trabecular defects. The perimembranous septum was involved in 102 patients, the trabecular in 121, the inlet septum in 12, and the infundibular septum in 9. Fifty patients had the "Swiss cheese" form of the lesion. Closure of the ventricular septal defects included Dacron patch and mattress sutures. They were always first approached through a right atriotomy, which was sufficient for complete repair in 82 patients. In midtrabecular ventricular septal defects, section of the moderator band (n = 24) allowed closure of all the defects with a single Dacron patch. In 48 patients a right atriotomy and a right (n = 32) or left (n = 14) (particularly for low trabecular ventricular septal defects) or both right and left (n = 2) ventriculotomies were necessary to secure the repair. The hospital mortality rate was 7.7% (10 patients). The causes of deaths were residual ventricular septal defect (n = 5), pulmonary hypertension (n = 2), hypoplastic right ventricle (n = 1) and left ventricle (n = 1), and myocardial infarction (n = 1). Among eighteen survivors with residual ventricular septal defect, six were reoperated on; there were two deaths. A permanent pacemaker was necessary in four patients. Low trabecular ventricular septal defects and left ventriculotomy were significant risk factors for morbidity (death, residual ventricular septal defect), p less than 0.01. At 7 years of follow-up, 90% of survivors were in New York Heart Association class I. Actuarial survival and freedom from reoperation at 7 years were 89.6% and 87.5%, respectively.     

Surgical repair of isolated ventricular septal defects in the first year of life.

Since October 1975, 6 infants ranging in age from 5 to 9 months and weighing from 5.2 to 7.8 kg have been treated with primary closure of ventricular septal defect (VSD) at Ullev?l Hospital. The indications for operation were large left-to-right shunts combined with persistence of heart failure in 4 patients, a large left-to-right shunt only in one and elevated pulmonary arterial resistance in one patient. Conventional cardiopulmonary bypass was used in all cases. There were no early or late deaths during the mean observation period of 17.3 months (range 3--25 months). One patient developed a recurrent VSD and was successfully re-operated on 8 months after the first operation; otherwise no signs of recurrence were found. The growth and weight gains have been satisfactory and the psychosomatic development of all the infants has been normal. All are in sinus rhythm with right bundle branch block in 4. Cardiac arrhythmias have not been in evidence.     

Surgical repair of post infarction ventricular septal defects: a national experience.

OBJECTIVES: Ventricular septal rupture is a rare but feared complication after acute myocardial infarction. Most reports about outcome after surgical treatment are single center experiences. We investigated the results after surgical repair in all patients in Sweden during a 7-year period. METHODS: All patients undergoing surgical repair 1992-1998 were identified with the aid of the Swedish Heart Surgery Registry. The patients (n=189, 63% men, mean age 69+/-8 years) were operated at 10 different centers. Pre-and peri-operative variables were collected from the Registry and individual patient charts. Mortality was calculated and a Cox proportional hazards regression model was used to identify independent predictors for early and late mortality. Mean follow-up was 2.4 years. RESULTS: Seventy-seven of the 189 patients died within 30 days (41%). Urgent repair (Risk Ratio 4.2 (2.0-8.9), P<0.001) and posterior rupture (RR 2.1 (1.3-3.4), P=0.002) were independent predictors of 30-day mortality. Total cumulative survival (Kaplan-Meyer) was 38% at 5 years. For patients that survived the first 30 days (n=112), 5 year cumulative survival was 67%. Independent predictors for mortality after 30 days were number of concomitant coronary anastomoses (RR 1.5 (1.2-2.0), P=0.001), residual postoperative shunt (RR 2.7 (1.4-5.4), P=0.004) and postoperative dialysis (RR 3.4 (1.5-7.5), P=0.003). CONCLUSIONS: Early mortality after surgical repair of post infarction septal rupture is still considerable. Early repair and posterior rupture are predictors of early mortality. Long-term survival in patients surviving the immediate postoperative period is limited by pre-existing coronary artery disease, postoperative renal failure and the presence of a residual postoperative shunt.     

Surgical closure of apical ventricular septal defects through a right ventricular apical infundibulotomy

BACKGROUND: We present a new understanding of the anatomic position of apical ventricular septal defects and its surgical relevance. These defects occur between the left ventricular apex and the infundibular apex, rather than between the left and right ventricular apices. Often a sizable apical recess, the infundibular apex lies anteriorly and inferiorly to the moderator band and is the most leftward part of the right ventricle. METHODS: Four patients (2 boys and 2 girls) with a mean age of 109 days (range, 48 to 217 days) underwent patch closure through an apical infundibulotomy, which allowed complete visualization of the muscular apical ventricular septal defect. RESULTS: There were no early or late deaths at operation. No significant residual shunt at ventricular level was detected by postoperative two-dimensional and Doppler echocardiography. Intraoperative comparison of right atrial and pulmonary arterial blood samples showed a difference of less than 5%. At a mean follow-up of 18 months, all the patients are asymptomatic and growing well. CONCLUSIONS: The successful outcome of these 4 patients indicates that surgical closure of apical ventricular septal defects can be achieved safely and completely in early infancy through a limited right ventricular apical infundibulotomy. Long-term follow-up of these and similar patients is needed to provide further evaluation of this approach.     

Surgical management of trabecular ventricular septal defects: the sandwich technique

BACKGROUND: Surgical closure of trabecular ventricular septal defects is difficult and often unsuccessful. OBJECTIVE: We performed closure of trabecular ventricular septal defects by sandwiching the septum between 2 polyester felt patches placed in the left ventricle and right ventricle without ventriculotomy. METHODS: Eleven patients (7 boys and 4 girls) underwent a sandwiching closure at a mean age of 4.7 years (range, 0.4-9.7 years) and a mean weight of 16.7 kg (range, 4.6-52 kg). Associated cardiac malformations were present in 9 of the 11 patients. Seven patients had undergone previous operations. The trabecular ventricular septal defects are exposed through the tricuspid valve and also from the left ventricular side through a coexisting large perimembranous ventricular septal defect or through the mitral valve through an interatrial septostomy. Two forceps, one each from the right and left ventricular side, lead a 3F Nelaton catheter through the trabecular defect. An oversized circular polyester felt patch mounted on a 3-0 Nespolen suture attached to the Nelaton catheter is then passed into the left ventricle. The suture ends are then passed through a slightly smaller polyester felt patch on the right ventricular side of the septum. The Nespolen suture is then tied, thereby sandwiching the septum between the 2 patches. RESULTS: Time required for the procedure was less than 20 minutes in each case. There were no hospital deaths, and the postoperative course was uneventful in all patients. There was no residual shunt in 3 patients, and a minimal residual shunt was observed in 5 patients. Mild residual shunt was observed in 3 patients. Cardiac catheterization was performed 1 month postoperatively in 8 patients in whom residual shunt was noted on echocardiography. Five of 8 patients had a minimal residual shunt (pulmonary blood flow/systemic blood flow ratio = 1.0). Three patients had a residual shunt (pulmonary blood flow/systemic blood flow ratio = 2.0, 1.6, and 1.2). The patient with a pulmonary blood flow/systemic blood flow ratio of 2.0 had a "Swiss cheese" ventricular septal defect, and a residual shunt remained around the patch. However, the residual shunt decreased to a pulmonary blood flow/systemic blood flow ratio of 1.6 at examination 16 months postoperatively. Echocardiography showed that the residual shunt had also decreased in another 2 patients. CONCLUSIONS: We conclude that the sandwich technique is safe and easy. Even in cases with a residual shunt present, the shunt is expected to decrease as time passes. Further experience and longer follow-up of these patients are necessary to conclude whether this technique is applicable to neonates and young infants.