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.     

Influence of age-related complications on clinical outcome in patients with surgical repair of atrial septal defect

BACKGROUND: The influence of perioperative characteristics on postoperative outcome has been obscure in the adult patients with atrial septal defect (ASD). This study was designed to investigate whether perioperative patient profiles and complications will contribute to postoperative outcome following surgical closure of ASD in adult patients. METHODS: Subjects were 39 (17 male and 22 female) ASD patients, aged 16 to 69 years (mean 53 +/- 15) who were scheduled for surgical repair of isolated secundum ASD between 1999 to 2003. All patients were evaluated for circulatory characteristics using echocardiography and cardiac catheterization. Postoperative complications were evaluated by examining duration of postoperative oxygen requirement, postoperative duration until first ambulation, intubation and hospital stay after surgery. RESULTS: In elderly group (over 50 years of age), preoperative %FEV1.0, preoperative oxygen index and creatinine clearance were lower compared with those of younger group (under 50 years of age) (P=0.0309, P= 0.0341 and P= 0.0112, respectively). Moreover, elderly group showed longer duration of oxygen requirement compared with younger group (3 +/- 5 days and 2 +/- 1 days; P=0.0273). Age and change of the left ventricular diastolic diameter (LVDd) affected the incidence of postoperative arrhythmia (P=0.0195 and P=0.0204). Preoperative oxygen index and %VC affected long term intubation (P=0.0201 and P=0.0363). TAP, smoking and pulmonary hypertension affected long term oxygen supply (P=0.0070, 0.0349 and 0.0355). Only %VC affected postoperative duration until first ambulation (P = 0.0219). Delirium and postoperative oxygen index affected the length of hospitalization (P=0.0072 and 0.0188). CONCLUSIONS: Respiratory function was important in short-term outcomes in the patients with ASD. In addition, preoperative small LVDd was a useful predictor for postoperative atrial fibrillation.     

房间隔缺损合并三尖瓣反流行房间隔缺损封堵术的疗效分析

目的分析房间隔缺损合并三尖瓣反流行房间隔缺损封堵术的治疗效果。方法自2006年7月至2012年1月上海交通大学医学院附属新华医院共对98例房间隔缺损合并三尖瓣反流患者施行房间隔缺损封堵术治疗,其中男36例、女62例,手术年龄2个月至80岁。所有房间隔缺损均为继发孔型,房间隔缺损直径3～23 mm。其中合并轻度三尖瓣关闭不全60例,中度三尖瓣关闭不全28例,重度三尖瓣关闭不全10例。所有患者均行房间隔缺损封堵术,其中数字减影血管造影（DSA）下封堵51例,经胸小切口封堵46例,经胸超声心动图引导下封堵1例。术后对患者进行超声心动图随访,观察封堵术后三尖瓣反流的变化情况。结果围术期无死亡,1例手术失败,术后第3 d出现房间隔缺损残余分流;1例于术后第3 d异常出血,再次开胸止血;其余患者恢复顺利。随访84例,随访时间1～64（26.56±21.35）个月。随访期间术后第3 d出现房间隔缺损残余分流患者随访至术后6个月时无明显好转,转为开胸手术。73例（86.90%）三尖瓣反流均有不同程度的减轻,其中10例三尖瓣重度反流改善为轻度反流8例,中度反流1例,1例无改善;26例三尖瓣中度反流改善为无反流6例、轻度反流18例、2例无改善;48例三尖瓣轻度反流改善为无反流40例,8例无明显改善。结论房间隔缺损合并三尖瓣反流的患者,对三尖瓣的处理可持保守治疗态度,单纯房间隔缺损封堵即可获得良好的效果,同时也避免体外循环造成的心肌损伤、肺损伤等并发症的发生。     

50岁以上房间隔缺损介入与外科治疗的对比研究

目的　探讨高龄继发孔房间隔缺损 (ASD)病人的最佳治疗方式。方法　收集 5年来 5 0岁以上继发孔ASD行常规外科手术修补 5 3例和同期经导管介入Amplatzer双盘封堵器堵闭ASD 4 2例的资料进行分析 ,两组病例均采用彩色多普勒超声心动图测量心尖四腔心的右室长径、肺动脉压、三尖瓣反流面积、左室舒张末内径 ,左室射血分数等进行对比。结果　外科手术组成功 5 2例 ,成功率 98 1% ,术后出现脑栓塞、心包积液等并发症 13例 ( 2 4 5 % ) ,死亡 1例 ( 1 9% )。导管介入组堵闭成功率 97 6 % ,仅 1例于术后第 4d封堵器脱落移位至肺动脉。两组术后超声心动图复查显示 ,右心室超负荷明显改善 ,右心腔缩小 ,肺动脉高压改善或消失 ;住院天数外科组为 ( 19 8± 12 2 3)d ;介入组 ( 5 0± 2 5 )d。结论　外科手术治疗ASD适应证范围较介入组宽 ,对合并心脏结构明显异常者 ,需行外科手术 ,方可矫正血流动力学异常。介入组术前病例选择非常重要 ,严格掌握适应证范围和尽可能准确地了解ASD的最大直径 ,恰当选择封堵器的大小极为重要 ,经筛选的高龄ASD病人应用经导管介入治疗成功率高、并发症少、疗效好 ,恢复得快。     

Safety and efficacy of minimally invasive atrial septal defect closure

BACKGROUND: Atrial septal defects (ASDs) have been surgically closed with low mortality utilizing the conventional sternotomy approach (CSA). The technical ease of ASD closure has triggered interest in minimally invasive closure (MIC) to obviate the morbidity associated with sternotomy. Our study assesses the safety and efficacy of minimally invasive ASD closure. METHODS: Preoperative, intraoperative, and postoperative data were collected on 68 patients (39 CSA, 29 MIC) who underwent ASD closure from January 1997 to August 2002. Using univariate analysis of 17 preoperative risk factors there was no statistically significant difference between the two groups. RESULTS: MIC resulted in equivalent success rates in ASD closures, with similar morbidity, no mortality, and a significant difference in postoperative length of stay (3.93 +/- 1.6 days versus 5.36 +/- 2.51 days, p = 0.006). CONCLUSIONS: In experienced hands, MIC is an excellent alternative to CSA in ASD closure.     

Surgical device closure a new technique of ASD closure

Background Conventional approach of atrial septal defect (ASD) closure with cardio pulmonary bypass using mid sternotomy, minimally invasive or endoscopic technique is time tested. We decided to use custom made device with direct minimally invasive approach without cardio pulmonary bypass. Percutaneous transfemoral route using custom made device is a well established procedure performed by interventional cardiologist with occasional trauma and vessels. Method We performed the procedure in 3 patients of secundum ASD deemed adequate for device closure. We used a mini Right anterior thoracotomy approach using a double umbrella device which was implanted through direct Right Atrial puncture. Results In two patients we were successful in deploying the device. The proedure lasted 30 minutes with small infra Mammary scar and the post operative period was uneventful. In the third case where our attempt at surgical device closure failed the inferior margin was only one mm. The optimal size device kept slipping into the right atrium when the guide-wire was tugged after final deployment. The placement of an oversize device distorted the mitral valve, may causing regurgitation. Conclusion We think that this is a simple and safe technique of secundum ASD closure without cardio pulmonary bypass.     

Intraoperative device closure of large secundum atrial septal defects; a safe alternative to transcatheter closure

OBJECTIVE: The aim of this study is to report our short and mid-term results of intraoperative device closure (IODC) in large secundum atrial septal defects (ASD), to evaluate its safety and to determine the impact of 'short' rim on the results. METHODS: Sixty-eight patients with an ASD underwent IODC through a right minithoracotomy. Patients were divided into two groups: 37 patients in group I with one short rim (< or =5 mm) and 31 in group II with sufficient rims. A 2.5-3 cm parasternal incision was made in the right third or fourth intercostal space. A specially designed plastic sheath loaded with the device was inserted through the purse-string sutures placed on the right atrium. Under transesophageal echocardiographic guidance, it was advanced through the ASD into the left atrium and the device was deployed in place. RESULTS: The procedure was successful in all patients. The maximum diameter of the ASD ranged from 20 to 37 mm (mean 25+/-5 mm). There were 16 patients with the diameter of ASD more than 30 mm. The mean size of implanted devices was 29+/-4mm. Redeployment with larger device occurred in seven patients in group I and three in group II (p>0.05). Intracardiac manipulation time was 22+/-10 min in group I and 16+/-11 min in group II (p<0.01). The total occlusion rate was 84% immediately after operation, 97% at 3 months, 98% at 1 year, and 100% at 2-, 3-, 4-year follow-up. There were no other late complications during the follow-up period of 3-63 months (mean 27+/-18 months). CONCLUSIONS: IODC is a safe and feasible technique in closing large ASDs. It has the advantages of cost savings, cosmetic results, and less trauma. Early and mid-term results are encouraging. In patients with ASD of a short rim, a larger device is recommended which does not influence the success rate of IODC.     

Totally endoscopic computer-enhanced atrial septal defect closure in six patients

BACKGROUND: Totally endoscopic procedures have been introduced into cardiac surgery with the application of telemanipulating robotic systems. We report 6 cases of closed-chest atrial septal defect (ASD) closure using a robotic device. METHODS: After deflating the right lung, the endoscopic camera and two robotic arms were inserted into the right hemithorax through 8-mm ports. An accessory port was placed for blood suction and for introduction of ancillary endoscopic instruments. After femoral-femoral cannulation for cardiopulmonary bypass (CPB), aortic occlusion, and cardioplegia delivery, the intracardiac correction was carried out in 5 patients with an ostium secundum ASD and in 1 patient with a patent foramen ovale (PFO) and atrial septal aneurysm (ASA). The ASDs were closed with a continuous braided polyester suture. The PFO closure with septal aneurysm plication was carried out with interrupted stiches. RESULTS: Mean CPB and cross-clamp times were 106 +/- 22 and 67 +/- 13 minutes, respectively. Extubation was carried out within the seventh postoperative hour. All patients returned to normal function within the first postoperative week. CONCLUSIONS: Totally endoscopic ASD closure can be carried out safely using robotic techniques with rapid postoperative recovery and an excellent cosmetic result.     

A comprehensive approach to fast tracking in cardiac surgery: ambulatory low-risk open-heart surgery

OBJECTIVE: Ambulatory surgery, where the processes of admission, surgery and discharge are completed within 24h, is an increasingly important part of many surgical specialties. The aim of this study was to evaluate suitability of ambulatory approach for low-risk open-heart procedures. METHODS: A retrospective analysis of 48 patients who had undergone atrial septal defect (ASD) closure at our centre (from October 2005 through November 2006) suggested that this open-heart procedure was optimally suited for treatment with ambulatory approach. Based on this, 15 patients with ostium secundum ASD underwent surgical closure as ambulatory patients, with targeted discharge within 24h of admission. Twenty patients receiving conventional surgery in the other two units of the department served as the control group. RESULTS: Fourteen of the 15 patients were successfully discharged within 24h of admission. One patient remained in the hospital for excess incision site pain and was discharged on the 2nd postoperative day. Mean hospital stay for the entire cohort of 15 patients was 1583+/-669 min, whereas the mean hospital stay in the control group was 9.8 days. Follow-up was 100% complete at 30 days. There were no in-hospital or out-of-hospital complications in either group. No patient was readmitted at our centre or elsewhere for any complication arising from the procedure. CONCLUSIONS: This study suggests that sufficient advancement in cardiac surgery has occurred to permit low-risk open-heart procedures (with an expected uneventful postoperative course) to be performed on an ambulatory basis. Once such a practice is firmly established, expanding its horizon may provide considerable improvement in patient satisfaction, more patient turnover per bed, and significant financial savings.     

Early extubation of the trachea after repair of secundum-type atrial septal defects in children

To investigate the role of anaesthetic management in early extubation of the trachea in children after closure of a secundum-type atrial septal defect (ASD II), a retrospective chart review for a two-year period was performed. We identified 36 children who underwent surgical repair of an isolated ASD II. In 19 children (53%) the tracheas were extubated in the operating room immediately after surgery and in 17 patients (47%) the tracheas remained intubated and the lungs were ventilated in the Intensive Care Unit. There was no difference in age (69.5 +/- 33.8 vs 72.9 +/- 45.0 mo) or weight (19.5 +/- 8.1 versus 20.5 +/- 12.7 kg) between the two groups (mean +/- SD). Children in the extubated group had a shorter duration of cardiopulmonary bypass (43.4 +/- 7.8 min) than those remaining intubated (31.7 +/- 12.7 min) (P < 0.05). The children whose tracheas were extubated early received a lower perioperative fentanyl dose (5.9 +/- 6.4 micrograms.kg-1) than those remaining intubated (35.1 +/- 8.5 micrograms.kg-1). Those children in the extubated group had a lower hourly requirement for morphine by infusion (13.6 +/- 5.7 vs 18.2 +/- 5.4 micrograms.kg-1.hr-1) and a shorter stay (20.5 +/- 3.7 versus 29.0 +/- 11.2 hr) in the Intensive Care Unit. Re-intubation of the trachea was not required in any of the children and no deaths occurred. Early extubation after ASD II repair is safe and, given the results of this study, may offer certain advantages over prolonged intubation and ventilation in these children.     

介入治疗继发孔房间隔缺损及合并畸形428例临床报告

目的探讨继发孔房间隔缺损(ASD)合并畸形的介入治疗适应证、操作原则及临床效果。方法继发孔型ASD住院患者428例,其中单一ASD 416例,多发型ASD 12例,合并畸形70例。介入术中导入球囊导管测量最大ASD伸展直径,用TTE或TEE测量ASD直径及确定ASD位置、大小及数目。用注入球囊中的混合造影剂抽出在体外卡尺测量ASD直径,据此选择合适的闭合器。结果428例ASD患者成功介入425例,介入技术成功率99.3%。介入手术并发症总发生率2.1%。本组合并畸形介入治疗成功率100%。结论ASD及合并畸形的介入治疗,主要掌握ASD及合并畸形疾病的适应证,操作规范化,成功率很高,而且安全有效。     

Atrial septal defect repair with minithoracotomy using two stage single venous cannula

AIM: Repair of atrial septal defect (ASD) via minimal access has been the preferred method to improve cosmesis and fast rehabilitation. A 2-stage single venous cannula introduced via the femoral route allows better vision of the surgical field and improves surgical acts through a limited incision. METHODS: From February 1999 to December 2001 a minithoracotomy approach was used for closure of secundum type ASD by using single bicaval venous cannula in 17 adult patients. A 6 to 7 cm anterior minithoracotomy (submammary) approach with femoral arterial and 2-stage single venous cannula were utilized. Defects were closed primarily by running suture in 14 and with a patch in 3 patients. RESULTS: Calculated flow levels were maintained with a single venous cannula without assisted venous drainage in all patients. The postoperative course was uneventful in all patients except 1 who required revision for bleeding which was done through the same incision. Extension of the thoracotomy or shifting to the classic sternotomy was never required. CONCLUSION: Single venous bicaval cannula allows efficient drainage of both vena cavae and improves the surgical vision and manipulation through the right minithoracotomy. With this technique, repair of ASD can be done safely with good cosmesis.     

实时三维心脏超声引导下右胸切口与传统开胸体外循环下房间隔缺损手术效果的比较

目的 比较实时三维心脏超声（RT-3DE）引导非体外循环（CPB）下经右胸小切口房间隔缺损（ASD）封堵与传统CPB下心内直视修补的手术效果。 方法 2009年4月至2012年4月在红河州第一人民医院接受手术的继发孔型ASD患者64例,按手术方式分为Ａ组和B组。A组35例接受传统CPB心内直视修补,男20例、女15例,年龄12～56 （16.4±4.0） 岁;B组29例接受RT-3DE 引导非体外循环（CPB）下经右胸小切口ASD封堵,男13例、女16例,年龄15～50 （18.5±0.2） 岁。比较2组手术时间、术后呼吸机辅助时间、术后住院时间、胸腔引流量、死亡、并发症等指标及随访结果。 结果 B组手术时间［（110.47±35.90） min vs. （159.32±20.60） min］、术后呼吸机辅助时间［（10.40±22.30） h vs. （16.40±12.20） h］、胸腔引流量［（106.71±85.20） ml vs. （146.70±75.63） ml］及术后住院时间［（4.0±1.0） d vs. （7.0±1.0） d］ 均较A组显著减少（P＜0.05）。A组死亡1例,发生术后并发症7例;B组无1例死亡,发生术后并发症3例。A组术后并发症总发生率高于B组（20.0% vs. 10.3%,P＜0.05）。 结论 对手术适应证明确的患者,RT-3DE引导非CPB下右胸小切口ASD封堵的微创外科手术优势明显。     

Transcatheter aortic valve implantation and simultaneous closure of ostium secundum atrial septal defect

We were faced with a difficult question: how to treat a high-risk patient with severe aortic valve stenosis and a secundum atrial septal defect (ASD II). An 85-year-old woman with progressive dyspnea and pedal edema and in New York Heart Association class IV was treated with concomitant transapical aortic valve implantation and transcatheter closure of the ASD II. The combined procedure and postoperative course were completely uneventful. At 2 years after the clinical follow-up, the patient is doing well. This case report demonstrates, for the first time, the feasibility, safety, and effectiveness of simultaneous application of 2 transcatheter methods--aortic valve implantation and closure of an ASD II. As surgeons, we should consider percutaneous treatment of combined structural heart disease in patients at high risk for conventional surgery.     

Need for closure of secundum atrial septal defect in infancy

OBJECTIVES: Closure of isolated secundum atrial septal defect is generally recommended at the age of 4 to 5 years. However, there are children with isolated secundum atrial septal defect in whom early closure should be performed. We aimed to assess the underlying conditions that led to earlier closure in this special patient group and to analyze the outcome. METHODS AND RESULTS: From January 1990 through August 2002, 24 infants with isolated secundum atrial septal defect underwent surgical closure within the first year of life. All children were symptomatic. Signs of pulmonary hyperperfusion, such as tachydyspnea, failure to thrive, recurrent respiratory infections, or heart failure, were present. Four infants required artificial ventilation. Ten patients had additional problems, such as prematurity with chronic lung disease, hepato-omphalocele and congenital diaphragmatic hernia, which were present in 1 patient each. Eleven patients had defined dysmorphic syndromes. All but 1 infant underwent preoperative invasive hemodynamic evaluation. Thirteen patients had pulmonary hypertension preoperatively. The follow-up time was 46 +/- 33 months (range, 4-125 months). At follow-up, pulmonary artery pressure proved to be normal in 11 of the 13 children who had pulmonary hypertension previously. One patient died of persistent pulmonary hypertension. Clinical performance, growth, and development improved in nearly all patients. All ventilator-dependent children could be weaned shortly after atrial septal defect closure. CONCLUSIONS: If lungs are compromised, even a minor left-to-right shunt might be poorly tolerated in infancy. In these children early surgical closure of an isolated secundum atrial septal defect should be performed to support thrive and growth and to prevent the onset of irreversible changes of the pulmonary vasculature.     

房间隔缺损介入治疗后随诊观察

目的评价房间隔缺损(ASD)介入治疗的近期及远期疗效。方法继发孔型ASD 428例,单一ASD 416例,多发ASD 12例,合并畸形70例。使用美国AGA-Amplatzer ASD闭合器及国产闭合器闭合ASD。结果428例ASD患者成功介入425例,介入技术成功率99.3%。介入手术并发症总发生率2.1%。合并畸形介入治疗成功率100%。425例患者介入后第2、3天行ECG、TTE及X线检查,均有不同程度的改善,其中225例患者于术后1个月、3个月、半年、1年以上进行心电图(ECG)、经胸超声心动图(TTE)及X线随诊,最长达6年。远期随诊主要症状为头痛,杂音消失80%。ECG不完全性右束支传导阻滞(IRBBB)在1年内可由72%降至3%,但ECG近期及远期效果心律失常发生率较高。TTE近期改变主要右室流出道(RVOT)及右室(RV)内径明显变小,远期随诊主要为房室瓣返流,均为轻度,残余漏仅1例,X线胸片心胸比值近、远期疗程均明显缩小。结论ASD介入治疗近期、远期疗效十分理想。     

Percutaneous cholecystostomy for acute cholecystitis in high-risk patients: experience of a surgeon-initiated interventional program

BACKGROUND: The treatment of choice for acute cholecystitis is cholecystectomy. However, percutaneous cholecystostomy (PC) is an alternative treatment in patients who are at high risk for urgent surgery. This study reviews our experience of PC for treatment of acute cholecystitis in a surgeon-initiated interventional program. METHODS: Clinical records of all high-risk patients who underwent PC placement by surgeons (group A; n = 22) for acute cholecystitis were reviewed. Treatment outcomes were compared with patients who underwent PC by interventional radiologists (group B; n = 26). RESULTS: Similar technical success, procedural complication, or treatment outcome were noted between the two groups. Seven patients (32%) in group A and 9 patients (35%) in group B underwent delayed elective cholecystectomy surgery. The time elapsed between the diagnosis to PC placement in groups A and B was 6.6 +/- 3.5 hours and 18.5 +/- 4.3 hours, respectively (P < .02). CONCLUSIONS: Ultrasound-guided PC is a safe and effective treatment for acute cholecystitis in high-risk surgical patients. Surgeons with endovascular skills can obtain clinical competence in this catheter-based procedure, which provides an added armamentarium in surgical biliary disease management.     

Surgical closure of atrial septal defect

Background: Closure of ostium secundum atrial septal defect (ASD) vis median sternotomy (MS) is a simple procedure for most cardiac surgeons. Minimally invasive cardiac surgery (MICS) has recently been applied in the management of intracardiac lesions. Methods: We report our experience in surgical closure of isolated ASD via MICS in 60 patients and via MS in 58 patients. There was no difference between these two groups in gender, age, body weight, ratio of systemic to pulmonary blood flow, and pulmonary arterial pressure. Results: The duration of cardiopulmonary bypass was significantly longer in the MICS group than in the MS group [27 to 126 min (42 ± 12) and 14 to 158 min (27 ± 11), respectively; (p < 0.001]. However, the length of incision, incidence of temporary pacemaker wire insertion rate, duration of endotracheal intubation, timing of oral intake, postoperative day drainage amount, incidence of parenteral analgesic injection, postoperative length of stay, and return to normal activity interval were significant shorter and lower in patients of the MICS group than in those of the MS group. All the patients recovered rapidly from the surgery. Follow-up was complete in all patients, with no late complications and no residual shunt. Conclusion: Our results suggest that MICS is a good option for surgical closure of ASD. Received: 4 June 1997/Accepted: 29 October 1997     

Results of surgical closure of isolated secundum atrial septal defect

Methods A retrospective analysis of all patients undergoing surgical closure of an isolated secundum atrial septal defect, at the Postgraduate Institute, Chandigarh between January 1974 and June 2000 was performed. 740 patients were divided into two groups. Group I. Included 435 patients under 20 yrs of age (223 male), 315 (72%) were asymptomatic, 265(61%) were in sinus rhythm. Group II. included 305 patients between 21 and 53 years (96 males), 27 patients (9%) were asymptomatic, 102(33%) were in sinus rhythm. Cardiopulmonary bypass with fibrillatory arrest and/or cold blood cardioplegia were used. In group I 291 patients (67%0 and in group II 64 patients (54%) underwent direct closure of the defect. In the remaining a patch was used for closure. Results There was 1 early death in group I (0.2%) and four in group II (1.3%) 96% of symptomatic patients in group I and 87% of patients in group II were improved. There were no instances of residual shunt. Follow up ranged from 6 months to 25 years (mean 8.3 yrs) and was 89% complete. Conclusions Closure of isolated secundum ASD is best performed before the patient attains adulthood.     

Outcome following tricuspid valve detachment for ventricular septal defects closure.

OBJECTIVES: Detachment of the septal leaflet of the tricuspid valve from the annulus (TVD) has been used to improve visualization of ventricular septal defects (VSDs), but may be associated with increased operative time, heart block, and the development of tricuspid regurgitation (TR). METHODS: Patients undergoing VSD closure between 1/1/96 and 31/12/99 were retrospectively reviewed. Follow-up was obtained from the patients' cardiologists. RESULTS: Transatrial VSD closure was performed in 172 patients with TVD in 36 (21%) at the surgeon's discretion. The leaflet incision was repaired with a separate suture (22) or with the VSD patch suture (14). Additional procedures including arch augmentation, closure of atrial septal defects, and closure of additional VSDs were performed in 93 (68%) non-TVD patients and 20 (56%) TVD patients. The median age was 6.2 months (range 1 day to 46 years) and the median weight was 5.9 kg (range 1.5-71.5 kg). Cardiopulmonary bypass (CPB) time was 64+/-24 min and cross-clamp time was 34+/-16 min. One hospital death occurred in an infant with tracheal stenosis. No child in either group developed complete heart block. The median duration of postoperative stay was 4 days (range 2-49 days). There were no differences in CPB time, cross-clamp time or postoperative stay between the TVD and non-TVD groups (P>0.1 for all). At a mean follow-up of 17+/-15 months, there have been two late deaths unrelated to cardiac disease. No child in the TVD group required reoperation for residual VSD, compared to three in the non-TVD group. No child in the TVD group has greater than mild TR, but six in the non-TVD group have greater than mild TR. No child in either group has undergone reoperation for TR. CONCLUSIONS: TVD is a safe, effective technique to improve visualization of VSD and is not associated with heart block, increased operative time, or TR. TVD may result in improved preservation of tricuspid valve architecture and decrease the incidence of significant postoperative TR.