Outcome following tricuspid valve detachment for ventricular septal defects closure

Ventricular Septal Defect Exposure by Tricuspid Valve Chordal Detachment-A Retrospective Matched Study

Background: Transatrial approach is the standard method in repairing ventricular septal defects (VSD) in the pediatric population. However, the tricuspid valve (TV) apparatus might obscure the inferior border of the VSD risking the adequacy of repair by leaving residual VSD or heart block. Detachment of the TV chordae has been described as an alternative technique to TV leaflet detachment. The aim of this study is to investigate the safety of such a technique. Methods: Retrospective review of patients who underwent VSD repair between 2015 and 2018. Group A (n = 25) had VSD repair with TV chordae detachment were matched for age and weight to group B (n = 25) without tricuspid chordal or leaflet detachment. Electrocardiogram (ECG) and echocardiogram at discharge and at 3 years of follow-up were reviewed to identify new ECG changes, residual VSD, and TV regurgitation. Results: Median ages in groups A and B were 6.13 (IQR 4.33-7.91) and 6.33 (4.77-7.2) months. New onset right bundle branch block (RBBB) was diagnosed at discharge in 28% (n = 7) of group A versus 56% (n = 14) in group B (P = .044), while the incidence dropped to 16% (n = 4) in group A versus 40% (n = 10) in group B (P = .059) in the 3 years follow-up ECG. Echocardiogram at discharge showed moderate tricuspid regurgitation in 16% (n = 4) in group A and 12% (n = 3) in group B (P = .867). Three years of follow-up echocardiography revealed no moderate or severe tricuspid regurgitation and no significant residual VSD in either group. Conclusion: No significant difference in operative time was observed between the two techniques. TV chordal detachment technique reduces the incidence of postoperative RBBB without increasing the incidence of TV regurgitation at discharge.

Tricuspid valve detachment for ventricular septal defect closure: A meta-analysis of existing evidence

BACKGROUND

Ventricular septal defect (VSD) is one of the most common congenital cardiac defects. However, in some cases, VSD sites are difficult to expose due to obstruction from chordal attachments and leaflets of the tricuspid valve (TV). To systematically review the efficacy and safety of tricuspid valve detachment, (TVD) versus conventional surgical repair (non-TVD) in the treatment of ventricular septal defect (VSD). This article is aimed to compare the many outcomes from existing studies and provide evidence regarding the necessity of performing TVD.

METHODS

We searched the following databases: PubMed via NCBI, the Cochrane Central Register of Controlled Trials (no date restriction), Medline via Ovid (from 1966 to May 2020); Embase via Ovid (no date restriction), and China National Knowledge Infrastructure for studies comparing the efficacy of TVD and other surgical techniques in VSD repair. Cardiopulmonary bypass time, Cross-clamp time; postoperative complications including residual defect, postoperative atrioventricular block, implantation of pacemakers, tricuspid regurgitation; length of stay (LOS), length of intensive care unit (ICU) stay were analyzed.

RESULTS

Only nine studies were included after selection, including seven retrospective cohort studies, one respective cohort study, and one prospective observational study, a patient pool of 1404 patients with 374 underwent TVD and 1030 underwent non-TVD procedures, met the inclusion criteria. Meta analysis has drawn to the following conclusions. First, TVD prolongs CPB time (MD = 7.75, 95% confidence interval [CI] = 2.60-12.89, p = .003) and cross-clamp time (MD = 7.77, 95% CI = 4.76-10.78, p < .001) compared with non-TVD techniques in VSD repair surgeries. Second, no significant difference exists in LOS, length of ICU stay, postoperative atrioventricular block, implantation of pacemakers, incidence of ≥mild tricuspid valve regurgitation (TR) postoperatively and at discharge, as well as the incidence of ≥small residual VSD after surgery and during follow-up (all p ＞ .05). Third, application of TVD increases the risk of TR during follow-up (odds ratio [OR] = 2.42, 95% CI = 1.55-3.76, p < .001).

CONCLUSION

VSD closure using TVD technique results in longer CPB and cross-clamp time, and increases risk of TR during follow-up. TVD provides equally viable and safe alternative in treating VSD.

Outcomes of Tricuspid Valve Detachment for Isolated Ventricular Septal Defect Closure

Partial detachment of the septal and anterior leaflets of the tricuspid valve (TV) is a technique to visualize a perimembranous ventricular septal defect (VSD) for surgical closure in cases where the VSD is obscured by TV tissue. However, TV incision bears the risk of causing relevant postoperative TV regurgitation and higher degree atrioventricular (AV) block. A total of 40 patients were identified retrospectively in our institution who underwent isolated VSD closure between January 2013 and August 2015. Visualization of the VSD was achieved in 20 patients without and in 20 patients with additional partial detachment of the TV. The mean age of patients with partial tricuspid valve detachment (TVD) was 0.7 ± 0.1 years compared with 1 ± 0.3 years ( p  = 0.22) of patients without TVD. There was no difference in cardiopulmonary bypass time between patients of both groups (123 ± 11 vs. 103 ± 5 minutes, p  = 0.1). Cross-clamp time was longer if the TV was detached (69 ± 5 vs. 54 ± 4 minutes, p  = 0.023). There was no perioperative mortality. Echocardiography at discharge and after 2.5 years (2 months–6 years) of follow-up showed neither a postoperative increase of tricuspid regurgitation nor any relevant residual shunt. Postoperative electrocardiograms were normal without any sign of higher degree AV block. TVD offers enhanced exposure and safe treatment of VSDs. It did not result in higher rates of TV regurgitation or relevant AV block compared with the control group.

Does tricuspid valve detachment improve outcomes compared with the non-tricuspid valve detachment approach in ventricular septal defect closure?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the tricuspid valve detachment (TVD) approach to ventricular septal defect repair provides superior outcomes compared with the non-TVD approach. Altogether more than 54 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. A total of 2059 participants were enrolled in the 10 studies, including 2 prospective studies and 8 retrospective studies. Six studies demonstrated a longer cardiopulmonary bypass time or aortic clamp time in the TVD group, whereas 4 studies showed no difference. Only 1 study reported a lower incidence of trivial tricuspid regurgitation in the TVD group, whereas the other 9 studies showed no significant difference. One study showed that a higher incidence of residual shunting occurred in those patients who had indications for TVD but did not perform detachment during surgery. No difference in postoperative residual shunting was demonstrated in the other 9 studies. We conclude that surgeons should be reassured that if TVD is required to repair the ventricular septal defect, although it may lead to longer cardiopulmonary bypass time and cross-clamp times, outcomes are equivalent in terms of the degree of tricuspid regurgitation and incidence of the residual ventricular septal defect.

Tricuspid valve detachment for ventricular septal defect closure in infants <5 kg: should we be hesitant?

 

OBJECTIVES

We compared the clinical outcomes between tricuspid valve detachment (TVD) and non-TVD for ventricular septal defect (VSD) closure in infants <5 kg.

METHODS

From January 2004 to April 2020, 462 infants <5 kg with VSD without more complex intracardiac lesions and who had undergone VSD closure through the trans-atrial approach were enrolled. Propensity score-matching analysis was performed. Clinical outcomes were compared between the paired TVD group (group D) and paired non-TVD group (group N).

RESULTS

The median age and body weight at operation were 1.9 months [interquartile range(IQR), 1.4-2.5] and 4.2 kg (IQR, 3.7-4.6). The median follow-up duration was 83.4 months (IQR, 43.5-130.4). After matching, 44 pairs were extracted from each group. There were no significant differences in all-cause mortality (P = 0.176), reoperation (P = 0.172), postoperative morbidities, including residual VSD, aortic regurgitation, atrioventricular block and significant tricuspid regurgitation (TR) (P = 0.346) between group D and group N. However, group D showed significantly less TR progression during follow-up (P = 0.019).

CONCLUSIONS

In infants <5 kg, TVD can be a reasonable and valid option for successful VSD closure without morbidities, including TR progression if the indication exists.

Key Regulatory Differentially Expressed Genes in the Blood of Atrial Septal Defect Children Treated With Occlusion Devices

Atrial septal defects (ASDs) are the most common types of cardiac septal defects in congenital heart defects. In addition to traditional therapy, interventional closure has become the main treatment method. However, the molecular events and mechanisms underlying the repair progress by occlusion device remain unknown. In this study, we aimed to characterize differentially expressed genes (DEGs) in the blood of patients treated with occlusion devices (metal or poly-L-lactic acid devices) using RNA-sequencing, and further validated them by qRT-PCR analysis to finally determine the expression of key mediating genes after closure of ASD treatment. The result showed that total 1,045 genes and 1,523 genes were expressed differently with significance in metal and poly-L-lactic acid devices treatment, respectively. The 115 overlap genes from the different sub-analyses are illustrated. The similarities and differences in gene expression reflect that the body response process involved after interventional therapy for ASDs has both different parts that do not overlap and the same part that crosses. The same portion of body response regulatory genes are key regulatory genes expressed in the blood of patients with ASDs treated with closure devices. The gene ontology enrichment analysis showed that biological processes affected in metal device therapy are immune response with CXCR4 genes and poly-L-lactic acid device treatment, and the key pathways are nuclear-transcribed mRNA catabolic process and proteins targeting endoplasmic reticulum process with ribosomal proteins (such as RPS26). We confirmed that CXCR4, TOB1, and DDIT4 gene expression are significantly downregulated toward the pre-therapy level after the post-treatment in both therapy groups by qRT-PCR. Our study suggests that the potential role of CXCR4, DDIT4, and TOB1 may be key regulatory genes in the process of endothelialization in the repair progress of ASDs, providing molecular insights into this progress for future studies.

Assessment of Tricuspid Valve Detachment Efficiency for Ventricular Septal Defect Closure: A Retrospective Comparative Study

Background

The aim of this study was to investigate the efficiency of tricuspid valve detachment (TVD) during the surgical treatment of perimembranous ventricular septal defects (VSDs) and to compare the early and mid-term results to patients without TVD in terms of tricuspid insufficiency.

Methods

A total of 170 patients who had undergone surgical closure of perimembranous VSDs between November 2012 and January 2019 were included in this study, of whom 50 had an additional TVD procedure during the surgery. All patients were examined by transthoracic echocardiography before and after the operation with regular intervals, and the tricuspid valve function was then evaluated.

Results

There was no significant difference between subgroups with an unchanging degree of TVR, however, the result was also similar among those who had a decreased degree of TVR at any level (p = 0.271, p = 0.451). At the end of the study, all patients were in New York Heart Association class I.

Conclusions

We suggest that, in appropriate patients, VSD closure can be safely performed with an additional TVD application through an incision of the septal leaflet of the tricuspid valve without impairing the valve function or reducing the growth potential of the valve at midterm follow-up.

The Destiny of Postoperative Residual Ventricular Septal Defects After Surgical Repair in Infants and Children

PURPOSE

Residual ventricular septal defects (rVSDs) of small size are commonly seen on transesophageal echocardiography after surgical repair. This study aimed to determine the destiny of rVSD found on intraoperative echocardiogram.

METHODS

Patients undergoing surgical repair of VSD as the primary procedure with available intraoperative and discharge echocardiograms between 2007 and 2017 were reviewed. Presence of an rVSD on intraoperative echo triggered review of discharge echo and of subsequent follow-up echocardiograms.

RESULTS

One hundred four patients were analyzed. The mean age and weight for the entire cohort were 1.4 ± 2.9 years (median, 5.4 months; range, 29 days to 14 years) and 8.8 ± 9.9 kg (median, 5.1 kg; range, 2.7-58 kg), respectively. Sixty (57%) patients had rVSD at discharge, with mean size of residual VSD of 1.38 ± 0.92 mm (mode, 0.6; median, 2.2 mm; range, 0.5-3.9 mm). The mean follow-up time was 3.7 ± 3.1 years (range, 1 month to 9.3 years). Among those with rVSD at discharge, a residual shunt persisted in 73% at one-month follow-up. On follow-up at three years postdischarge, of the 60 patients with early rVSD, 6 had a persistent rVSD (10%) with a mean diameter of 3.0 ± 0.8 mm (range, 2.4-3.9 mm).

CONCLUSIONS

Residual VSD after surgical repair is detected frequently on postoperative echocardiogram. The presence of rVSD was not associated with any preoperative, intraoperative, or postoperative factors. By three years of follow-up, only six patients continued to demonstrate rVSD with a mean diameter of 3 mm, suggesting that defects 3 mm or greater may be less likely to close spontaneously after three years.

Short- and medium-term follow-up of transcatheter closure of perimembranous ventricular septal defects

BACKGROUND

Transcatheter closure of perimembranous ventricular septal defects is one of the greatest challenges in interventional cardiology. Short- and midium-term follow-up data for large samples are limited. This report presents our experience with transcatheter closure of perimembranous ventricular septal defects using an occluder.

METHODS

Two hundred fifty-three patients included in the database of the Second Affiliated Hospital and Yuying Children's Hospital from January 2011- December 2015 with transcatheter closure of perimembranous ventricular septal defects and discharged from follow-up. All patients were invited for clinical and transthoracic echocardiography, electrocardiogram, and thoracic radiography check-up.

RESULTS

Device implantation was successful in 252 of 253 patients (99.6%). The median age was 42 months (range 27-216 months). The median follow-up duration was 36 months (range 6-60 months). The mean defect diameter was 3.5 ± 1.4 mm and the mean size of the ventricular septal defect rim below the aortic valve was 3.7 ± 1.8 mm. The mean diameter of the devices used was 4 mm. Thirty-seven patients developed arrhythmia after the procedure and recovered within 24 months; four patients had hemolysis and four had moderate tricuspid valve regurgitation. No other serious adverse event occurred during the follow-up period.

CONCLUSION

Transcatheter closure of perimembranous ventricular septal defects using an occluder is safe and effective in most patients.

A Retrospective Survey Comparing Suture Techniques Regarding the Risk of Permanent Epicardial Pacemaker Implantation After Ventricular Septal Defect Closure

Objective

The aim of this study is to compare the continuous and combined suturing techniques in regards to the needing epicardial pacing at the time of weaning from cardiopulmonary bypass (EP-CPB) and to evaluate permanent epicardial pacemaker (PEP) implantation in patients who had undergone surgical ventricular septal defect (VSD) closure.

Methods

This single-centre retrospective survey includes 365 patients who had consecutively undergone VSD closure between January 2006 and October 2015.

Results

The median age and weight of the patients were 15 months (range 27 days - 56.9 years) and 10 kg (range 3.5 - 100 kg), respectively. Continuous and combined suturing techniques were utilised in 302 (82.7%) and 63 (17.3%) patients, respectively. While 25 (6.8%) patients required EP-CPB, PEP was implanted in eight (2.2%) patients. Comparison of the continuous and combined suturing techniques regarding the need for EP-CPB (72% vs. 28%, P=0.231) and PEP implantation (87.5% vs. 12.5%, P=1.0) were not statistically significant. The rate of PEP implantation in patients with perimembraneous VSD without extension and perimembraneous VSD with inlet extension did not reveal significant difference between the suture techniques (P=1.0 and P=0.16, respectively). In both univariate and multivariate analyses, large VSD (P=0.001; OR 8.63; P=0.011) and perimembraneous VSD with inlet extension (P<0.001; OR 9.02; P=0.005) had a significant influence on PEP implantation.

Conclusion

Both suturing techniques were comparable regarding the need for EP-CPB or PEP implantation. Caution should be exercised when closing a large perimembraneous VSD with inlet extension.

Long-Term Follow-Up Study of Temporary Tricuspid Valve Detachment as Approach to VSD Repair without Consequent Tricuspid Dysfunction

Temporary tricuspid valve detachment improves the operative view of certain congenital ventricular septal defects (VSDs), but its long-term effects on tricuspid valve function are still debated. From 2002 through 2012, we performed a prospective study of 68 children (mean age, 1.28 ± 1.01 yr) who underwent transatrial closure of VSDs following temporary tricuspid valve detachment. Sixty patients had conoventricular and 8 had mid-muscular VSDs. All were in sinus rhythm. Seventeen patients had systemic pulmonary artery pressures. Preoperative echocardiograms showed trivial-to-mild tricuspid regurgitation in 62 patients and tricuspid dysplasia with severe regurgitation in 6 patients. Patients were clinically and echocardiographically monitored at 30 postoperative days, 3 months, 6 months, every 6 months thereafter for the first 2 years, and then once a year. No in-hospital or late death was observed at the median follow-up evaluation of 5.9 years. Mean intensive care unit and hospital stays were 1.6 ± 1.1 and 7.3 ± 2.7 days, respectively. Residual small VSDs occurred in 3 patients, and temporary atrioventricular block in one. After VSD repair, 62 patients (91%) had trivial or mild tricuspid regurgitation, and 6 moderate. Five of these last had severe tricuspid regurgitation preoperatively and had undergone additional tricuspid valve repair during the procedure. The grade of residual tricuspid regurgitation remained stable postoperatively, and no tricuspid stenosis was documented. All patients were in New York Heart Association class I at follow-up. Temporary tricuspid valve detachment is a simple and useful method for a complete visualization of certain VSDs without incurring substantial tricuspid dysfunction.

Tricuspid Septal Leaflet Detachment for Ventricular Septal Defect Repair in Adults

We report a 21-year-old patient with a ventricular septal defect (VSD) with an embolic vegetation on the tricuspid valve using a technique of septal leaflet detachment to facilitate the repair of the VSD. Although described in the pediatric patients, this technique has not been reported in adults. The technique of septal leaflet mobilization is described, along with other techniques of tricuspid leaflet mobilization that aid in VSD visualization and repair. Tricuspid leaflet detachment has application for adult surgeons repairing perimembranous, postinfarction, and iatrogenic VSD encountered in resection of subaortic stenosis.

Percutaneous Closure of Perimembranous Ventricular Septal Defect with Modified Double-disk Occluder: What Is the Outcome at 10-year Follow-up?

OBJECTIVE

Percutaneous closure of perimembranous ventricular septal defect is one of the greatest challenges in interventional cardiology. The long-term follow-up data are still limited. This report presents our experience in percutaneous closure of perimembranous ventricular septal defect with modified double-disk occluder.

DESIGN

The study is a retrospective analysis of cases from the Changhai Hospital clinic database.

SETTING

We reviewed the clinic database from December 2001 to December 2005.

PATIENTS

We included 117 patients who underwent percutaneous closure of perimembranous ventricular septal defects.

OUTCOME MEASURES

Procedural data and complications were assessed by an expert panel of cardiologists.

RESULTS

Device implantation was successfully accomplished in 113 of a total 117 patients (96.6%). The mean age was 31.1 ± 12.5 years (range 2-56 years). The patients were followed for a period of 86-134 months. The diameter of defect was 2-15 mm (mean 4.9 ± 2.9 mm). The ventricular septal defect rim below the aortic valve was 1-5 mm. The mean diameter of device used was 6.9 ± 3.7 (range 4-24 mm). Four patients presented complete atrio-ventricular block within 1 week after the procedure and recovered within 3 weeks. No other patient encountered serious adverse events during the follow-up.

CONCLUSIONS

Percutaneous closure of ventricular septal defect is safe and effective in most selected patients with modified double-disk occluder. Additional studies with larger cohorts and longer follow-up are needed to evaluate its safety.

Temporary Tricuspid Valve Detachment for Ventricular Septal Defect Closure: Is It Worth Doing It?

<p><b>Background:</b> Tricuspid valve detachment (TVD) may improve the access for closing certain ventricular septal defects (VSDs), but it has some potential risks. We aimed to study the benefits and drawbacks of this technique.</p><p><b>Methods:</b> The midterm outcomes of all 20 patients who underwent a TVD closure for VSD were reviewed and compared with a control group of 15 patients with VSD closure without TVD.</p><p><b>Results:</b> There was no significant residual shunt in either group at the last actuarial follow-up. Tricuspid regurgitation occurred in both groups (45% in the TVD group and 27% in the control group, <i>P</i> = .48). These lesions were considered insignificant in all patients. There were no atrioventricular blocks, and all patients were in sinus rhythm. The cardiopulmonary bypass times were significantly higher in the TVD group than in the control group (91.6 � 17.2 minutes versus 68.3 � 15.7 minutes, <i>P</i> ? .01), as were the aortic cross-clamping times (50.7 � 12.1 minutes versus 35.9 � 14.4 minutes, <i>P</i> ? .01).</p><p><b>Conclusion:</b> Our results, along with results from other series, suggest that TVD can be used effectively and safely for closure of certain VSDs.</p>

Percutaneous options for heart failure in adults with congenital heart disease

In the context of congenital heart disease (CHD), the complex biochemical and physiologic response to the pressure- or volume-loaded ventricle can be induced by stenotic and shunt/regurgitant lesions, respectively. A range of transcatheter therapies have recently emerged to expand the therapeutic potential of the more traditional surgical and medical interventions for heart failure in patients with CHD. Together, these complementary interventions aim to treat the growing patient population with adult CHD (ACHD). In this article, the most commonly used transcatheter interventions for heart failure in patients with ACHD are reviewed.

The Role of Tricuspid Valve Surgery in the Late Management of Tetralogy of Fallot

While surgical repair of tetralogy of Fallot (TOF) is generally associated with good early outcomes, late complications affect long-term survival and may require reoperation. Pulmonary regurgitation (PR) and tricuspid regurgitation (TR) may increase the risk of arrhythmias, reduced cardiac function, and sudden death. Tricuspid valve function can be compromised secondarily in the setting of PR or directly as a result of injury or alteration of the valve related to the original TOF repair. This article reviews the etiologic mechanisms, pathophysiological implications, and surgical interventions for TR. Effective management following TOF repair requires consideration of TR to optimize late outcomes.

Is the function of all cardiac valves after the arterial switch operation influenced by an associated ventricular septal defect?

A ventricular septal defect in transposition of the great arteries is frequently closely related to the cardiac valves. The valvar function after arterial switch operation of patients with transposition of the great arteries and ventricular septal defect or intact ventricular septum was compared. We analysed the function of all cardiac valves in patients who underwent the arterial switch operations pre- and post-operatively, 1 year after the procedure and on follow-up. The study included 92 patients - 64 with transposition of the great arteries/intact ventricular septum and 28 with transposition of the great arteries/ventricular septal defect. The median age at surgery was 5.5 days in transposition of the great arteries/intact ventricular septum (0-73 days) and 7.0 days in transposition of the great arteries/ventricular septal defect (4-41 days). Follow-up was 51.7 months in transposition of the great arteries/intact ventricular septum (3.3-177.3 months) and 55 months in transposition of the great arteries/ventricular septal defect (14.6-164.7 months). Neo-aortic, neo-pulmonary, and mitral valvar function did not differ. Tricuspid regurgitation was more frequent 1 year post-operatively in transposition of the great arteries/ventricular septal defect (n = 4) than in transposition of the great arteries/intact ventricular septum. The prevalence of neo-aortic regurgitation and pulmonary stenosis increased over time, especially in patients with transposition of the great arteries/intact ventricular septum. The presence of a ventricular septal defect in patients undergoing arterial switch operation for transposition of the great arteries only has a minor bearing for the development of valvar dysfunction on the longer follow-up.

Radial incision for ventricular septal defect with membranous septal aneurysm

Surgical exposure and accurate closure of a ventricular septal defect with a membranous septal aneurysm beneath the septal tricuspid leaflet carries a risk of tricuspid valve dehiscence and conduction disturbances when the septal leaflet is detached along the tricuspid annulus. To avoid these problems, we use a radial incision to expose and close perimembranous ventricular septal defects. We reviewed recent cases to determine the risks and benefits of this technique. From January 2005 through September 2008, 30 patients underwent closure of a perimembranous ventricular septal defect through a right atrial approach at our institution. The operation included radial incision of the membranous septal aneurysm to improve visualization of the perimembranous ventricular septal defect in 9 patients. There was no perioperative or late death. The operative and postoperative courses were uneventful in all cases. A residual leak was detected in only one patient. No patient had more than mild postoperative tricuspid valve insufficiency, none underwent reoperation, and no new arrhythmia or conduction disturbance was detected during follow-up. The radial incision for closure of a ventricular septal defect with a membranous septal aneurysm provides satisfactory exposure of the defect through the right atriotomy, for safe and accurate closure.

Catheters, wires, tubes and drains on postoperative radiographs of pediatric cardiac patients: the whys and wherefores

Surgical treatment of congenital heart disease has advanced dramatically since the first intracardiac repairs in the mid-20th century. Previously inoperable lesions have become the focus of routine surgery and patients are managed successfully in intensive care units around the world. As a result, increasing numbers of postoperative images are processed by departments of radiology in children's hospitals. It is important that the radiologist accurately documents and describes the catheters, wires, tubes and drains that are present on the chest radiograph. This article reviews the reasons for the placement and positioning of perioperative equipment in children who have surgical repair of atrial septal defect, ventricular septal defect or transposition of the great arteries. Also included are a brief synopsis of each cardiac anomaly, the surgical procedure for its correction, and an in-depth discussion of the postoperative chest radiograph including illustrations of catheters, wires, tubes and drains.

Surgical closure of a perimembranous ventricular septum defect with a running suture

A ventricular septum defect (VSD) is a common defect in congenital surgery, either isolated or associated with other malformations. Most of the defects are located around the membranous septum and hence are called 'perimembranous'. The less damaging approach to close them is certainly through an incision in the right atrium. In some trunco-arterial malformation, an incision in the infundibulum is necessary to connect the right ventricle to the pulmonary arteries. A perimembranous VSD can then also be closed using the same incision. The videos show the closure of a perimembranous VSD using these two common approaches. Although many surgeons opt for interrupted stitches reinforced with pledgets to close these defects, a running suture can also be used and, in our opinion, is a reliable and rapid alternative technique.

Permanent Pacemaker for Atrioventricular Conduction Block After Operative Repair of Perimembranous Ventricular Septal Defect

OBJECTIVES

This study sought to discover the incidence of permanent pacemaker (PPM) placement for atrioventricular conduction block (AV block) after operative repair of perimembranous ventricular septal defect (PMVSD) in a large multi-institutional database and in the subgroup of patients comparable to those considered for transcatheter device closure of PMVSD.

BACKGROUND

Atrioventricular conduction block is a complication of operative repair of PMVSD and of device closure of this defect. Earlier reports do not report the incidence of AV block by VSD type.

METHODS

The Pediatric Cardiac Care Consortium database was searched for all children who had operative PMVSD repair except those with abnormalities that increase risk of AV block. The patient group was searched for those with subsequent PPM placement for AV block. Demographic data and time to PPM placement were available for all patients.

RESULTS

Of 4,432 patients with PMVSD repair, 48 (1.1%) underwent PPM placement for AV block. The PPM group was more likely to have Down syndrome (41% vs. 18%; p < 0.001), was younger (mean age 14 vs. 26 months; p < 0.001), and had longer mean length of postoperative hospital stays (20 vs. 8 days; p < 0.001). The most significant risk factor for AV block was Down syndrome (odds ratio 3.62, 95% confidence interval 2.02 to 6.39; p < 0.005). Modal time to PPM placement was 7 days (range 0 to 4,078 days). Out of 1,877 patients comparable to those currently considered for device closure, 13 (0.8%) underwent PPM placement after PMVSD repair.

CONCLUSIONS

Operative AV block and PPM placement occurred in 1.1% of patients in the total group and in 0.8% of patients comparable to those considered for device closure of PMVSD. A PPM placement is more likely in patients with Down syndrome. These data should be considered as devices are developed and in the future when counseling families about options for PMVSD closure.

Anatomical Exposure of Ventricular Septal Defect

The ventricular septal defect approached through the right atrium is associated with inadequate exposure and thus difficulty in its closure. The retraction, to expose the defect, leads to distortion of anatomy and a limitation of space to operate. We propose a simple procedure of retracting sutures to expose the defect without this limitation.

Is complete heart block after surgical closure of ventricular septum defects still an issue?

BACKGROUND

A serious complication after surgical closure of ventricular septal defect (VSD) is complete heart block. In this retrospective study, we reviewed the incidence of complete heart block after surgical closure of a VSD at Great Ormond Street Hospital from 1976 to 2001 to identify any particular anatomic features that still predisposed patients to surgically-induced complete heart block and to provide anatomic guidelines to avoid this in future.

METHODS

Data were extracted from our local database for patients having (1) isolated VSD or VSD in the setting of (2) tetralogy of Fallot with pulmonary stenosis or (3) tetralogy of Fallot with pulmonary atresia; (4) absent pulmonary valve syndrome; (5 and 6) coarctation or interruption of the aortic arch; and (7) subaortic fibrous shelf. We carefully reviewed the operative notes from all patients with postoperative complete heart block to discover any predisposing anatomical reasons to explain the complication.

RESULTS

Two thousand seventy-nine patients had a VSD closure. Permanent complete heart block developed in 7 of 996 patients (0.7%) with an isolated defect and in 1 of 847 patients (0.1%) with tetralogy of Fallot. Four more patients had postoperative complete heart block.

CONCLUSIONS

Instances of iatrogenic complete heart block continue to occur after surgical VSD closure, either because of unexpected biological variations or because of unawareness of the disposition of the atrioventricular conduction axis in particular circumstances. This report emphasizes the latter aspect in details and suggests a risk of iatrogenic complete heart block of less than 1%.

Indications for Tricuspid Valve Detachment in Closure of Ventricular Septal Defect in Children

BACKGROUND

Different techniques have been described for tricuspid valve detachment to improve visualization in ventricular septal defect repair. Our hypothesis was that preoperative echocardiographic criteria are important in deciding which patients should undergo ventricular septal defect repair by tricuspid valve detachment, and patients who undergo this procedure may have a better surgical outcome than those who fulfilled the criteria but were actually operated on with the standard surgical approach.

METHODS

Between January 2000 and December 2004 we prospectively studied 179 patients scheduled for ventricular septal defect repair and criteria for tricuspid valve detachment were established. Of these, 84 patients did not have any criteria for tricuspid valve detachment and were classified as the control group (group 1). Ninety-five patients with at least one criterion for tricuspid valve detachment were intraoperatively divided by patients who underwent tricuspid valve detachment into group 2 (n = 41), and those who did not undergo tricuspid valve detachment into group 3 (n = 53).

RESULTS

Surgical complications occurred more frequently in group 3 (26%) as opposed to group 2 (10%) and group 1 (7%). Residual ventricular septal defect and atrioventricular block occurred only in group 3. Tricuspid regurgitation occurred in 15% of group 3 versus 9.8% of group 2 and 7.1% of group 1.

CONCLUSIONS

Preoperative criteria for tricuspid valve detachment can be established before repair of ventricular septal defect. Patients who had indications for tricuspid valve detachment who actually had detachment performed during repair had fewer postoperative surgical complications as opposed to patients who fulfilled the criteria but did not undergo detachment.

Transcatheter closure of perimembranous ventricular septal defects using the new Amplatzer membranous VSD occluder: results of the U.S. phase I trial

OBJECTIVES

This phase I study attempted to report the initial safety and efficacy results of transcatheter closure of perimembranous ventricular septal defects (PmVSDs) using the new Amplatzer Membranous VSD Occluder (AGA Medical Corp., Golden Valley, Minnesota) in the U.S.

BACKGROUND

The most common congenital heart disease is PmVSD. Surgical repair is widely accepted, but still carries a small but definite risk of morbidity and mortality.

METHODS

Between October 2003 and August 2004, a total of 35 patients with PmVSD underwent an attempt of transcatheter closure under transesophageal and/or intracardiac echocardiographic guidance. The median age was 7.7 years (range, 1.2 to 54.4 years) and median weight was 25 kg (range, 8.3 to 110 kg). The median Qp/Qs ratio was 1.8 (range, 1 to 4), and the median VSD size as assessed by echocardiography was 7 mm (range, 4 to 15 mm).

RESULTS

The attempt to place a device was successful in 32 patients (91%). The median device size used was 10 mm (range, 6 to 16 mm). The complete closure rates by echocardiography at 10 min (transesophageal/intracardiac), 24 h, 1 month, and 6 months (transthoracic) were 47% (15/32), 63% (20/32), 78% (25/32), and 96% (27/28), respectively. The median fluoroscopy time was 36 min (range, 14 to 191 min), and the median total procedure time was 121 min (range, 67 to 276 min). Three patients (8.6%) had serious adverse events of complete heart block, peri-hepatic bleeding, and rupture of tricuspid valve chordae tendineae. No other patient encountered serious adverse events during the follow-up.

CONCLUSIONS

Transcatheter closure of a PmVSD is technically feasible and seems safe enough in children over 8 kg in weight to warrant continuation of clinical trials to assess the long-term safety and efficacy.

Liberal use of tricuspid valve detachment for transatrial ventricular septal defect closure

BACKGROUND

Although temporary tricuspid valve detachment is useful for improved visualization of ventricular septal defect through right atriotomy, liberal use of this adjunct is not widely supported, mainly because of concerns about iatrogenic complications such as heart blocks and tricuspid valve dysfunction. The objective of this study was to determine whether liberal use of this adjunct can improve operative outcome.

METHODS

Between January 1997 and March 2002, trans-atrial closure of isolated ventricular septal defect (conoventricular or canal type) was performed in 87 consecutive patients. Tricuspid valve detachment was used in 4 out of 44 patients (prudent-use group) and 19 out of 43 patients (liberal-use group) in the first and second half of this period, respectively (p = 0.0002). Patient demographics and use of other surgical and cardiopulmonary bypass techniques remained virtually unchanged during this period.

RESULTS

In the prudent-use group, there was one operative death with prolonged bypass time and one residual defect that required reoperation; neither of these patients underwent tricuspid valve detachment. All other patients (both groups) were free from mortality and clinically significant complications, including heart block, tricuspid regurgitation, and residual defect. The liberal-use group had shorter cardiopulmonary bypass time than the prudent-use group (59 +/- 14 vs 67 +/- 22 minutes, p = 0.037).

CONCLUSIONS

Tricuspid valve detachment should be used liberally for moderate- or even low-difficulty exposure of ventricular septal defect, regardless of patient background, because it is a safe and effective adjunct that can improve speed, programmability, reproducibility, and reliability.

Detachment of the anterior leaflet of the tricuspid valve to expose perimembranous ventricular septal defects

BACKGROUND

Detachment of the septal leaflet of the tricuspid valve has been described for better access to perimembranous ventricular septal defects. Detachment confined to the anterior leaflet is less known, although it provides a better exposure of the subaortic area and puts less jeopardy on the conduction tissues.

METHODS

Data regarding 49 consecutive patients who had congenital perimembranous ventricular septal defect closure were retrospectively reviewed. Thirty-three patients (67%) underwent temporary detachment of the anterior leaflet of the tricuspid valve. The defect was closed with a Gore-Tex patch and a continuous suture. In 10 patients (29%), concomitant right ventricular outflow tract enlargement was performed. Follow-up was obtained in every patient (median time, 11 months; range, 2 to 26 months).

RESULTS

No early or late death occurred. Closure of the ventricular septal defect was complete, with no more than trivial residual jet leaks found in perioperative echocardiography. All patients were in sinus rhythm. The tricuspid valve never showed more than mild insufficiency after repair. No patient showed subaortic obstruction.

CONCLUSIONS

Detachment of the anterior leaflet of the tricuspid valve to expose the ventricular septal defect is a safe approach that allows rapid closure of the defect with a continuous suture and provides excellent results.

Tricuspid valve detachment for transatrial closure of ventricular septal defects

Tricuspid leaflet detachment improves visualization and accuracy of closure of ventricular septal defects via the transatrial route. Between July 1998 and March 2001, surgical correction was performed in 296 cases of isolated ventricular septal defect, 215 cases of tetralogy of Fallot, and 16 cases of double-outlet right ventricle. Of these, 132 patients (79 with isolated ventricular septal defect, 49 with tetralogy of Fallot, and 4 with double-outlet right ventricle) underwent transatrial repair with temporary detachment of tricuspid leaflets for ventricular septal defect closure. The septal leaflet was detached in most cases, with anterior or posterior leaflets being detached when indicated. Median duration of intensive care was 3.6 days, and median hospital stay was 7 days. There was no incidence of tricuspid regurgitation attributable to leaflet detachment, as confirmed by postoperative echocardiography. Reoperation was not required for a residual defect or tricuspid regurgitation. The benefits of temporary leaflet detachment for transatrial repair of various difficult defects far outweigh the risk of postoperative tricuspid regurgitation.