Surgical repair of infundibular ventricular septal defect and aortic regurgitation

Progression of aortic regurgitation following transcatheter closure of intracristal ventricular septal defects in children: a mid- to long-term follow-up study

Background

Early surgical closure is warranted to prevent aortic valve lesion and aortic regurgitation (AR) in intracristal ventricular septal defects (icVSDs). Experiences for transcatheter device closure of icVSDs are still limited. Our objectives are to investigate AR progression following transcatheter closure of icVSDs in children and to explore the risk factors for AR progression.

Methods and results

From January 2007 to December 2017, 50 children with icVSD who had successfully undergone transcatheter closure were enrolled. With 4.0 (interquartile range: 3.0-6.2) years of follow-up, AR progression was observed in 20% (10/50) of patients after icVSD occlusion, among which 16% (8/50) remained in mild level and 4% (2/50) evolved to moderate. None progressed to severe AR. Freedom from AR progression was 84.0%, 79.5%, and 79.5% at 1, 5, and 10 years of follow-up. A multivariate Cox proportional-hazards model revealed that x-ray exposure time [hazard ratio (HR): 1.11, 95% confidence interval (CI): 1.04-1.18, P = 0.001] and the ratio of pulmonary to systemic blood flows (HR: 3.38, 95% CI: 1.11-10.29, P = 0.032) were independent predictors for AR progression.

Conclusions

Our study suggested that transcatheter closure of icVSD in children is safe and feasible in mid- to long-term follow-up. No serious AR progression occurred after icVSD device closure. Greater left-to-right shunting and longer x-ray exposure time were both risk factors for AR progression.

Long-Term Outcomes of Surgical Repair for Ventricular Septal Defect in Adults

Data of the outcomes of ventricular septal defect (VSD) closure in adults are limited to establish recommendations. Therefore, we reviewed our experience with surgical VSD closure in adult patients. We retrospectively reviewed 152 patients who underwent surgical VSD closure between January 1996 and April 2020. The median age of the patients was 30.5 [interquartile range (IQR) 23.1-42.7] years. The median follow-up duration was 10.9 (IQR 4.8-16.1) years. VSDs were classified according to the Society of Thoracic Surgeons classification as type 2 (n = 66, 43.4%), type 1 (n = 59, 38.8%), and type 4 (n = 27, 17.8%). Aortic cusp prolapse (n = 86, 56.6%) and aortic valve regurgitation (AR, n = 75, 49.3%) were the most common indications for surgical closure. Four patients underwent late reoperation (2.6%) due to AR, infective endocarditis and residual VSD. In the log-rank test, preoperative trivial or more degree of AR (P = 0.004) and coronary cusp deformity (P = 0.031) was associated with late moderate or greater degree of AR. Preoperative moderate or greater AR was associated with reoperation (P = 0.047). Only concomitant aortic valve (AV) repair at the time of VSD closure was a significant risk factor for late significant AR progression in the multivariable analysis. VSD closure in adults can be performed with low mortality and morbidity rates. AR can progress after VSD closure because the aortic cusp may have irreversible damage from long-standing shunt flow exposure. We conclude that VSD with AV deformity or AR in adults should be treated aggressively before disease progression with irreversible damage occurs.

Usefulness of transaortic approach for a complex double-outlet right ventricle

Surgical procedures for double-outlet right ventricle with ventricular septal defect are based on rerouting the blood flow of the left ventricle to the aorta through the ventricular septal defect (VSD) with an intraventricular baffle. The right atriotomy is the most common approach combined with a right ventriculotomy in some cases, particularly in pulmonary stenosis association. However, in complex cases, this standard operative strategy may not provide an adequate exposure. We describe the transaortic approach as an alternative procedure to repair a complex case of double-outlet right ventricle (DORV) with subaortic stenosis.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s12055-021-01261-7.

Aortic valve repair in patients with ventricular septal defect

BACKGROUND

The aim of the study is to evaluate early and late clinical outcomes of patients undergoing the aortic valve repair in patients associated with ventricular septal defect and to analyze whether age is a risk factor predicting repair failure.

METHODS

All patients who were underwent aortic valve repair with concomitant ventricular septal defect closure from 2006 to 2018 were included and divided into two groups: less than 10 years (Group 1) and more than or equal to 10 years (Group 2).

RESULTS

About 159 patients were included (Group 1 = 92; Group 2 = 67). Overall median age was 8 years, 70% were males. The most common ventricular septal defect was perimembranous in both groups. Two patients in Group 2 had to undergo aortic valve replacement subsequently which resulted in early mortality. Univariable analysis showed prolonged ventilation (p < .001), postoperative intensive care unit stay (p = .019) as significant factors for early mortality. Estimated survival was 97.6% ± 2.4 at the end of 5 years and 10 years in Group 1 and 93.6% ± 3.6 in Group 2. Freedom from residual aortic regurgitation more than or equal to moderate at 5 years and 10 years was 85.6% ± 4.9 and 55% ± 13.8 in Group 1 and 76.9% ± 6.7 and 47.4% ± 12.2 in Group 2, however, it was not significant (p = . .084).

CONCLUSION

The aortic valve repair in patients with ventricular septal defect provides satisfactory early and late results in terms of mortality and need for reintervention in all age groups.

Laubry-Pezzi syndrome with aortic root dilatation treated with a bentall and De Bono procedure

Laubry-Pezzi syndrome is a clinical entity in which prolapse of an aortic valve cusp into a subjacent ventricular septal defect (VSD) due to Venturi effect results in progressive aortic valve insufficiency. Aortic valve prolapse is found in over 5% of children with VSDs, most commonly in association with supracristal VSDs, and the risk of development of aortic regurgitation increases during childhood, peaking at 5 to 10 years of age. The VSD closure eliminates the low-pressure zone that is the cause of ongoing aortic valve cusp deformity and, if performed early, prevents the development of aortic regurgitation. However, the management of this rare pathology is still a matter of some debate with respect to indications, operative techniques, and timing. We report the case of a patient with Laubry-Pezzi syndrome, originally operated on at six years of age for VSD closure and plasty between the left and the right aortic cusps. However, in the follow-up the patient developed severe aortic regurgitation and aortic root dilatation. Eventually, a Bentall and De Bono procedure was performed.