Aortic regurgitation associated with ventricular septal defects in adults. Clinical course, haemodynamic, angiographic and echocardiographic findings

Aortic valvar involvement in patients undergoing closure of ventricular septal defect via the pulmonary trunk

BACKGROUND

To determine how often the aortic valve is involved in doubly-committed ventricular septal defect in a surgical series, and when to intervene to minimize aortic valvar impediments.

METHODS

The defect was surgically closed in 415 patients via the pulmonary trunk, age at operation ranging from 2 months to 76 years old. In infants, pulmonary hypertension or pulmonary high flow was the exclusive indication. Any progressive deformity of the aortic leaflet or aortic regurgitation was an alternative principal indication in older children or adolescents. No additional manoeuvres were employed for the aortic root unless aortic regurgitation is more than slight. Otherwise, the aortic valve was repaired or replaced. When the sinus of Valsalva was significantly deformed or ruptured, the structure was surgically restored.

RESULTS

Significant aortic regurgitation or the ruptured sinus of Valsalva was increasingly found beyond the paediatric age. Bacterial endocarditis was seen in 8% of adults or adolescents. Silent herniation of the aortic leaflet was not uncommon after 4 years old, seen in more than 40% of patients. Need of aortic valvar repair was rare before 2 years old, and in approximately 10% between 2 and 15 years old. Freedom from reoperation was 89% at 10 years and 78% at 25 years after aortic valvar repair, and 91% and 84%, respectively, after replacement, versus 100% and 99.4%, respectively, after no additional valvar procedure.

CONCLUSION

Aortic valvar involvement was rare, and ventricular septal defect was closed without impediments, before 2 years old. Surgery should be arranged before any additional aortic valvar manoeuvre is needed.

Reoperations in adults with congenital heart disease: analysis of early outcome

BACKGROUND

Grown-ups with congenital heart disease (GUCH) are an increasingly important group of patients, with many requiring reoperations because of late complications or residual defects, correction after palliation, further palliation or heart transplantation.

METHODS

In order to identify perioperative risk factors, we have retrospectively analysed perioperative mortality and morbidity of 66 consecutive GUCH patients needing reoperations between July 1987 and December 2000 with a mean age of 28+/-12 (14.2-63.5) years and preoperative ejection fraction of 57+/-21%. Primary cardiac defects were LVOT pathology (17 patients), coarctation (10), Tetralogy of Fallot (TOF) (9), VSD (9), transposition of the great arteries (TGA) (7), Marfan syndrome (6), ASD (5) and others (3).

RESULTS

Reoperations included various aortic valve procedures (28), aortic replacements (16), ASD/VSD closures (16), conduits (11), RVOT procedures (8), coarctation repair (5), cardiac transplantation (3) or others (8). Early mortality was 7.6%. Serious postoperative complications occurred in 24%. Presence of cyanosis, heart failure, VSD, TGA, pulmonary atresia, correction after palliative surgery and number of previous operations were preoperative risk factors and duration of operation, cardiopulmonary bypass and aortic cross-clamp, core temperature, low output syndrome, use of epinephrine, pneumonia and ARDS, renal failure, dialysis and stroke perioperative risk factors for fatal outcome.

CONCLUSIONS

Reoperations in GUCH patients are mostly due to outflow tract lesions, coarctations and TOF. Perioperative risks remain important especially with cyanosis, TGA, pulmonary atresia and poor ventricular function. Therefore, close follow-up, timely referral for re-intervention and adequate perioperative management are mandatory to reduce perioperative risks and improve results.

Sudden death due to ventricular septal defect

Ventricular septal defects (VSD) are usually considered non-life-threatening, usually closing spontaneously or causing symptoms of congestive heart failure, which can be surgically treated in time to save the patient's life. Despite the usually benign clinical course of VSD, serious arrhythmias occur in 16-31% of patients. Sudden death accounted for one-third of all deaths in a series of medically managed patients and occurred in 4.2% of patients in a study of VSD and arrhythmias. Cardiac hypertrophy is the common denominator in all cases reported in detail of VSD-associated sudden death. We have encountered four cases of sudden unexpected death from VSD in infants ranging in age from 1 week to 3 and (1/2) months. In each case there was cardiomegaly and in one case there was pulmonary arteriolar medial thickening, with extension of smooth muscle into small intralobular vessels. In half of our cases the attending physician was sued for malpractice. We believe that VSD in infants and young children are potentially life-threatening malformations which warrant careful clinical follow-up.

Considerations in the surgical management of ventricular septal defect and aortic insufficiency--a case report

A 23-year-old man presented with progressive exercise-related dyspnea and easy fatigability. He gave a history of a murmur of aortic insufficiency since childhood. Cardiac catheterization demonstrated severe aortic insufficiency. At surgery the patient was found to have prolapse of the right coronary cusp into a significant supracristal ventricular septal defect. Repair was carried out with a Dacron patch closure of the septal defect and replacement of the valve with a 29-mm St. Jude valve. The patient recovered uneventfully and is fully active and employed 5 years later. Review of the literature documents that this is an uncommon lesion. The approaches to preoperative diagnosis include transesophageal echo. The management techniques have included ventricular septal defect closure, alone and with valvuloplasty, and septal defect closure with aortic valve replacement. The anatomic and patient characteristics guide selection of the most suitable management of these patients.

Usefulness of color-flow Doppler in diagnosing and in differentiating supracristal ventricular septal defect from right ventricular outflow tract obstruction

Color-flow Doppler is used for special localization of cardiac flows. The transeptal jet in supracristal ventricular septal defect (VSD) is directed toward the pulmonary valve and is often difficult to distinguish from the right ventricular (RV) outflow tract flow. Pulsed- and continuous-wave Doppler can misread the VSD jet as a stenotic lesion in the RV outflow tract. This study describes the color-flow Doppler characteristics of supracristal VSD and determines if color-flow Doppler can differentiate supracristal VSD jets from RV outflow tract flow. The study group comprised 28 patients ranging in age from 3 days to 23 years (mean 6.4), with catheter-diagnosed supracristal VSD in 14, isolated pulmonary valve stenosis in 10 and RV infundibular obstruction in 4. The echocardiographic Doppler and color-flow Doppler data of all patients were reviewed without knowledge of catheterization diagnosis. In all patients with supracristal VSD, color-flow Doppler revealed an abnormal transeptal jet directed toward the pulmonary valve that occurred 5 to 10 ms before RV outflow tract flow was identified. VSD and RV outflow tract jet could be differentiated by pulsed- and continuous-wave Doppler alone in 10 of 14 patients (71%). In 4 patients, differentiation was possible only with color-flow Doppler and electrocardiographic gating. Associated aortic regurgitation, or a fistula, or both, were detected in 6 patients. Pulsed- and continuous-wave Doppler with or without color-flow Doppler correctly identified the level of obstruction in all patients with RV outflow tract lesions (14 of 14). Supracristal VSD jet occurs in early systole and is directed toward the pulmonary valve.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term follow-up in isolated ventricular septal defect considered too small to warrant operation

An isolated ventricular septal defect (VSD) was diagnosed in 70 patients (39 men and 31 women, mean age 29 years, range 10-64 years). Surgery was judged unnecessary. The follow-up period was at least 10 years, or until death or 31 December 1988, comprising a mean duration of 21 (range 6-29) years. The mortality was 11/69 (one lost to follow-up), and was not significantly higher than in a matched 'normal' group. Six deaths were cardiac, four of which could probably be related to the VSD. The follow-up study revealed that: (1) 14 (22%) subjects had major, VSD-related complications, and cardiac surgery was indicated in eight patients; (2) six (10%) had minor complications. By the end of 1988, 24% of subjects had significant dyspnoea, 22% had chest pain and 19% used cardioactive drugs. Only 33% were receiving regular cardiac control in a hospital. Thus unoperated adults with a small VSD should be monitored closely, since this condition is far from benign.

Long follow-up (to 43 years) of ventricular septal defect with audible aortic regurgitation

From 1946 to March 1989, 92 patients (33 women and 59 men) were seen with ventricular septal defect (VSD) and audible aortic regurgitation (AR). The VSD was subcristal in 62 patients, subpulmonary in 21 and unknown in the remaining 9. The median age of onset of AR was 5.3 years. The risk of developing AR was 2.5 times greater in those with a subpulmonary VSD. The aortic valve was tricuspid in 90% and bicuspid in 10%. Prolapse was seen in 90% of those with subcristal VSD and in all with subpulmonary VSD. Pulmonary stenosis was seen in 46% of the patients with gradients ranging from 10 to 55 mm Hg. The incidence of infective endocarditis was 15 episodes/1,000 patient years. Among 20 patients followed medically, for 297 patient years, 1 died (1959) and most have been stable, including 2 followed for greater than 30 years. In the 72 patients operated on, there were 15 perioperative and 5 late deaths. Operations consisted of VSD closure alone in 7, VSD closure and valvuloplasty in 50 and VSD closure and aortic valve replacement in the other 15. Valvuloplasty was more effective in those operated on under age 10 compared to those older than 15 years (46 vs 14%). The durability of the valvuloplasty was 76% at 12 years and 51% at 18 years.

Doubly committed subarterial ventricular septal defects: echocardiographic features and surgical implications

Doubly committed subarterial (supracristal, subpulmonary) ventricular septal defects are often complicated by aortic regurgitation resulting from aortic valve herniation into the defect. The clinical, echocardiographic and catheterization findings in 48 patients aged 0.3 to 46.4 years (median 9.5) with a doubly committed subarterial ventricular septal defect were reviewed. Aortic valve herniation was present in 38 (79%) and 55% of these had aortic regurgitation. The prevalence of both findings increased gradually with advancing age. The defect was closed surgically in 41 patients. Surgery during the first 2 years of life (median 0.4 year) was performed in 13 patients (group I), mainly because of a large shunt with a pulmonary to systemic flow ratio (Qp/Qs) 3.8 +/- 1.4 (mean +/- SD). Aortic regurgitation was present preoperatively in two patients (15%), persisted postoperatively in one patient and did not develop in any after repair (median duration of follow-up 2.3 years, range 0.1 to 7.4). In the other 28 patients (group II) surgery was performed between 4.8 and 46.4 years of age (median 11.5). These patients were generally less symptomatic and had a smaller shunt (Qp/Qs 1.5 +/- 0.5, p less than 0.001). Preoperative aortic regurgitation was present in 18 (64%). It persisted in 15 postoperatively, but in 13 of these it had diminished. Two-dimensional echocardiography in multiple views identified the site of the ventricular septal defect in all patients. Serial echocardiographic examinations demonstrated the progressive nature of aortic valve herniation, the partial occlusion of the defect by the herniated sinus and the development of aortic regurgitation. These findings suggest that timely surgical closure of these defects may prevent aortic regurgitation.

Social function of adults with isolated ventricular septal defects. Possible negative effects of surgical repair?

Possible long-term deterioration of social function has been studied in adults over 30 years of age with congenital, isolated ventricular septal defects (VSD). This deterioration may possibly have been caused by brain damage connected with open heart surgery performed after age 10 years. Thirty-five patients with a mean age of 39 (range 31-61) years have been followed up for an average of 15 (3-21) years when restudied after surgical repair of VSD performed at a mean age of 23 (10-51) years (Group 1). Their social status was compared with 61 non-operated subjects with basically smaller defects, mean age 43 (31-73) years, who had been followed up for an average of 14 (3-21) years. Group 1 had a higher educational level, were less stressed at work, had a higher gross income (NS) and were less physically disabled (p less than 0.01). Both groups had a higher educational level than normal 40-year-old Norwegians. The percentages receiving disablement pension were 12% in group 1 and 13% in group 2. Despite a higher abortion rate (33% vs. 18%), group 1 females had a higher number of liveborn babies than those in group 2 (NS). Regular medical check-ups were attended by 45% and 60% in groups 1 and 2 respectively, and about half took antibiotics prophylactically. Unlike when initially investigated, group 1 had a better cardiac condition than group 2. Compared with the non-operated group, the operated patients had suffered no detrimental effects on their social function. We therefore advocate a liberal policy for surgical repair of VSD after age 10 years.