A review of the therapeutic management of multiple ventricular septal defects

Evaluation of multiple ventricular septal defects using three-dimensional reconstruction models†

OBJECTIVES

Although there has been rapid development in the field of three-dimensional morphological analyses of congenital heart disease, with the three-dimensional volume-rendered images providing visualization of the external vascular anatomy, the precise reproduction of 'Swiss-cheese' ventricular septum is not well established. We created three-dimensional printed models and computer graphics based on multi-slice computed tomography of patients with complex multiple ventricular septal defects for surgical decision planning of this difficult cardiac defect.

METHODS

Seven patients with complex multiple ventricular septal defects were evaluated preoperatively using 3-dimensional printed models and computer graphics to plan therapeutic interventions.

RESULTS

The three-dimensional printed models detected muscular VSDs in 9 out of 15 (60%) regions. On the other hand, 3-dimensional computer graphics detected 10 out of 15 (67%) regions. The 3-dimensional printed models and computer graphics allowed the evaluation of the muscular ventricular septal defects from both the left and right ventricular aspects of the septum.

CONCLUSIONS

Our preliminary experiences suggest that three-dimensional printed models and computer graphics can help plan surgery in patients with complex multiple ventricular septal defects. Three-dimensional printed models allowed surgeons to understand the three-dimensional positioning of complex multiple ventricular septal defects preoperatively. High-quality three-dimensional computer graphics provided precise information about the size, shape and localization of muscular ventricular septal defects especially from the left ventricular side.

Predictive value of NT-pro BNP on outcomes of children with ventricular septal defect surgery

Background

Limited study has shown whether NT-proBNP is related to the prognosis of children wth ventricular septal defect (VSD) surgery. The study was conducted to determine the predictive value of NT-proBNP on outcomes of children with VSD surgery.

Methods

A total of 798 children with VSD surgery were enrolled, with NT-proBNP measured at preoperatively and 24-h postoperatively. The short- and mid-term clinical outcomes were recorded. Propensity scores (PS) was performed to acquire pre-op and post NT-proBNP 24-h PS-matched cohorts for comparisons between groups.

Results

In the pre NT-proBNP PS-matched cohort, the higher NT pro-BNP group had longer hospitalization time and lower post-op 1-month EF value compared with low NT pro-BNP group (all P < 0.05), and there wasn't significant difference of mechanical ventilation time, cardiopulmonary bypass (CPB) time, intensive care unit (CCU) stay, and ejection fraction (EF) values of 3 month to 12 months after surgery (all P > 0.05). In the post NT-proBNP PS-matched cohort, there wasn't significant difference of mechanical ventilation time, CPB time, CCU stay, hospitalization time, and EF values of 1 month to 12 months after surgery between two groups (all P > 0.05).

Conclusions

VSD children with higher pre NT-proBNP level had longer hospital stays after surgery than those with lower level. Pre NT-proBNP level had no effect on mechanical ventilation time, CPB time, ACC time and CCU stay and cardiac function after 3 months postoperatively. Post-op 24-h NT pro-BNP level wasn't associated with clinical outcomes.

The Surgical Significance of Phenotypic Variability in the Setting of Tetralogy of Fallot

The phenotypic feature of tetralogy of Fallot is anterocephalad deviation of the muscular outlet septum, or its fibrous remnant, relative to the septoparietal trabeculation, coupled with hypertrophy of septoparietal trabeculations. Although this feature permits recognition of the entity, no two cases are identical. Once diagnosed, treatment is surgical. The results of surgical treatment have improved remarkably over recent decades. The results are now sufficiently excellent, including those in the developing world, that attention is now directed toward avoidance of morbidity, while still seeking, of course to minimize any fatalities due to surgical intervention. It is perhaps surprising that attention thus far has not been directed on the potential significance of phenotypic variation relative to either mortality or morbidity subsequent to surgical correction. The only study we have found specifically addressing this variability focused on the extent of aortic override, and associated malformations, but made no mention of variability in the right ventricular margins of the interventricular communication, nor the substrates for subpulmonary obstruction. In this review, therefore, we assessed the potential significance of known morphological variability to the outcomes of surgical intervention in over 1,000 individuals undergoing correction by the same surgeon in a center of excellence in a developing country. We sought to assess whether the variations were associated with an increased risk of postoperative death, or problems of rhythm. In our hands, double outlet ventriculoarterial connection was associated with increased risk of death, while the presence of a juxta-arterial defect with perimembranous extension was associated with rhythm problems.

Occluder Device Removal and Total Septation of "Swiss-Cheese" Ventricular Septal Defects

"Swiss-cheese" ventricular septal defects present complex treatment challenges. Despite difficult defect visualization and closure, complete septation is the treatment of choice. We present the case of a 2-year-old with residual apical "Swiss-cheese" ventricular septal defects after failed percutaneous device closure with 2 occluder devices. Surgical removal of 1 device and primary closure of the defects via right apical ventriculotomy resulted in successful complete septation.

Surgical repair of "Swiss Cheese" ventricular septal defects with two-patch and right ventricular apex-exclusion technique: mid-term follow-up results

BACKGROUND

"Swiss Cheese" ventricular septal defects represent a serious congenital heart disease with suboptimal clinical outcomes and a lack of consensus regarding its management. This study presents mid-term follow-up results of surgical repairs for "Swiss Cheese" ventricular septal defects, utilizing the two-patch and right ventricle apex-exclusion technique.

METHODS

A retrospective review was conducted on 13 patients who underwent surgical repair utilizing the two-patch and right ventricle apex-exclusion technique at our institution between May 2014 and October 2021. The procedure involved the closure of defects in the outflow tract ventricular septal and the apex trabecular ventricular septal regions using two patches, with concurrent exclusion of the right ventricular apex from the right ventricular inflow tract.

RESULTS

Median follow-up was 4.9 ± 2.1 years (range: 2-9 years). All cases were successful without mortality or major complications. Two years post-surgery, cardiac magnetic resonance revealed median values for left ventricular ejection fraction, right ventricular ejection fraction, left ventricular end-diastolic volume and right ventricular end-diastolic volume of 63.9% ± 1.8% (range: 61-67%), 49.2% ± 2.6% (range: 46-55%), 39.15 ± 2.11 ml (range: 36.2-42.7 ml), 44.55 ± 3.33 ml (range: 38.7-48.6 ml), respectively. No thrombosis occurred. The latest echocardiography results confirmed normal cardiac function in all cases.

CONCLUSIONS

The surgical repair of "Swiss Cheese" ventricular septal defects utilizing the two-patch and right ventricle apex-exclusion technique is a viable approach with favorable mid-term outcomes. More cases and long-term follow-up results are needed to validate the feasibility and safety of this technique.

Multiple ventricular septal defects associated to anomalous venous returns, mitral valve disease, myocardium hypertrophy, and right outflow obstruction: a multimodality imaging assessment

We report a rare congenital heart disease characterized by multiple ventricular septal defects associated to anomalous systemic and pulmonary venous returns, marked apical myocardial hypertrophy of both ventricles and of right outflow, and hypoplastic mitral anulus. Multimodality imaging is mandatory to assess anatomical details.