Atrial Septal Defect vs Ventricular Septal Defect: Getting the Right Mix in Transposition of the Great Arteries

Transposition of the great arteries (TGA) is the second most common cyanotic congenital cardiac defect and affects around 4.7 in 10,000 live births. Patients present at birth with profound cyanosis due to inadequate oxygen delivery to the systemic circulation. Typical management after birth involves the administration of prostaglandins and oxygen while awaiting surgical repair. Balloon atrial septostomy may be performed depending on the adequacy of the interatrial communication. In this case report, we present a challenging case of TGA ventricular septal defect (VSD) and pulmonary stenosis (PS), demonstrating the importance of bedside clinical examination along with applying basic management principles. The patient underwent a right modified Blalock-Taussig-Thomas shunt (BTT) along with left pulmonary artery (LPA) reconstruction and main pulmonary artery band as an initial palliative procedure. The patient deteriorated post-operatively, with increasing desaturations and oxygen requirements. Though imaging suggested sufficient inter-circulatory mixing, the clinical picture of desaturation without respiratory distress and lack of response to oxygen and pulmonary vasodilatory therapy strongly suggested otherwise. The child therefore underwent a balloon atrial septostomy. Their clinical condition improved and they were discharged three days later. We describe this case's clinical course, medical and surgical management, and learning points.

Presentation of Complex Congenital Cardiac Anomalies in a Newborn Pediatric Patient: A Case Report

Tricuspid atresia, a critical congenital heart defect (CHD), accounts for approximately 1% of all cases of CHDs. When tricuspid atresia is coupled with numerous other unexpected congenital cardiac anomalies, a patient's condition becomes more serious and more complex. We present a case that demonstrates the stepwise approach to the holistic treatment of congenital tricuspid atresia in the presence of normally related great vessels, a large ventricular septal defect (VSD), atrial septal defect (ASD), and trivial patent ductus arteriosus (PDA). While expanding upon the implementation of chest X-ray imaging, serial transthoracic echocardiogram (TTE) imaging, and the balloon atrial septostomy (BAS) procedure, we also provide insight into the multidisciplinary team-based approach utilized for this patient's case. This case illustrates a rare critical CHD coupled with other, more common congenital anomalies, and suggests that with multidisciplinary management and treatment, it is possible the mortality rates associated with this diagnosis could decline.

The Unrepaired Tetralogy of Fallot: A Tale of Delayed Presentation and Limited Access to Care

Tetralogy of Fallot (TOF) is a common cyanotic congenital heart disease characterized by four distinct anatomical features. While surgical repair has significantly improved long-term outcomes, some individuals, particularly those from low socioeconomic backgrounds who lack access to medical care, may suffer from complications such as pulmonary hypertension (pHTN) and heart failure. We present a case report of a young female with unrepaired TOF who presented with acute-on-chronic hypoxic respiratory failure and heart failure, highlighting the complex nature and challenges associated with this condition.

Role of ECG in the Accidental Finding of an Atrioventricular Septal Defect in an Asymptomatic Patient Undergoing Cosmetic Surgery

Electrocardiogram (ECG) is an important diagnostic tool in identifying congenital heart disease (CHD), as demonstrated by this case of a 48-year-old female who presented for a preoperative evaluation for cosmetic surgery. ECG showed a right bundle branch block (RBBB) and first-degree atrioventricular (AV) block, and further testing revealed a primum atrial septal defect (ASD) with mitral valve anterior leaflet cleft and a membranous ventricular septal defect (VSD). She underwent successful surgical repair and was discharged home without complications. This case highlights the importance of performing additional tests like echocardiography or other imaging modalities in cases of abnormal ECG findings to accurately diagnose the underlying heart condition and ensure proper treatment.

Echocardiographic Study of Ventricular Septal Defect in 1- to 12-Year-Old Children Visiting a Tertiary Care Center in Patna, India

Background Symptoms of serious heart problems present at birth often appear during the first few days, weeks, or months of a child's life. Shunt formation between the left and right ventricle is a crucial component of the pathophysiology of ventral septal defects. Objectives We aim to determine the most frequent types of ventricular septal defect (VSD) by echocardiography and whether there is any gender variation in the type of ventricular septal defect. Material and methods A total of 100 children who were clinically suspected of or diagnosed with VSD at the age of 1-12 years were enrolled in this study. The septum of the atrioventricular (AV) canal, the muscular septum, and the parietal band of the distal conal septum were evaluated by color Doppler. Ventricular septal defect (VSD) size and kind are similarly impacted by the 2D echo mode. The size and site of the VSD, associated congenital anomaly, and significant morphological changes in ventricular cavities, gender discrimination, and relation-specific types of ventricular septal defect were observed. Results A total of 100 VSD children presented with clinical symptoms of fast breathing, retraction of the chest, cough, cyanosis, fever, difficulty during feeding, cyanotic spell, chest pain, and edema at 65%, 62%, 54%, 52%, 54%, 29%, 9%, 11%, and 4%, respectively. Conclusion Early diagnosis is essential for effective medical care of diseases such as infective endocarditis (IE), which is present in some cases of VSD, and the avoidance of persistent pulmonary veno-occlusive disease (PVOD).

Late Presentation of Acute Coronary Syndrome Complicated by Ventricular Septal Rupture

Acquired ventricular septal rupture (VSR) is a rare but potentially fatal complication of late-presenting myocardial infarction (MI). In the era of revascularization and reperfusion therapy, the incidence of VSR has significantly decreased. Ruptures occur predominantly in patients with late-presenting ST elevation MI. Patients may present with a wide variety of symptoms ranging from chest pain and mild hemodynamic instability to profound cardiogenic shock. Inotropes, vasopressors, and mechanical support with intra-aortic balloon pumps and extracorporeal membrane oxygenation can be used to bridge patients to surgery. Despite treatment with ventricular septal repair, postsurgical mortality remains high. There is a wide variety of complications that can occur in the postoperative period. A multidisciplinary approach is vital in these patients who develop VSR. Improving awareness among healthcare professionals regarding the symptoms of acute coronary syndrome can hopefully help prevent delayed presentation of patients to healthcare facilities.

Post-myocardial Infarction Ventricular Septal Defect in the Setting of No-Reflow and COVID

The occurrence of post-myocardial infarction (MI) ventricular septal defect (VSD) is a rare but life-threatening complication. This case report presents a unique case of a 49-year-old female patient with an anterolateral ST-segment elevation MI who underwent percutaneous coronary intervention (PCI) and drug-eluting stent (DES) placement, complicated by a no-reflow phenomenon in the distal left anterior descending artery (LAD) and subsequent development of a hemodynamically significant VSD. Notably, this case occurred during the COVID-19 pandemic, which added to the complexity of the patient's management. The patient's clinical course was further complicated by cardiogenic shock, acute respiratory failure, COVID-19 pneumonia, and gastrointestinal bleeding. Despite these challenges, the patient received prompt treatment and optimal medical management, including the use of vasopressor support, insulin therapy, and bicarbonate infusions. The patient also underwent surgical repair of the VSD at a quaternary center, resulting in a favorable outcome. This case report highlights the increased incidence of mechanical complications, such as VSD, during the COVID-19 pandemic due to delayed presentation and patient concerns about exposure to the virus. It also emphasizes the occurrence of a no-reflow phenomenon during PCI, which can lead to adverse outcomes, including larger infarct size and potential ventricular septal rupture. The case further underscores the importance of multidisciplinary collaboration and early subspecialist involvement in managing complex cases of post-MI VSD.

Outcomes of Surgical Repair of Tetralogy of Fallot: A Comparison Between the Adult and Pediatric Population

Introduction Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Early detection and timely treatment have provided successful repair of the anomaly in the developed world. However, in the developing world, there is still a burden of uncorrected TOF patients reaching adulthood. The goal of this study is to determine whether there is any difference in postoperative complications between adult and pediatric populations following surgical correction for TOF. Methods This study involved all those patients who received primary or secondary surgical repair for TOF in our facility between January 2017 and December 2020. The patients were split according to their age into the pediatric group if they were under 18 years and the adult group if they were 18 years or older. Patients with absent pulmonary valve or pulmonary atresia were not included in this study. Patients with large major aortopulmonary collateral arteries (MAPCA) were also excluded from this study. All patients underwent total correction through a median sternotomy approach. The ventricular septal defect was closed with a Bard knitted fiber patch. The right ventricular outflow tract (RVOT) was augmented by excising muscle bands or fibrous bands in the RVOT. If the annulus was smaller than the 3.5 z score, then a transannular patch was done using an autologous pericardium. The main pulmonary artery was augmented in every surgery using an autologous pericardial patch. All patients were shifted to the ICU on the ventilator and were extubated after fulfillment of the extubation criteria. Postoperative complications measured included re-opening, re-intubation, prolonged ventilation (>24 hours), and mortality within the index hospital admission. The clinical data of all patients were prospectively collected and analyzed using the chi-square test and t-test. A p-value of less than or equal to 0.05 was considered significant. Results The total number of patients was 134. This included 83 males (60.1%). A total of 114 patients who were aged below 18 years were included in the pediatric group, and 20 patients aged equal to or more than 18 years were included in the adult group. The mean average perfusion time in minutes in the adult group was 125.8 and in the pediatric group, it was 98.79. Similarly, the mean average of the cross-clamp time was also longer in the adult group at 89.55 minutes versus 69.63 minutes in the pediatric group. Overall, in the adult group, three (15%) patients had postoperative complications, while in the pediatric group, a total of 14 (11.9%) patients had postoperative complications (p = 0.001). However, there was no significant difference in the number of re-openings (8.5% vs. 10%; p = 0.8). The total mortality observed was 16 (11.59%). This included 14 (11.9%) in the pediatric group and two (10%) in the adult group. There was no significant difference between the two groups (p = 0.8). Conclusions Surgical repair of TOF can be performed in both adult and pediatric populations with acceptable outcomes. The mortality rate was found to be slightly greater in the pediatric population compared to the adults. However, it can be seen that the number of postoperative complications is greater in adults. Further research is needed to optimize outcomes for both pediatric and adult patients with TOF.

Postinfarction Ventricular Septal Ruptures During the COVID-19 Pandemic: Two Case Series

This case series highlights the occurrence of hemodynamically significant ventricular septal defects (VSDs) in two patients presenting with ST-elevation myocardial infarction (STEMI) during the COVID-19 pandemic. This paper aims to emphasize the delayed presentation of cardiac emergencies, such as STEMI, due to concerns about contracting COVID-19. This delay has led to an increased risk of rare complications, including VSD, associated with STEMI. The first case involves a 92-year-old male with a history of hypertension, hyperlipidemia, chronic kidney disease, and coronary artery disease. He presented with acute chest pain, and diagnostic tests revealed ST elevations and a VSD. Despite intervention efforts, including hemodynamic support, the patient's condition deteriorated, and he passed away due to advanced age and high surgical risk. The second case involves a 62-year-old female with a medical history of diabetes, hypertension, and hyperlipidemia. She presented with left-sided chest pain, and an angiogram revealed a mid-right coronary artery stenosis and a thrombus. During the procedure, the patient experienced hypotension, requiring hemodynamic support. Subsequent evaluations identified a large VSD with right ventricular dysfunction. The patient underwent a series of interventions, including a ventricular assist device and VSD closure, but experienced multi-organ failure and ultimately passed away. VSDs following acute myocardial infarction (MI) are rare but life-threatening complications. Early revascularization is crucial in preventing the development of VSDs. These cases demonstrate the importance of prompt diagnosis and intervention, as delayed presentation increases the risk of mechanical complications. Surgical closure remains the definitive treatment for postinfarction VSDs.

Sudden Cardiac Arrest in Patient With Ventricular Septal Defect and Marijuana Consumption: A Case Report and Review of Literature

This case report presents a detailed analysis of a 28-year-old woman who experienced sudden cardiac arrest (SCA). The patient had a history of marijuana consumption and was also diagnosed with a congenital ventricular septal defect (VSD) with no prior intervention or treatment. VSD is a common acyanotic congenital heart disease, which poses a constant risk of premature ventricular contractions (PVCs). During the evaluation, the patient's electrocardiogram PVCs and a prolonged QT interval were revealed. This study highlights the risk associated with the administration or consumption of drugs that can prolong the QT interval in patients with VSD. It also indicates that patients with VSD and who have a history of marijuana consumption should be cautioned about the risk of arrhythmias causing SCA due to prolonged QT interval caused by the cannabinoid. This case emphasizes the requirement of cardiac health monitoring in individuals with VSD and caution while prescribing medications that can affect the QT interval leading to life-threatening arrhythmias.

Utility of Fetal Magnetic Resonance Imaging After Ultrasound in Differentiating Dicephalic Dibrachius Dipus Twin Gestation From Craniopagus Parasiticus

Conjoined twins represent a very rare congenital anomaly, and the dicephalic dibrachius dipus (DDD) type of conjoined twinning is so rare that the exact prevalence is unknown. Only a few published case studies have mentioned this anomaly. Not enough data are available where antenatal ultrasonography (USG) and MRI have been employed in the workup of such cases. This study describes the case of a 24-year-old woman who came to our department for an anomaly scan at 25 weeks of gestation and was diagnosed with a dicephalic type of conjoined twinning with multiple anomalies. However, USG could not differentiate between DDD twinning and craniopagus parasiticus; hence, the patient was referred for fetal MRI. On MRI, the diagnosis of DDD was confirmed. In craniopagus parasiticus twinning, the surgical removal of the parasitic head can allow an everyday life. However, DDD twinning with multiple anomalies is not compatible with life, and the mother was thoroughly explained the grave prognosis. In such doubtful cases, fetal MRI should always be employed to ascertain the diagnosis for proper management and counseling.

Concomitant Single-Stage Unifocalization and Cavopulmonary Anastomosis (Glenn Shunt) in an Adolescent Patient With Univentricular Physiology and Major Aortopulmonary Collateral Arteries: A Technically Challenging Case

Long-segment pulmonary atresia (PA), non-confluent branch pulmonary arteries, ventricular septal defect, tricuspid valve atresia (type 1A), and single ventricle physiology is a relatively rare and extremely heterogeneous form of congenital heart disease. This subset of patients having pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries (MAPCAs) have to undergo multiple unifocalization staging operations before a complete repair is attempted. Most of the patients were deemed inoperable. We report a rare case of a concomitant single-stage unifocalization and cavopulmonary anastomosis (bi-directional Glenn procedure) in an adolescent cyanotic girl with tricuspid valve atresia (type 1 A), long-segment pulmonary atresia, non-confluent branch pulmonary arteries, bilateral patent ductus arteriosus, MAPCAs, and single-ventricle physiology. Reconstruction of the absent central pulmonary artery and non-confluent branch pulmonary arteries was achieved by dividing the bilateral patent ductus arteriosus feeding the bilateral pulmonary arteries.

Delayed Presentation During COVID-19 Pandemic Leading to Post-Myocardial Infarction Ventricular Septal Defect

Post-myocardial infarction ventricular septal defect (post-MI VSD) is a rare complication of ST-elevation myocardial infarction (STEMI) with an incidence of <1% in early revascularization era. Here we present the case of a 66-year-old woman with post-MI VSD owing to delay in her presentation in the current pandemic. Patient presented with worsening back pain and chest pain with confusion, and an EKG positive for inferior wall STEMI. She underwent emergent percutaneous intervention with placement of drug-eluting stent in her right coronary artery. She developed worsening heart failure and new-onset heart murmur and was found to have a VSD on a transthoracic echo. Because of her poor prognosis, family decided to pursue comfort care and patient unfortunately passed.

Delay in seeking health care during the pandemic, as seen in our patient, is multifactorial including fear of contracting infection, decreased emergency medical services members, and concerns for overburdening healthcare systems. Lack of standardized in-hospital approach to emergencies while ensuring adequate protection from infection to healthcare workers, especially during the initial phase of the pandemic, led to increased door-to-balloon times in addition to the increased time to first medical contact. The importance of media outreach ensuring availability of health care in emergencies, changing emergency response algorithms to ensure safety of patients and healthcare providers, and including thrombolytic therapy where there is a delay due to stringent screening or delayed COVID-19 testing can be used to prevent worsening complications following STEMI.

Complete Dissection of the Interventricular Septum Following Myocardial Infarction

In this report, we present a case of interventricular septal dissection (IVSD) following inferior wall myocardial infarction (MI) in a 64-year-old patient; the patient ultimately recovered after prompt resuscitation and intervention, despite the high mortality associated with these cases.

A 64-year-old male with a history of hypertension and obesity was brought to the hospital following an episode of syncope at home. He had been experiencing chest tightness over the past few days prior to the admission. On physical exam, he had a heart rate of 72 beats per minute and blood pressure of 73/52 mmHg. His electrocardiogram revealed ST-segment elevations in leads II, III, and aVF. Emergent coronary angiography revealed 100% occlusion of the right coronary artery (RCA) with no collateral supply and 95% stenosis of the left anterior descending (LAD) artery. Aspiration thrombectomy and balloon angioplasty and subsequent stenting of the RCA were performed. Transthoracic echocardiogram with color Doppler was performed, which confirmed the presence of a defect in the septum. Color Doppler demonstrated a clear jet entering the ventricular septum from the left ventricle (LV), with the jet traversing the entire length of the septum through a dissection and entering into the right ventricle (RV), consistent with complete IVSD. The patient subsequently underwent a successful bovine pericardial patch repair of the ventricular septum.

IVSD is a rare anomaly of the IVS. An echocardiogram is a useful tool to establish the diagnosis. The mortality rate after ventricular septal rupture remains high. Fortunately, our patient had interventricular dissection without rupture. Prompt surgical repair remains the choice of treatment for this condition.

A Rare Complication of Myocardial Infarction: Ventricular Septal Defect

Ventricular septal defect (VSD) is a rare but lethal complication of myocardial infarction. We present a case of a 65-year-old male who presented with a history of progressive shortness of breath associated with productive cough. Physical examination was significant for crepitation in both lower lung fields and bilateral lower extremity edema. Chest X-ray revealed bilateral reticular opacities with small bilateral pleural effusions. Polymerase chain reaction (PCR) for COVID was positive. Echo showed a left ventricular ejection fraction (LVEF) of 30-35%, ischemic cardiomyopathy, and muscular ventricular septal defects with left to right shunting and severely elevated pulmonary artery systolic pressure. Overtime during the hospital course, he developed respiratory and fulminant hepatic failure. Our patient had VSD due to an undiagnosed old myocardial infarction (MI). Initially heart failure was compensated and treated with medical management. Later on, he developed respiratory complications related to COVID-19 infection as well as hepatic failure in addition to a cardiomyopathy which made him a poor surgical candidate leading to death.

Paroxysmal ventricular tachycardia as a rare complication of interventional closure of ventricular spetal defect and its treatment by radiofrequency catheter ablation: A case report (CARE-compliant)

INTRODUCTION

Trans-catheter closure of peri-membranous ventricular septal defects (VSDs) using Amplatzer-Type devices, has been widely reported in the past decade. We hereby report a rare complication of frequent premature ventricular contractions (PVCs) and paroxysmal ventricular tachycardia (PVT) sustained 48 days after the closure of VSD.More importantly, the arrhythmias were successfully treated with radiofrequency catheter ablation (RFCA) after medical therapy failed to restore and maintain sinus rhythm.

PATIENT CONCERNS

We reported an 8-year-old boy with frequent PVCs and PVT sustained 48 days after the closure of VSD. The boy has no palpitation, chest distress and other uncomfortable symptoms.

DIAGNOSIS

This patient was diagnosed as frequent PVCs and PVT by Holter monitoring for 24 hours.

INTERVENTIONS

RFCA was administered.

OUTCOMES

The patient was discharged 48 hours with no complication and remained asymptomatic 12 months after the ablation.

CONCLUSION

Radiofrequency ablation helps treat PVCs and PVT in children and has a higher efficacy in restoring and maintaining sinus rhythm.

Comparisons of periventricular device closure, conventional surgical repair, and transcatheter device closure in patients with congenital ventricular septal defects: A Protocol for Systematic Review

BACKGROUND

Surgical treatments for ventricular septal defects (VSDs) mainly include 3 approaches: conventional surgical repair (CSR), transcatheter device closure (TDC), and perventricualr device closure (PDC). PDC has been introduced in over 10 years, although there remain concerns about adverse events. This network meta-analysis is to compare PDC, CSR, and TDC in the treatment of congenital VSD.

METHODS

We will search MEDLINE, EMBASE, Clinical Trials, Cochrane Library, and China National Knowledge Infrastructure databases for comparative studies on device closure and conventional repair for congenital VSDs to August 2019. A network meta-analysis with frequentist frame will be performed to compare the 3 approaches involving the success rate, in-hospital indexes, and incidences of complications, using risk ratio with 95% confidence intervals.

RESULTS

This study will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This network meta-analysis will assess the safety and efficacy of PDC, CSR, and TDC in the treatment of congenital VSDs, and provide more evidence-based guidance in clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42019125257.