Ventricular septal defect with aortic insufficiency

Progressive Reinvention or Destination Lost? Half a Century of Cardiovascular Tissue Engineering

The concept of tissue engineering evolved long before the phrase was forged, driven by the thromboembolic complications associated with the early total artificial heart programs of the 1960s. Yet more than half a century of dedicated research has not fulfilled the promise of successful broad clinical implementation. A historical account outlines reasons for this scientific impasse. For one, there was a disconnect between distinct eras each characterized by different clinical needs and different advocates. Initiated by the pioneers of cardiac surgery attempting to create neointimas on total artificial hearts, tissue engineering became fashionable when vascular surgeons pursued the endothelialisation of vascular grafts in the late 1970s. A decade later, it were cardiac surgeons again who strived to improve the longevity of tissue heart valves, and lastly, cardiologists entered the fray pursuing myocardial regeneration. Each of these disciplines and eras started with immense enthusiasm but were only remotely aware of the preceding efforts. Over the decades, the growing complexity of cellular and molecular biology as well as polymer sciences have led to surgeons gradually being replaced by scientists as the champions of tissue engineering. Together with a widening chasm between clinical purpose, human pathobiology and laboratory-based solutions, clinical implementation increasingly faded away as the singular endpoint of all strategies. Moreover, a loss of insight into the healing of cardiovascular prostheses in humans resulted in the acceptance of misleading animal models compromising the translation from laboratory to clinical reality. This was most evident in vascular graft healing, where the two main impediments to the in-situ generation of functional tissue in humans remained unheeded–the trans-anastomotic outgrowth stoppage of endothelium and the build-up of an impenetrable surface thrombus. To overcome this dead-lock, research focus needs to shift from a biologically possible tissue regeneration response to one that is feasible at the intended site and in the intended host environment of patients. Equipped with an impressive toolbox of modern biomaterials and deep insight into cues for facilitated healing, reconnecting to the “user needs” of patients would bring one of the most exciting concepts of cardiovascular medicine closer to clinical reality.

Single cusp replacement in patients with ventricular septal defect and aortic insufficiency

OBJECTIVE

The aim of this study was to analyze the mid- and long-term outcome of single cusp replacement in patients with ventricular septal defect and aortic insufficiency.

METHODS

From September 2005 through March 2014, 172 patients underwent single cusp replacement and ventricular septal defect (VSD) closure. The median age was 19.5 years (range, 9 months to 67 years). Additional techniques were used to repair associated anomalies including sinus of Valsalva aneurysm, patent ductus arteriosus, patent foramen ovale, subaortic membrane, and intramural coronary artery.

RESULTS

One patient with large left ventricle (preoperative end-diastolic diameter: 9.8 cm) died after the procedure from incurable heart failure. Four patients required a second pump run for residual aortic insufficiency (AI) (two patients, 1.16%) and residual VSD (two patients, 1.16%). Four patients required re-exploration for postoperative bleeding or cardiac tamponade. Mean follow-up was 53.27 ± 25.37 months (median, 56.5 months; range, 3 to 104 months). Redo aortic valve surgery was performed in three patients. Three patients had moderate-severe AI during the following period without reoperation. There was no post-operative endocarditis.

CONCLUSION

Single cusp replacement can be safely used in patients with VSD-AI.

Suspension string: a new method of aortic valvuloplasty for aortic insufficiency and ventricular septal defect

In a 4-year-old boy with ventricular septal defect, severe aortic insufficiency, and mild infundibular stenosis, a new method was used to reconstruct the prolapsed aortic cusp. Two ends of a pledged stitch were passed through the aorta at each side of the right, noncoronary commissure and then through another pledget, and were then tied repeatedly in a row. The length of the row of knots was equal to that of the free edge of left coronary or noncoronary leaflet. The remainder of the stitch was passed through a pledget and then the aortic wall at each side of the left and right coronary commissure to the extraaortic wall pledget and were tied. A suspension string was formed by the row of knots and supported by a Teflon (Dupont Teflon, Wilmington, DE) felt pledget sandwich at each of two commissures. The free margin of the prolapsed cusp was attached to the suspension string by a continuous suture. The concomitant anomalies were corrected. The result was satisfactory.

Doubly committed subarterial ventricular septal defect with severe aortic regurgitation: the "two-patch" technique

Doubly committed subarterial ventricular septal defect complicated by severe aortic regurgitation caused by a prolapsed aortic cusp still represents a challenging surgical problem. We report on our "two-patch" technique, were the ventricular septal defect is closed through the aortic valve by a patch anchored to another patch through the prolapsed cusp. This second patch is pulled up with the prolapsed cusp and is then fixed to the aortic wall. Since May 1990, 15 patients with a mean age of 12 years underwent repair of this cardiac malformation with the "two-patch" technique. The aortic regurgitation was severe in all patients. All patients survived. In a mean follow-up of 10 years, two patients were successfully reoperated for progression of the aortic regurgitation. All the remaining patients were in NYHA functional class I. In conclusion, the "two-patch" technique is simple, easily reproducible, and can be a valid surgical option for this complex cardiac malformation.

Anatomic correction of the syndrome of prolapsing right coronary aortic cusp, dilatation of the sinus of Valsalva, and ventricular septal defect

BACKGROUND

Although the syndrome of ventricular septal defect and aortic regurgitation was described a long time ago, there is still no agreement about the anatomic and functional components of the syndrome and the optimal methods of management.

OBJECTIVE

Our objective was to describe a new simple technique of anatomic correction of all the components of the syndrome, based on redefining the salient anatomic and functional features of the syndrome.

METHODS

Anatomic correction of the syndrome is achieved through a transaortic approach with the placement of a series of pledget-supported mattress sutures using autogenous pericardium. The sutures are used to close the ventricular septal defect, plicate the aortic sinus, and correct the outward and downward displacement of the anulus of the aortic valve. The technique is designed to correct all the anatomic functional components including severe aortic regurgitation when present.

RESULTS

Between 1972 and 1996, 46 patients with this syndrome underwent surgical treatment. The current technique was used in most of the patients operated on before 1981 and in all patients since that date. There were no early or late deaths during a follow-up period varying from 3 months to 24 years (mean 8.4 years). Aortic regurgitation was abolished in 16 and improved in the remaining patients, The hemodynamic results have been maintained except in five patients operated on early in the series, in whom additional procedures on the cusps were performed.

CONCLUSIONS

Anatomic correction of all the components of the syndrome of prolapsing right coronary cusp, dilatation of the sinus of Valsalva, and ventricular septal defect, can be achieved by a very simple technique. This technique can be applied in young children and prevents progression and secondary changes. Early correction in all patients with this syndrome is warranted.

Transaortic approach has a role in the surgical treatment of ventricular septal defects

A transaortic approach was used for surgical closure of ventricular septal defects (VSDs), sometimes as first choice and otherwise as an alternative approach. This paper presents the experience in a group of 124 patients who underwent VSD closure by a transaortic approach in an 18-year-period, between 1974 and 1992. Patients were divided in three groups: (I) Isolated VSD, 89 patients (mean age 7.6 years); (II) VSD associated with other malformations, 27 patients (mean age 10.8 years); and (III) recurrent VSD, eight patients (mean age 15.6 years). Two deaths occurred in the postoperative period (2/124), one after closure of VSD in a patient with severe pulmonary hypertension; another death was observed after transaortic closure of the VSD as part of the repair of a complex heart malformation. There were no instances of new right bundle branch block (RBBB) in the group operated on for isolated VSDs. Three cases of left bundle branch block (LBBB) (3.4%) occurred in the isolated VSD group. There were no cases of complete aortic valve (AV) block in the whole series and no instances of AV dysfunction. The transaortic approach is an alternative for the surgical treatment of ventricular septal defects. The ease of exposure and closure of defects suggest this technique to be a particularly attractive approach in the treatment of small to moderate-sized VSDs and also in recurrent VSDs.

Intraoperative TEE assessment of ventricular septal defect with aortic regurgitation

BACKGROUND

It is desirable to repair but not replace the aortic valve in patients with ventricular septal defect and acquired aortic regurgitation. Precise definition of the valvar pathology with monitoring of its repair perioperatively would enhance the surgical management of this condition.

METHODS

Fourteen consecutive patients (age, 10.6 +/- 6 years; weight 29.7 +/- 5.7 kg) who underwent repair of ventricular septal defect with aortic regurgitation were studied by intraoperative transesophageal echocardiography. The severity of prolapse of each of the individual aortic cusps and its adjacent sinus was assessed and the valvar regurgitation quantified by Doppler-derived regurgitant indices. The echocardiographic and surgical findings were correlated and the preoperative and postoperative echocardiographic data were compared to assess the effectiveness of operation.

RESULTS

Eight subarterial and six perimembranous defects were located accurately and their sizes (11.8 +/- 3.0 mm) correlated well (r = 0.80) with the surgical measurements. Transesophageal echocardiography detected prolapse of the aortic valve and its sinus in all 14 patients. The severity of the prolapse was severe in 10, moderate in 4, and mild in 5 leaflets. One the basis of these findings, together with the Doppler-derived mean regurgitant indices, exploration of the valve and valvuloplasty were executed appropriately in 12 of 14 patients. In all 14 patients, transesophageal echocardiography after bypass revealed no further cuspal prolapse and significant reduction of the mean regurgitant index (0.55 +/- 0.23 to 0.17 +/- 0.15, p < 0.0001). Residual ventricular septal defect was detected in 5 patients and the only patient with significant shunting who required reexploration was identified correctly.

CONCLUSIONS

Intraoperative transesophageal echocardiography can assess effectively the surgical repair of ventricular septal defect with aortic regurgitation and provide information that directs and alters surgical plans to the benefit of patients.

Present status of reconstructive surgery for aortic valve disease

Most surgical techniques for reconstruction of the aortic valve, although described a long time ago, are now feasible with satisfactory results. The general surgical principles for successful reconstruction, and the operative techniques of annuloplasty, commissurotomy, free edge resuspension, unrolling and thinning, and cusp extension are described. Methods for intraoperative evaluation of the repaired valve are also described. Between August 1988 and April 1992, 166 patients underwent aortic valve reconstruction with a 3.2% hospital and 1.2% late mortality. There were no thromboembolic events in the patients with isolated aortic valve repair. The reoperation rate was 6.5%. Echocardiographic study at last follow-up showed stable results at 4 years maximum follow-up.

Infundibular septal defect with severe aortic regurgitation: a new surgical approach

Aortic regurgitation associated with prolapse of an aortic cusp and an infundibular septal defect is caused by the lack of anatomical support for the aortic annulus by the conal septum. This fact is taken into consideration in the new surgical approach that we performed in 5 children 3 to 16 years of age with infundibular ventricular septal defect and severe aortic regurgitation. The ventricular septal defect is closed by a patch anchored to another patch through the prolapsed cusp. This second patch is pulled up with the prolapsed cusp and is then fixed in the aortic wall. In all 5 patients, all clinical signs of aortic insufficiency disappeared, and only minimal aortic regurgitation could be demonstrated by color Doppler mapping.

Methods for repair of simple isolated ventricular septal defect

One hundred fifteen consecutive patients underwent repair of a variety of "isolated" simple ventricular septal defects (VSD), from February 1985 through December 1989. In no patient was a ventriculotomy required to accomplish the ventricular septal defect closure. There were no instances of permanent complete atrioventricular dissociation, and there have been no reoperations for residual or recurrent VSD. Postoperative echocardiographic and Doppler studies were performed in each patient and revealed good surgical results. There was one hospital death. The technical strategies used to accomplish the repair are described. These include methods for transatrial, transaortic, and transpulmonary approach to VSD closure. Enabling methodologies described include detaching the septal leaflet of the tricuspid valve to enhance VSD exposure in patients wherein the defect is obstructed by the tricuspid valve with "aneurysm of the membranous septum." Also, splitting of the VSD patch in order to manage tricuspid valve chordal straddling is outlined.

Surgical treatment of supracristal type of ventricular septal defect

Surgically treated ventricular septal defect (VSD) was of supracristal type in 120 of 389 Chinese patients; 93 of the 120 were younger than 15 years. Concomitant aortic anomalies were present in 58 of the patients (regurgitation in 23 and cusp prolapse in 35). Corresponding figures among the 93 patients of the under-15 group were 40 (9 + 31). Direct suture or patch closure of the supracristal VSD and replacement or plication of anomalous aortic valves were the methods used. The results of direct closure were equal to those of patch closure. One patient died of subacute bacterial endocarditis, which had been present preoperatively. There were no other deaths. The postoperative observation period was 6 months to 7 years. As the incidence of associated valvulopathy increases with patient age, early operation for supracristal VSD, regardless of shunt volume, is advocated.

Long-term follow-up after aortic valvuloplasty and defect closure in ventricular septal defect with aortic regurgitation

The clinical course was studied in 25 patients with ventricular septal defect (VSD) and aortic regurgitation (AR) who had undergone aortic valvuloplasty and VSD closure. Twelve patients had a doubly committed subarterial VSD and 13 had a perimembranous type of VSD. Preoperatively, progressive hemodynamic disturbance after the onset of AR occurred in 11 patients (44%). The follow-up period extended from 6 months to 23 years (mean 10 years). Four patients required prosthetic valve replacement after valvuloplasty. One of these had had initial improvement of the AR but required valve replacement 20 years later; the condition of the other 3 did not improve initially and their valves were replaced 1 month to 8.5 years later. Four other patients had no initial improvement as a result of valvular reconstructive surgery, but the AR did not progress and remained hemodynamically well tolerated. Hence, the overall success rate of the valvuloplasty, defined as improving or preventing progressive AR, was 21 of 25 (84%). Since initial and long-term improvement in aortic valve function can be expected in most patients after valvuloplasty and closure of the VSD, early surgical intervention is recommended in patients with a VSD and AR.

Ventricular septal defect associated with aortic regurgitation

The effectiveness of aortic valvuloplasty and the indications for aortic valve replacement were examined in 76 patients with ventricular septal defect associated with aortic regurgitation. Results of this study indicate aortic regurgitation is associated with rapid deterioration and that aortic valvuloplasty should be performed as soon as aortic regurgitation is detected. The data also suggest that aortoplasty is indicated if aortic valvuloplasty alone is inadequate for coaptation of the aortic cusps with thickening.

Closure of a ventricular septal defect through the aortic valve: a note of caution regarding resultant narrowing of the aortic valve annulus

Closure of ventricular septal defects through the aortic valve annulus has been described for a variety of cardiac anomalies. This technique is most appropriate when simultaneous aortic valve replacement is anticipated. A continuous suture through the patch material may produce a purse-string effect upon the aortic valve annulus. The appropriate size of the aortic valve prosthesis should be determined after the closure of the ventricular septal defect is completed to avoid selecting one which may be too large.

Interventricular septal defect shown by left ventricular cine-angiocardiography

Images