Ventricular septal defect associated with aortic valve incompetence: results of two surgical managements

Effect of right anterolateral thoracotomy versus median sternotomy on postoperative wound tissue repair in patients with congenital heart disease: A meta-analysis

Right anterolateral thoracotomy (RAT) and median sternotomy (MS) are two major methods for treatment of congenital cardiac disease. But there are various types of surgery that provide a better operative outcome for the patient. Therefore, we carried out a meta-analysis to investigate the effects of these two methods in the treatment of wound tissue, hospitalization and so on, to find out which surgery method could provide the best short-term effect. In this research, we chose an English controlled trial from 2003 to 2022 to evaluate the influence of right anterolateral thoracotomy and median sternotomy on the short-term outcome of Cardiopulmonary bypass (CPB), time of operation, time spent in the hospital, and the time of scar formation. Our findings suggest that the RAT method was associated with a shorter surgical scars for congenital heart disease operations compared to MS with respect to post-operation scars (WMD, 3.55; 95% CI, 0.04, 7.05; p = 0.05). The RAT method is better suited to the needs of patients who care about their injuries. Nevertheless, in addition to other surgery related factors which might affect post-operative wound healing, we discovered that MS took a shorter time to perform CPB compared with RAT surgery (WMD, - 1.94; 95% CI, -3.39, -0.48; p = 0.009). Likewise, when it comes to the time taken to perform surgery, MS needs less operational time compared to RAT methods (WMD, -12.84; 95% CI, -25.27, -0.42; p = 0.04). On the other hand, the time needed for MS to recover was much longer compared to the RAT (WMD, 0. 60; 95% CI, 0.02, 1.18; p = 0.04). This indicates that while RAT is advantageous in terms of shortening the duration of post-operative scar, it also increases the time needed for surgical operations and CPB.

Anterolateral minithoracotomy versus median sternotomy for the surgical treatment of atrial septal defects: a meta-analysis and systematic review

Background

To compare the short-term safety and efficacy of right anterolateral minithoracotomy (ALMT) and median sternotomy (MS) for the surgical treatment of atrial septal defects (ASDs).

Methods

The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for comparative studies focusing on surgical repair of ASDs via ALMT or MS published up to the end of April 27, 2020. We used random-effect or fixed-effect models to obtain pooled estimates.

Results

A total of 7 publications, including 665 patients (ALMT 296 and MS 369), were included. Age (WMD: 1.80 years, 95% CI 0.31–3.29), weight (WMD: − 0.91 kg, 95% CI − 5.57 to 3.75), sex distribution (OR: 1.00, 95% CI 0.74–1.35) and surgical type (patch or direct closure) (OR: 1.00, 95% CI 0.67–1.49) were comparable in the ALMT group and MS group. No significant differences in the success rate (OR 0.23; 95% CI 0.05–1.07) or severe complication rate (OR 1.46; 95% CI 0.41–5.22) were found between the ALMT group and the MS group. In addition, the differences in the cardiopulmonary bypass (CPB) time (WMD 6.33; 95% CI − 1.92 to 14.58 min, p = 0.13) and the operation time (WMD 5.23; 95% CI − 12.49 to 22.96 min, p = 0.56) between the ALMT group and the MS group were not statistically significant. However, the ALMT group had a significantly longer aortic cross-clamp time (2.37 min more, 95% CI 1.07–3.67 min, p = 0.0003). The intubation time was 1.82 h shorter (95% CI − 3.10 to − 0.55 h; p = 0.005), the intensive care unit (ICU) stay was 0.24 days shorter (95% CI − 0.44 to − 0.04 days; p = 0.02), and the postoperative hospital stay was 2.45 days shorter (95% CI − 3.01 to − 1.88 days; p < 0.00001) in the ALMT group than in the MS group. Furthermore, the incision length was significantly shortened by 8.97 cm in the ALMT group compared with the MS group (95% CI − 9.36 to − 8.58 cm; p < 0.00001).

Conclusions

In the surgical treatment of ASD, ALMT and MS are equally safe and effective in terms of success rates and severe complication rates. The surgical procedures are equally difficult, but ALMT is associated with a faster functional recovery and better cosmetic results. Compared to MS, ALMT is the better choice for select ASD patients.

Aortic valve neocuspidization for aortic regurgitation associated with ventricular septal defect

 

OBJECTIVES

Different methods of aortic valve repair have been described in the literature for aortic regurgitation (AR) associated with doubly committed subarterial ventricular septal defects. Our goal was to present our experience with aortic valve reconstruction of a single leaflet using the aortic valve neocuspidization technique in this subset of patients.

METHODS

It is a retrospective review of 7 patients with doubly committed subarterial ventricular septal defects with significant (>moderate) AR who underwent the single-leaflet neocuspidization technique of aortic valve reconstruction from January 2016 to January 2019. Data were collected from medical records. All patients had thorough 2-dimensional echocardiographic assessment preoperatively and during the follow-up period. Primary end points were freedom from postoperative AR and freedom from reoperation and all-cause mortality within the follow-up period with secondary end points of freedom from thromboembolism and infective endocarditis.

RESULTS

Out of 7 patients, 6 were male and 1 was female. There were no perioperative deaths. The mean follow-up period was 2.6 ± 0.8 years. No deaths occurred during the follow-up period. At the latest follow-up examination, only 2 patients showed mild AR and were asymptomatic. There was no documented event of infective endocarditis or thromboembolism during the follow-up period.

CONCLUSIONS

The aortic leaflet neocuspidization procedure for the aortic valve is a relatively new concept. Availability of a template makes it an easily reproducible valve repair in paediatric patients with a single-leaflet abnormality. This technique preserves the remaining 2 normal leaflets, thus promoting the growth potential while maintaining near normal aortic root complex dynamics.

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.

Update on shunt closure in neonates and infants

Introduction: Cardiac defects that result in shunting are the most common types of congenital heart anomalies. Although these lesions can be simple, they can cause significant hemodynamic changes and can be challenging to manage in neonates and infants. Over the recent decades, the development of new transcatheter techniques and devices has made it safe and feasible to manage such defects when indicated, even in the smallest of patients. Understanding these interventional procedures is essential in order to manage those patients.Areas covered: In this article, we review the techniques and experience for closure of atrial septal defects, ventricular septal defects, patent ductus aarteriosus,as well as coronary arteriovenous malformations and fistulas in neonates and infants. Literature review of PubMed articles was performed through January 2021, with focus on the latest data and results of the usage of interventional techniques in treating these lesions specifically in this age-group.Expert opinion: Significant shunting lesions can be particularly challenging to manage in neonates and infants. Newer lower profile devices will likely continue to be developed in the future, allowing their use for transcatheter interventions in even smaller patients and those with more complex anatomy.

Patient-Specific CT-Based Fluid-Structure-Interaction Aorta Model to Quantify Mechanical Conditions for the Investigation of Ascending Aortic Dilation in TOF Patients

Background

Some adult patients with Tetralogy of Fallot (TOF) were found to simultaneously develop ascending aortic dilation. Severe aortic dilation would lead to several aortic diseases, including aortic aneurysm and dissection, which seriously affect patients' living quality and even cause patients' death. Current practice guidelines of aortic-dilation-related diseases mainly focus on aortic diameter, which has been found not always a good indicator. Therefore, it may be clinically useful to identify some other factors that can potentially better predict aortic response to dilation.

Methods

20 TOF patients scheduled for TOF repair surgery were recruited in this study and were divided into dilated and nondilated groups according to the Z scores of ascending aorta diameters. Patient-specific aortic CT images, pressure, and flow rates were used in the construction of computational biomechanical models.

Results

Simulation results demonstrated a good coincidence between numerical mean flow rate at inlet and the one obtained from color Doppler ultrasonography, which implied that computational models were able to simulate the movement of the aorta and blood inside accurately. Our results indicated that aortic stress can effectively differentiate patients of the dilated group from the ones of the nondilated group. Mean ascending aortic stress-P1 (maximal principal stress) from the dilated group was 54% higher than that from the nondilated group (97.97 kPa vs. 63.47 kPa, p value = 0.044) under systolic pressure. Velocity magnitude in the aorta and aortic wall displacement of the dilated group were also greater than those of the nondilated group with p value < 0.1.

Conclusion

Computational modeling and ascending aortic biomechanical factors may be used as a potential tool to identify and analyze aortic response to dilation. Large-scale clinical studies are needed to validate these preliminary findings.

Outcomes of closure of doubly committed subarterial ventricular septal defects in adults

BACKGROUND

Outcome data of doubly committed subarterial ventricular septal defect closure in adults are limited.

METHODS

A review was made of the inpatients >18 years of age who underwent doubly committed subarterial ventricular septal defect closure between June 2010 and June 2017.

RESULTS

The patients were categorised into two groups: The valve intervention group consisted of 31 patients who underwent aortic valvuloplasty, aortic valve replacement, or repair of sinus Valsalva aneurysm in addition to doubly committed subarterial ventricular septal defect closure; non-valvular intervention group comprised 58 patients who underwent only doubly committed subarterial ventricular septal defect closure. The groups did not differ by sex and age. Patients in the valve intervention group, with a larger ventricular septal defect size, were shorter and tended to be lighter. The valve intervention group had more patients with pneumonia perioperatively. No infective endocarditis and reoperation were noted during the study period. At last follow-up, 91 and 96.6% of the studied patients were free from left ventricle dilation and pulmonary hypertension. In patients without pre-operative aortic regurgitation, 12 developed new mild aortic regurgitation during the follow-up.

CONCLUSIONS

About 34.8% of adult patients with doubly committed subarterial ventricular septal defect required concurrent intervention on aortic valve or sinus Valsalva aneurysm. The midterm results of doubly committed subarterial ventricular septal defect closure in adult patients were favourable. However, the incidence of new mild aortic regurgitation after ventricular septal defect closure was high (27.3%). Long-term follow-up of aortic regurgitation progression is needed.

A meta-analysis of perventricular device closure of doubly committed subarterial ventricular septal defects

Background

To investigate the safety and efficacy of perventricular device closure of doubly committed subarterial ventricular septal defects (dcsVSDs).

Methods

PubMed and Scopus were searched for studies in English that focused on perventricular device closure of dcsVSDs and were published up to the end of September 2019. We used a random-effects model to obtain pooled estimates of the success and complication rates.

Results

A total of 9 publications including 459 patients with dcsVSDs were included. The median follow-up duration ranged from 2 months to 5 years, with the mean age of patients ranging from 6.1 months to 4.5 years. The pooled estimate of the overall success rate of device closure in the 9 studies was 0.89 (95% CI: 0.86–0.93, I² = 26.5%, P = 0.208). Further meta-regression analysis indicated no significant correlation between the success rate and the following factors: publication year, sample size, study type, mean age, mean weight, mean VSD size, and ratio of device size/weight. The pooled rate of postoperative aortic regurgitation was 0.045 (95% CI: 0.018–0.071, I² = 50.96%, P = 0.000). The pooled rate of follow-up aortic regurgitation (AR) was 0.001 (95% CI, − 0.003-0.004, I² = 63.00%, P = 0.009.) The pooled estimated rate of severe intraoperative complications was 0.106 (0.073–0.140, I² = 70.7%, P = 0.208). Postoperative and follow-up complications were rare. No occurrence of a complete atrioventricular block was reported up to the last follow-up visit.

Conclusions

Perventricular device closure may be an alternative to conventional surgical repair in selected patients with dcsVSDs. The success rate was stable regarding the publication year and sample size, suggesting a relatively short learning curve and the technique’s potential for application.

Ascending aortic dilation in adult patients with congenital ventricular septal defect: An observational study

Many adult patients with congenital ventricular septal defect (VSD) also developed ascending aortic dilation, but few report the clinical features and surgical management of these patients. This study was designed to study ascending aortic dilation in adult patients with congenital VSD, and summarized the treatment experience and prognosis.To assess the clinical features and surgical management, we performed a retrospective analysis on preoperative data, intraoperative data, and postoperative data from the adult patients with congenital VSD who developed ascending aortic dilation in our institution from February 2010 to December 2016.From February 2010 to December 2016, we operated on 13 adult patients (12 males, 92.31%) with VSD who developed ascending aortic dilation. Median age was 37 (interquartile range 14) years. All patients suffered from perimembranous VSD and received surgical treatment. Their symptoms were all improved after surgery, no deaths occurred.Surgery is feasible for the ascending aortic dilation in adult patients with congenital VSD. Both proper perioperative treatment and close monitoring are required for the successful surgery.

Doubly committed Subarterial Ventricular Septal defect repair: An experience of 51 cases

Objective:

To review the surgical outcome of doubly committed subarterial (DCSA) ventricular septal defect repair.

Method:

Data of 51 patients of doubly committed sub arterial Ventricular septal defect from January 2012 to June 2017 that were referred to Chaudhary Pervaiz Elahi institute of Cardiology Multan was retrospectively reviewed using electronic database. All patients were operated by first author. In our study, we segregated patients into four main groups depending on presence or absence of aortic structural defect and degree of aortic valve regurgitation. Group-A comprised of nineteen (37%) patients who neither had aortic structural nor functional abnormality while Group-B had six (11.7%) patients, having aortic valve cusp prolapse without aortic regurgitation. Group-C and Group-D consists of seventeen (33.3%) and nine (17.6%) patients respectively depending upon degree of aortic regurgitation. Furthermore, six (11.7%) patients among these 51 had associated defects as well.

Results:

Group-A patients had no aortic valve regurgitation post operatively and at follow up of 22.6 months (1.8 years) as well. In Group-B, aortic valve was not addressed and aortic regurgitation was also not present post operatively or on follow up of 33.6 months (2.8 years). Similarly, in Group-C aortic valve was not addressed, these patients also did not show progression of disease on regular follow up of 18 months (1.5 year). While, in Group-D, eight patients underwent aortic valve repair and one patient had aortic valve replacement. Aortic regurgitation improved significantly in all patients of this group and remained unchanged on follow up of 22.7 months (1.8 years).

Conclusion:

Early closure of doubly committed subarterial ventricular septal defect with appropriate management of aortic valve disease can halt the process of disease progression.

Perventricular device closure of doubly committed sub-arterial ventricular septal defects via a left infra-axillary approach

BACKGROUND

This study sought to evaluate the feasibility, safety, and efficacy of perventricular device closure of a doubly committed sub-arterial ventricular septal defect (dcVSD) through a left infra-axillary approach.

METHOD

Forty-five patients, with a dcVSD of less than 8 mm in diameter, were enrolled in this study. The pericardium was exposed and opened through a left infra-axillary mini-incision. Two parallel purse-string sutures were placed on the right ventricle outflow tract and under transesophageal echocardiography guidance, a delivery sheath loaded with the device was inserted into the right ventricle and advanced through the defect into the left ventricle. The device, connected to a delivery cable, was then deployed.

RESULTS

Forty-one patients achieved successful device closure. In four patients, the device failed to occlude the VSD due to device dislodgement, device-related aortic regurgitation, and residual shunts, and open surgical repair was required. The mean dcVSD diameter was 4.5 ± 1.0 mm (range, 3.0-8.0 mm). The implanted device size was 6.0 ± 1.5 mm (range, 4-10 mm). All patients were implanted with an eccentric device. The mean intracardiac manipulation time was 20.9 ± 7.1 min (range, 9-45 min). The procedure time was 62.5 ± 19.5 min (range 34-105 min). There were no severe adverse events.

CONCLUSIONS

Perventricular device closure of a dcVSD through a left infra-axillary approach is feasible, safe, and efficacious in selected patients with dcVSD.

Surgery for Aortic Insufficiency Associated with Ventricular Septal Defect

Aortic valve repair in children is a challenge. We have adopted a technique of single aortic cusp extension with an autologous pericardial strip in patients diagnosed with severe aortic insufficiency (AI) associated with a ventricular septal defect (VSD). The purpose of this study was to report the short-term outcomes. Seven patients were operated on between January 2002 and December 2003. The mean age was 11.28 ± 2.1 years (range 8–14 years). The VSD was closed with a synthetic patch. Aortic cusp extension was performed at the right coronary cusp in 6 patients and the remainder had a non-coronary cusp extension. The mean diastolic arterial pressure increased from 35.71 ± 6.09 to 74.28 ± 7.31 mm Hg after the operation ( p < 0.001). The postoperative grade of AI was trivial in 4 patients, mild in 1 patient and non-existent in 2 patients. The mean follow-up period was 12.85 ± 6.12 months (range 2–20 months). This technique is very effective in patients with severe AI associated with a VSD. However, long-term durability will need to be carefully followed.

Aortic Valve Repair: Techniques and Results

Twenty-two patients underwent aortic valve repair for rheumatic aortic regurgitation (AR) from April 1991 to August 1993. Six patients were female. Thirteen patients required mitral valve repair and 3 patients underwent mitral valve replacement. One patient required tricuspid valve repair in addition to aortic and mitral valve reconstruction.

There was 1 early death and 5 early failures. Of these, 3 were considered unsatisfactory valves for repair and replaced after an attempt at repair. In 2 others, the aortic valve was replaced within a week of initial attempt at repair. There were 2 late failures, 1 of which had aortic valve replacement and another who is awaiting reoperation. Fourteen of 22 patients have been judged to have good results clinically and echocardiographically.

Aortic Regurgitation with Ventricular Septal Defect in the Young

This study was carried out to assess the outcome in patients who had aortic valve replacement compared to those who underwent aortic valve repair for aortic regurgitation associated with a ventricular septal defect. Of 300 patients undergoing ventricular septal defect closure between May 1990 and December 2003, 36 (12%) had moderate to severe aortic regurgitation; 7 underwent concomitant aortic valve repair and 29 had aortic valve replacement. The mean age of these 36 patients was 17.72 ± 6.84 years, and 69% were male. Follow-up was 8.20 ± 4.97 years in the valve replacement group and 4.1 ± 0.8 years in the valve repair group. The freedom from re-operation after valve repair was 76% after 4 years. After one year of follow-up in 35 patients, 27 were in New York Heart Association class I (77%) and 8 were in class II (23%). After 8 years, 12/21 (57%) patients were in class I, 5 (24%) in class II, and 2 (10%) in class III. Of 22 patients who had a dilated left ventricle, 15 regained normal left ventricular function and volume. Valve repair is preferred, but increasing age makes valve replacement a better alternative.

Transfemoral Device Occlusion and Minimally Invasive Surgical Repair for Doubly Committed Subarterial Ventricular Septal Defects

Transfemoral device occlusion and minimally invasive surgical repair are performed for doubly committed subarterial ventricular septal defect (dcVSD) to reduce the invasiveness of the conventional surgical repair through a median sternotomy. However, few studies have compared them in terms of effectiveness and cost. Inpatients with isolated dcVSD who had undergone transfemoral device occlusion or minimally invasive surgical repair from January 2011 to June 2014 were reviewed for a comparative investigation between the two procedures. Procedure success was achieved in 36 transfemoral (75 %) and in 36 surgical (100 %) procedures (p = 0.001). Transfemoral patients were older, with a VSD size similar to that of surgical patients (14.5 ± 11.7 vs 4.4 ± 2.9 years, p < 0.001; 4.5 ± 1.5 vs 4.4 ± 1.3 mm, p = 0.577, respectively). No significant difference was observed in complication rates between the two treatment groups (p = 1). No large residual shunt was observed. Small residual shunt was noted in two transfemoral patients and four surgical patients (p = 0.674). All these small residual shunts closed spontaneously during follow-up. The surgical repair costs 26 % less than the device occlusion (Yuan 22063.2 ± 343.9 vs Yuan 29970.1 ± 1335.2, p < 0.001), where most of the cost was attributed to the occluder in the amount of Yuan 19,500. Compared with device occlusion, minimally invasive surgical repair can provide superior efficacy and comparable complication rates. In addition, it is 26 % cheaper than device occlusion. In low-income countries where healthcare resources are limited, medical resources must be judiciously allocated to the treatment that allows for effective treatment of the largest number of patients.

Anatomic and functional aortic valvuloplasty for correction of aortic valve prolapse in ventricular septal defect with aortic insufficiency

We describe a new procedure of aortic valvuloplasty for aortic valve prolapse in ventricular septal defect with aortic insufficiency syndrome. This technique allows an anatomic and functional aortic valve reconstruction that prevents late failure of aortic valve repair and reoperation. Midterm results demonstrate the feasibility and durability of this new procedure.

Progression of aortic regurgitation after surgical repair of outlet-type ventricular septal defects

BACKGROUND

Progression of aortic regurgitation (AR) in repaired outlet ventricular septal defects (VSDs) remains unclear, especially for muscular outlet and perimembranous outlet VSDs. We tried to identify the risk factors for AR progression and aortic valve replacement (AVR) at long-term follow-up.

METHODS

Four hundred patients with complete follow-up after the repair of their outlet VSD between 1987 and 2002 were studied.

RESULTS

Juxta-arterial VSD, perimembranous outlet VSD, and muscular outlet VSD were noted in 190, 148, and 62 patients, respectively. There were 377 patients with none to mild AR (group I) and 23 with moderate to severe AR (group II) preoperatively. Aortic valve replacement was performed on 11 patients (all from group II), with 10 having received AVR concomitantly with VSD repair and 1 having received it 4 years later. Only severity of preoperative AR and older age (>15 years) at VSD repair were significant predictors of AVR. With a total follow-up of 2230 person-years, the 10-year freedom from AVR after VSD repair for group I was 100% and that for group II was 50.2%. In group I, AR progressed in 4 patients only (1.2%, 2 juxta-arterial and 2 perimembranous outlet) and aortic valvular (aortic valve prolapse or ruptured sinus Valsalva aneurysm) or subvalvular anomalies were present in all. The event-free (AR or AVR) survival rates among the 3 outlet-type VSDs however showed no difference.

CONCLUSIONS

Aortic regurgitation progression modes after surgical VSD repair were similar among the 3 outlet-type VSDs. Aortic valve replacement was rarely necessary for patients who were operated on when they were younger than 15 years. Aortic regurgitation of a less-than-moderate degree preoperatively rarely progressed after VSD repair.

Aneurysm of the sinus of valsalva

Aneurysms of the sinus of Valsalva (ASVs) are rare. They can be congenital or acquired through infection, trauma, or degenerative diseases. They frequently co-occur with ventricular septal defects, aortic valve dysfunction, or other cardiac abnormalities. Although unruptured ASVs are usually asymptomatic, ruptured ASVs often cause symptoms similar to those of heart failure and produce a continuous, mechanical-sounding murmur. Transsternal or transesophageal echocardiography is usually effective in detecting ASVs. Because symptomatic ASVs pose significant risks for the patient, and because the repair of asymptomatic ASVs generally produces excellent outcomes, surgery is indicated in most cases. The primary goals of surgical repair are to close the ASV securely, remove or obliterate the aneurysmal sac, and repair any associated defects. Operative mortality is generally low except in patients with concomitant bacterial endocarditis or other infections. Late events are uncommon and tend to be related to aortic valve prothesis or Marfan syndrome.

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.

Surgical repair of infundibular ventricular septal defect and aortic regurgitation

Interpretation of the anatomy of the defect and the pathophysiology has guided the surgical technique and indications for infundibular ventricular septal defect VSD. Infundibular ventricular septal defects are located in the infundibular septum, between the two commissures of the right coronary cusp. The defect is associated with an anomaly of the right sinus of Valsalva where the transition to cusp tissue occurs higher than normally. There is development of fibrous adherences between the ventricular surface of the right coronary cusp and the crest of the septum. This reduces the height of the cusp and destabilizes the valve. The aim is to reposition the hinge point of the right coronary cusp to restore the normal height of the cusp, hence a normal surface of apposition. This is achieved with a trans-aortic approach. The major difference with other techniques described is the extensive mobilization of the cusp. The procedure is completed by a reduction of the free edge of the right coronary cusp if it is elongated. This technique is indicated in all patients with infundibular ventricular septal defect in whom an aortic regurgitation appears or increases during follow-up. Fifteen patients were operated on with this technique between 1996 and 2005. Thirteen have achieved good results at follow-up. There was one late death.

A 32-year experience with surgical repair of sinus of valsalva aneurysms

INTRODUCTION

Sinus of Valsalva (SoV) aneurysms are rare (0.15% to 1.5% CPB cases) and five times more frequent in Asians. Usually congenital, SoV aneurysms arise from the right or noncoronary sinus, are associated with other cardiac defects, and are repaired primarily or with a patch. Acquired SoV aneuryms develop secondary to infection or trauma. Here, we describe our 32-year experience with SoV aneurysm repair in a Western population.

METHODS

A retrospective review identified 22 patients who underwent SoV aneurysm repair between 1971 and 2003. Data is presented as mean +/- standard error (median).

RESULTS

Dyspnea was the most common presenting symptom. Nineteen of 22 patients were ruptured at the time of operation; three were found incidentally. Fifteen patients had associated cardiac defects including ventricular septal defect (VSD) (6), aortic insufficiency (6), and coarctation (3). One patient, repaired primarily, required reoperation for recurrence. All other patients underwent patch repair. The operative survival was 95% (21/22). There were five known late deaths at 6.6 +/- 2.3 (5.7) years post-repair. Five and ten year survival rates were 84.9 +/- 11% and 59.4 +/- 17%, respectively.

CONCLUSION

Observed differences in the sinus of origin, age at presentation, associated cardiac malformations, and mortality in our Western series versus previous Asian cohort studies likely reflect a racial disparity and higher prevalence of acquired versus congenital SoV aneurysms. We recommend a thorough search for a VSD in all cases and use of patch repair, regardless of size, to reduce risk of recurrence.

Impact of preoperative aortic cusp prolapse on long-term outcome after surgical closure of subarterial ventricular septal defect

BACKGROUND

Previous reports on the long-term outcome of surgical closure of subarterial ventricular septal defect were based on a relatively small number of patients.

METHODS

We reviewed the long-term outcome of 135 patients who underwent closure of their defect and, in light of the findings, assessed the impact of preoperative aortic cusp prolapse and surgical interventions on occurrence of aortic regurgitation (AR) in the long-term. The patients were categorized into three groups for comparison: group I consisted of 79 patients with no aortic cusp prolapse and underwent simple closure of ventricular septal defect, group II comprised 39 patients with mild to moderate cusp prolapse who similarly had only closure of the defect performed, whereas group III comprised 17 patients who had additional aortic valvoplasty for greater than moderate to severe cusp prolapse.

RESULTS

Group I patients had significantly higher pulmonary arterial pressure (p < 0.001) and ratio of pulmonary blood flow to systemic blood flow (p < 0.001). None of these patients had AR before their operation, and none experienced AR afterward at a median follow-up of 6.1 years. Of the 39 group II patients, 30 (77%) had trivial or mild AR preoperatively. The AR improved in 15 patients, remained trivial or mild in 14 and absent in 7, but progressed to trivial or mild in 3 at a median follow-up of 3.1 years. None required further interventions. In contrast, 14 (82%) of the 17 group III patients had moderate to severe AR before operation. The regurgitation improved in 10, but remained moderate or severe in 4 and worsened further in 3 at a median follow-up of 4.6 years. The freedom from failure of aortic valvoplasty was (mean +/- standard error of the mean) 71%+/-11%, 64%+/-12%, and 43%+/-19% at 1, 5, and 10 years, respectively. An older age at latest follow-up was the only identifiable significant risk factor (p = 0.03).

CONCLUSIONS

Our data do not support the need of aortic valvoplasty for mild to moderate aortic cusp prolapse. Close follow-up is warranted in those with greater than moderate to severe cusp prolapse despite valvoplasty as there is continued failure on follow-up. Nothing, however, is better than early closure of defects before development of aortic valve complications.

A new operation for ventricular septal defect with aortic incompetence

Two boys, 10 years of age, with ventricular septal defect and severe aortic insufficiency were treated using a new method. An autograft of anterior pulmonary artery wall and the adjacent leaflet and subpulmonary muscle was excised. The excised pulmonary artery segment was used to replace the prolapsed right coronary cusp, and the autograft muscle was used to close the ventricular septal defect. The right ventricular outflow tract and pulmonary valve were repaired using an autologous pericardial patch with an autologous single cusp. The results in both cases were satisfactory.

Risk factors for failure of aortic valvuloplasty in aortic insufficiency with ventricular septal defect

BACKGROUND

Aortic insufficiency (AI) associated with ventricular septal defect (VSD) is often repaired using a modification of Trusler's aortic valvuloplasty technique. The purpose of this study was to identify the risk factors for failure of aortic valve (AV) repair in patients who underwent repair of associated VSD.

METHODS

A univariate analysis was performed in this retrospective study to identify the possible risk factors for failure of the repair resulting in the need for AV replacement (AVR).

RESULTS

The study included 24 patients, 15 (62%) boys and 9 (38%) girls, with a mean age of 9.1 +/- 1.2 (SEM) years. The VSD was perimembranous in 15 (62%) and subarterial in 9 (38%). The prolapsed aortic cusp was the right in 13 (54%), the noncoronary in 6 (25%), and both in 5 (21%). Plication was performed at one end of the free edge of the prolapsed cusp(s) in 12 (50%) and at more than one end in 12 (50%) of the patients. The VSD was closed by use of a patch in 21 (88%) and by direct suture closure in 3 (12%). At the mean follow up of 7.3 +/- 1.3 years, the degree of AI was none in 6 (25%), trivial in 5 (21%), mild in 9 (38%), moderate in 1 (4%), and severe in 3 (12%). The 15-year actuarial freedom from reoperation was 81% +/- 19% (95% confidence limit). By univariate analysis, the possible risk factors for AV repair failure were the degree of AI at hospital discharge (p = 0.004), direct closure of the VSD (p = 0.061), smaller size of the VSD (p = 0.081), and plication of more than one end of the prolapsed cusp(s) (p = 0.095).

CONCLUSIONS

Trusler's AV repair is an effective and durable technique for the surgical treatment of patients with VSD-AI syndrome. The adequacy of the initial repair is the most important determinant of the long-term results.

Management of ventricular septal defect: a survey of practice in the United Kingdom

BACKGROUND

A survey of pediatric cardiac surgeons was performed to establish current opinions in the United Kingdom concerning closure of ventricular septal defect.

METHODS

Questionnaires were sent to 14 pediatric cardiac centers in 1995 (16 surgeons, 100% response), and again in 1997 (20 surgeons, 100% response).

RESULTS

Results are presented for 1997, with findings from 1995 shown in parentheses. Eleven (6) surgeons used bypass exclusively, 9 (10) sometimes used circulatory arrest. Operative techniques were similar, although the material used for the patch varied. Multiple defects were approached via the transatrial route by 18 (15), right ventriculotomy by 11 (7) and left ventriculotomy by 7 (6). The juxta-arterial defect was approached via the transpulmonary route by 16 (13), a combination by 9 (11), transatrial by 10 (6), and transventricular by 9 (5). The most common indications for pulmonary arterial banding were "Swiss cheese" defect for 13 (13), and functionally single ventricle for 5 (6). Ventricular septal defect associated with coarctation was repaired in two stages by 13 (10), a single stage by 5 (3), or either by 1 (3).

CONCLUSIONS

Pediatric cardiac surgeons in the United Kingdom demonstrate a uniform, evidence-based approach to the management of ventricular septal defect.

Normalization of left ventricular dimensions after Ross operation with aortic annular reduction

BACKGROUND

Fifty-seven patients (August 1995 to November 1998) with a dysplastic dilated aortic root, a relative contraindication to the Ross operation, received an extended Ross operation with aortic annulus reduction and external cuff fixation (age 14-54 years). To assess the efficacy of these operations, echocardiographic assessment of autograft valve function and left ventricular function and dimensions were reviewed.

METHODS

Preoperative and postoperative assessment of 27 patients with aortic insufficiency (AI group) and 30 patients with aortic stenosis (>20 mm Hg peak gradient) and aortic insufficiency (AS group) were compared. Aortic annulus size, valvular gradient, valve insufficiency, left ventricular dimensions at end-systole and end-diastole, left ventricular fractional shortening, and left ventricular mass were assessed.

RESULTS

There was one late death. Aortic annulus size, degree of AI, left ventricular internal dimensions, and left ventricular mass were all significantly reduced (p<0.05) postoperatively in the AI group. Mean peak pressure gradients for this group were 6.8+/-6.7 mm Hg before operation and 8.7+/-6.4 mm Hg at 1 year after operation. Peak pressure gradient, aortic annulus size, degree of AI, left ventricular internal dimensions, and left ventricular mass were significantly reduced (p<0.05) in the AS group. Mean fractional shortening was within normal limits pre- and postoperatively for both groups.

CONCLUSIONS

Regression of left ventricular dilatation and hypertrophy, excellent autograft valve function, and survival suggest that this modification of the Ross operation may be offered to patients with a dysplastic aortic root requiring aortic valve replacement.

Outcome of surgical closure of doubly committed subarterial ventricular septal defect

BACKGROUND

From 1986 to March 1997, 128 patients diagnosed to have doubly committed subarterial ventricular septal defects (VSD) were reviewed. Patients with aortic regurgitation (AR), and aortic valve (AV) deformity or a large left-to-right shunt across the VSD were offered operation. Forty-five patients (27 men, 18 women) agreed to surgical closure of their VSDs.

METHODS

Thirty-eight patients had VSD closure alone, and 7 had an additional AV repair. Other associated defects corrected at operation were closure of atrial septal defects, closure of other ventricular septal defects, ligation of patent ductus arteriosus, and repair of ruptured sinus Valsalva aneurysm.

RESULTS

There was no mortality nor major morbidity associated with operation. In the 26 patients with AR and AV deformity preoperatively, valve repair was performed in 6 patients. The condition of AR improved in 4, and remained unchanged in 22 patients. In the 10 patients with a deformity of the AV and no AR preoperatively, the condition remained unchanged in 5 patients, from whom 1 had valve operation, but progressed in 5 patients postoperatively at a mean follow-up of 6.4 years. In 9 patients with no deformity of the AV and no AR preoperatively, there was no postoperative AR and no progress of valve deformity.

CONCLUSIONS

Excellent results were obtained with VSD closure and AV repair. Surgical closure of VSD, if performed before the onset of AV deformity, may prevent progressive AR. If AV repair is performed after the onset of AV deformity, progressive AR may not always be prevented.

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.

Leaflet's free edge suspension for correction of aortic insufficiency associated with ventricular septal defect

Aortic valve regurgitation in association with ventricular septal defect results from the mechanical effect of the ventricular septal defect, which primarily affects the free edge. The elongated free edge can be repaired by plicating it using several techniques designed to restore a normal geometry to the prolapsing aortic leaflet. We describe 4 cases in which aortic insufficiency was treated by a technique of plication that allows suspension of the free edge along a pericardial strip applied from one commissure to the other.

Pulmonary autografts in patients with aortic annulus dysplasia

BACKGROUND

Pulmonary autograft replacement of the aortic valve is indicated in the young, in patients with an active life style, and when anticoagulation is contraindicated. Its use in patients with a dilated aortic annulus or sinotubular junction has historically had a less satisfactory result.

METHODS

To extend the advantages of the pulmonary autograft to this group of patients, we performed the Ross operation as a root replacement and "fixed" and narrowed the aortic annulus with external woven Dacron in 12 patients, Teflon felt in 5, and pericardium in 3. Twenty patients, aged 7 to 47 years (median, 27 years), are reported to assess the effectiveness of this operative technique. Preoperative aortic annulus diameter was 23 to 33 mm (13 were >27 mm).

RESULTS

There were no operative or late deaths. Early postoperative, echocardiographic evaluation of autograft valve function revealed no significant obstruction, grade 0 aortic insufficiency in 5, trace to 1+ in 12, and 2+ in 2. Late evaluation of 1 to 4 years is available in 12 patients and has shown no increase in autograft insufficiency.

CONCLUSIONS

This experience suggests that operative fixation of the aortic annulus with an external Dacron cuff is effective and is recommended in patients with an aortic annulus that is significantly greater than normal for their body size.

Pulmonary autograft in ventricular septal defect-aortic insufficiency complex

Pulmonary autograft aortic root replacement in a child with the ventricular septal defect-aortic insufficiency complex is described. It offers all the advantages of the autograft, avoids closure of the ventricular septal defect, and prevents the use of prosthetic material.

Reoperation after the arterial switch operation for transposition of the great arteries

Although most children after an arterial switch operation for transposition of the great arteries have normal development and cardiac function, a few require reoperation. During the last 10 years, 68 of 753 patients who underwent arterial switch operations (9.3%) underwent 75 reoperations. Thirty underwent early reoperation (< 30 days or during the same hospital stay) and 38 underwent late reoperation. Causes for reoperation included pacemaker insertion (n = 5), left diaphragm plication (n = 4), revision for hemostasis (n = 1), mediastinitis (n = 2), superior vena cava thrombosis (n = 9), subvalvular pulmonic stenosis (n = 5), supravalvular pulmonic stenosis (n = 16), residual atrial (n = 2) or ventricular (n = 8) septal defects, isolated mitral valve insufficiency (n = 2), aortic valve insufficiency (either isolated [n = 1] or in association with mitral incompetence [n = 1] or stenosis [n = 1]), left coronary artery ostial stenosis (n = 1), and recurrent aortic (n = 6) or neoaortic (n = 4) aortic coarctation. In all but 27 patients, the residual defects were already present immediately after the completion of the arterial switch operation; however, only patients with critical lesions were reoperated on early. Interventional catheterization procedures were performed when indicated; however, they only postponed inevitable reoperation. Successful relief of superior vena cava thrombosis was achieved by atriojugular bypass grafting in two patients, by early open thrombectomy in six patients, and by direct patch angioplasty of the superior vena cava once. Patch plasty for subvalvular or supravalvular pulmonic stenosis was carried out in 21 patients, septal defect closure was carried out in nine patients, and pulmonary artery banding was performed in one patient with criss-cross atrioventricular relationship and multiple ventricular septal defects. Valve repair was performed in all five patients with either isolated or combined aortic and mitral valve dysfunction. One patient with left coronary ostial stenosis underwent a patch enlargement of this ostium. Recoarctation was repaired by end-to-end anastomosis in eight patients and by a subclavian flap and a patch angioplasty in one patient each. Seven patients underwent a second reoperation for supravalvular pulmonary stenosis (n = 3), mitral valve replacement (n = 1), ventricular septal defect closure (n = 1), and recurrent coarctation (n = 2). There were six intraoperative (8.8%) and two late deaths. All early deaths occurred after early reoperations.(ABSTRACT TRUNCATED AT 400 WORDS)

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.