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Talwar S, Kapoor PM, Narula J, Keshri VK, Choudhary SK, AIran B. Right-to-left shunting through the unidirectional valved patch after closure of ventricular septal defect. Ann Card Anaesth 2017; 20:243-244. [PMID: 28393787 PMCID: PMC5408532 DOI: 10.4103/aca.aca_43_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Postoperative transesophageal echocardiography images of a patient undergoing unidirectional valved patch closure of ventricular septal defect in the setting of severe pulmonary hypertension are presented. The images and videos elegantly demonstrate a functioning valve without any obstruction to the left ventricular outflow.
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Affiliation(s)
- Sachin Talwar
- Department of Cardiothoracic and Vsscular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Poonam Malhotra Kapoor
- Department of Cardiac Anaestheia, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Jitin Narula
- Department of Cardiac Anaestheia, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Kumar Keshri
- Department of Cardiothoracic and Vsscular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Shiv Kumar Choudhary
- Department of Cardiothoracic and Vsscular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Balram AIran
- Department of Cardiothoracic and Vsscular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Makhija N, Narula J, Keshri VK, Gupta SK, Talwar S. Unidirectional ventricular septal valved patch for repair of late presenting ventricular septal defect with aortopulmonary window. Ann Pediatr Cardiol 2016; 9:90-3. [PMID: 27011704 PMCID: PMC4782481 DOI: 10.4103/0974-2069.171404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Management of long standing left to right shunt lesion resulting in elevated pulmonary vascular resistance (PVR) is challenging. Limited surgical options are further complicated by an unpredictable postoperative period. Unidirectional valve patch (UVP) closure has shown to be useful in cases of the large ventricular septal defect (VSD) who present late. We report a case of large aortopulmonary window coexisting with a large VSD with severe pulmonary artery hypertension and significantly elevated PVR that was managed surgically by closure of the window by sandwich technique and closure of the septal defect with a UVP. This report emphasizes the importance of UVP in the management of such patients.
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Affiliation(s)
- Neeti Makhija
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Jitin Narula
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Kumar Keshri
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kumar Gupta
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sachin Talwar
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
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Rosic M, Susak S, Redzek A, Velicki L. Closure of an atrial septal defect with a one-way flap patch in a patient with severe pulmonary hypertension. Interact Cardiovasc Thorac Surg 2016; 22:856-8. [PMID: 26920727 DOI: 10.1093/icvts/ivw032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 01/18/2016] [Indexed: 11/14/2022] Open
Abstract
An isolated atrial septal defect (ASD) can occasionally go unrecognized for decades and accounts for 25-30% of congenital heart disease cases diagnosed in adulthood. Pulmonary hypertension often develops as a result of a long-lasting, left-to-right shunt and may ultimately be associated with a fixed increase of pulmonary vascular resistance, sometimes rendering these patients inoperable. To reduce the risk of developing postoperative morbidity and possible mortality, we employed our technique of a unidirectional valved patch for the closure of ASD.
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Affiliation(s)
- Milenko Rosic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia Clinic for Cardiovascular Surgery, Institute of Cardiovascular Diseases Vojvodina, Sremska Kamenica, Serbia
| | - Stamenko Susak
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia Clinic for Cardiovascular Surgery, Institute of Cardiovascular Diseases Vojvodina, Sremska Kamenica, Serbia
| | - Aleksandar Redzek
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia Clinic for Cardiovascular Surgery, Institute of Cardiovascular Diseases Vojvodina, Sremska Kamenica, Serbia
| | - Lazar Velicki
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia Clinic for Cardiovascular Surgery, Institute of Cardiovascular Diseases Vojvodina, Sremska Kamenica, Serbia
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Talwar S, Keshri VK, Choudhary SK, Gupta SK, Ramakrishnan S, Juneja R, Saxena A, Kothari SS, Airan B. Surgical strategies for patients with congenital heart disease and severe pulmonary hypertension in low/middle-income countries. HEART ASIA 2015; 7:31-7. [PMID: 27326218 DOI: 10.1136/heartasia-2015-010645] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/02/2015] [Accepted: 09/18/2015] [Indexed: 11/04/2022]
Abstract
In this review, we discuss specific surgical strategies that are used in patients with congenital heart disease and severe pulmonary arterial hypertension. Our own experience, with the use of unidirectional valved patches in managing these patients, is also discussed in detail.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Vikas Kumar Keshri
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Shiv Kumar Choudhary
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Saurabh Kumar Gupta
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | | | - Rajnish Juneja
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Anita Saxena
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Shyam Sunder Kothari
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Balram Airan
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
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Talwar S, Keshri VK, Choudhary SK, Gupta SK, Ramakrishnan S, Saxena A, Kothari SS, Juneja R, Kumar G, Airan B. Unidirectional valved patch closure of ventricular septal defects with severe pulmonary arterial hypertension: hemodynamic outcomes. J Thorac Cardiovasc Surg 2014; 148:2570-5. [PMID: 24332111 DOI: 10.1016/j.jtcvs.2013.10.052] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 09/13/2013] [Accepted: 10/29/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of the present study was to study the midterm hemodynamic outcomes of unidirectional valved patch closure of ventricular septal defects (VSDs) in patients with VSD and pulmonary arterial hypertension (PAH). METHODS From January 2006 to January 2012, 20 patients with VSD with PAH and a pulmonary vascular resistance index >8 Wood units underwent VSD closure with a unidirectional valved patch using the technique previously described by us. Of these, 13 patients agreed to follow-up cardiac catheterization and were studied at a mean follow-up of 34.7 ± 18.6 months (range, 2-56). The mean age of these 13 patients was 8.5 ± 4.4 years (range, 2-19; median, 9), and the mean preoperative systemic saturation was 94.1% ± 3.4% (range, 87-99; median, 95.0) The mean preoperative pulmonary artery systolic pressure was 96.2 ± 13.6 mm Hg (range, 75-115; median, 103.0), and the mean preoperative pulmonary vascular resistance index was 10.0 ± 2.1 Wood units (range, 8.0-15.1; median, 9.3). RESULTS At follow-up cardiac catheterization, the mean systemic saturation had increased to 98.92%. The pulmonary vascular resistance index had decreased significantly to 5.8 ± 2.1 Wood units (P = .02). A significant decrease was seen in the pulmonary artery systolic, diastolic, and mean pressures (P = .000), and none of the patients had severe PAH. No patients died, and all patients were in New York Heart Association class I. CONCLUSIONS Unidirectional valved patch closure of VSD is a promising technique for patients with a large VSD and severe PAH. It had a favorable effect on the immediate, early, and midterm clinical outcomes and hemodynamic parameters.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Vikas Kumar Keshri
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Shiv Kumar Choudhary
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kumar Gupta
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | | | - Anita Saxena
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Shyam Sunder Kothari
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Rajnish Juneja
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Balram Airan
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Talwar S, Choudhary SK, Garg S, Saxena A, Ramakrishnan S, Kothari SS, Juneja R, Airan B. Unidirectional valved patch closure of ventricular septal defects with severe pulmonary arterial hypertension. Interact Cardiovasc Thorac Surg 2012; 14:699-702. [PMID: 22402503 DOI: 10.1093/icvts/ivs044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Delayed presentation of ventricular septal defect (VSD) is common in developing countries. Such patients often have severe pulmonary arterial hypertension (PAH), which increases post-operative morbidity and mortality. To address these problems, we used our technique of unidirectional valved patch (UVP) for closure of VSD. Between January 2006 and December 2010, 17 patients (age 2-23 years, median 9 years) with a large VSD and severe PAH underwent VSD closure with UVP. Pre-operative mean indexed pulmonary vascular resistance (PVRI) was 10.9 ± 2.2 Wood units and mean pre-operative systemic saturation was 93.4 ± 2.6%. Shunt was bidirectional in 15 patients and predominantly right to left in two. After VSD closure, intra-operative transoesophageal echocardiography revealed a right to left shunt across the patch in three patients 2, 7 and 9 years of age who had pre-operative PVRI of 9.5, 9.8 and 11.1 Wood units, respectively. There were no in-hospital deaths and all patients had uneventful recovery. Mean follow-up was 30 ± 14.7 months and all patients are well without cyanosis. Echocardiography showed no shunt across the patch and all have systemic saturation >95%. We conclude that UVP is a promising technique in patients with large VSD and severe PAH.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India.
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Talwar S, Choudhary SK, Nair VV, Chauhan S, Kothari SS, Juneja R, Saxena A, Airan B. Arterial switch operation with unidirectional valved patch closure of ventricular septal defect in patients with transposition of great arteries and severe pulmonary hypertension. World J Pediatr Congenit Heart Surg 2012; 3:21-5. [PMID: 23804680 DOI: 10.1177/2150135111421939] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE For patients with dextro-transposition of great arteries (d-TGAs), ventricular septal defect (VSD), and severe pulmonary arterial hypertension (PAH), the common surgical options are palliative arterial switch operation (ASO) or palliative atrial switch operation leaving the VSD open. We evaluated the role of ASO with VSD closure using a fenestrated unidirectional valved patch (UVP). METHODS Between July 2009 and February 2011, six patients with TGAs, VSD, and severe PAH (mean age 39.8 ± 47.4 months, median 21, range 8-132 months), weighing 10.7 ± 9.2 kg (median 8.6, range 4.3-29 kg), underwent ASO with VSD closure using our simple technique of UVP. Mean pulmonary artery systolic pressure before the operation was 106 ± 12.7 mm Hg (median 107.5, range 95-126 mm Hg) and pulmonary vascular resistance was 9.5 ± 4.22 units (median 9.5, range 6.6-17.1 Wood units). RESULTS There were no deaths. All patients had a postoperative systemic arterial saturation of more than 95%, although there were frequent episodes of systemic desaturation due to right-to-left shunt across the valved VSD patch (as seen on transesophageal and transthoracic echocardiograms). Mean follow-up was 10 ± 7.6 months (median 7.5, range 1-22 months). At most recent follow-up, all patients had systemic arterial saturation of more than 95% and no right-to-left shunt through the VSD patch. In one patient, the follow-up cardiac catheterization showed a fall in pulmonary artery systolic pressure to 49 mm Hg. CONCLUSION Arterial switch operation with UVP VSD closure is feasible with acceptable early results. It avoids complications of palliative atrial switch (arrhythmia and baffle obstruction) and partially or completely open VSD.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi, India
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Talwar S, Choudhary SK, Saxena A, Kothari SS, Juneja R, Airan B. Unidirectional valved patches for closure of septal defects in patients with severe pulmonary hypertension. Ann Pediatr Cardiol 2011; 1:114-9. [PMID: 20300252 PMCID: PMC2840745 DOI: 10.4103/0974-2069.43876] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pulmonary hypertension due to delay in presentation, diagnosis, referral, and surgery for septal defects is not uncommon in the developing world and translates into high morbidity and mortality following open heart surgery to close these defects. Leaving a small atrial communication may not always be effective. Extracorporeal membrane oxygenation and inhaled nitric oxide therapy in the immediate postoperative phase may not be available or may not be financially feasible in many institutions which are economically challenged. Unidirectional valved patch is emerging as a new and effective solution to this problem and promises to make at least the immediate postoperative results more predictable in this subset of patients.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Talwar S, Choudhary SK, Airan B. Palliative arterial switch for transposition of the great arteries, ventricular septal defect, and pulmonary vascular obstructive disease. J Thorac Cardiovasc Surg 2011; 141:848; author reply 848-9. [PMID: 21335138 DOI: 10.1016/j.jtcvs.2010.10.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2010] [Accepted: 10/27/2010] [Indexed: 11/25/2022]
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The unidirectional valve patch provides no benefits to early and long-term survival in patients with ventricular septal defect and severe pulmonary artery hypertension. J Thorac Cardiovasc Surg 2010; 139:950-5. [DOI: 10.1016/j.jtcvs.2009.05.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Revised: 04/09/2009] [Accepted: 05/15/2009] [Indexed: 11/17/2022]
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Talwar S, Choudhary SK, Reddy S, Saxena A, Kothari SS, Juneja R, Airan B. Total anomalous pulmonary venous drainage beyond childhood. Interact Cardiovasc Thorac Surg 2008; 7:1058-61. [PMID: 18786944 DOI: 10.1510/icvts.2008.186734] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We studied the anatomic characteristics and results of surgery in 27 patients with total anomalous pulmonary venous drainage who were 15 years or older between January 1997 and July 2007. Mean age was 19.7+/-11.6 years (15-48 years). The anatomic subtypes were supracardiac (n=15), cardiac (n=7), and mixed (n=5). Fourteen patients were in NYHA class II and 13 were in NYHA class III. Eleven patients had severe and the rest had moderate pulmonary arterial hypertension; six patients had significant right ventricular dysfunction. All patients underwent complete repair. A small inter-atrial communication was left open in four patients and in two patients, a fenestrated unidirectional valved patch was used to close the atrial septal defect. There were no early or late deaths. Follow-up was 3-127 months (mean 61.2+/-36.1 months). Twenty patients were in NYHA class I and seven were in class II. Echocardiography showed normal right and left ventricular function in all patients with reduction of pulmonary arterial pressures in 26 patients. One patient underwent radiofrequency ablation for new onset atrial flutter. Surgery can be safely undertaken in a few naturally selected group of patients with total anomalous pulmonary venous drainage who survive beyond childhood.
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Affiliation(s)
- Sachin Talwar
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
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