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Chowdhury UK, Anderson RH, Spicer DE, Sankhyan LK, George N, Pandey NN, Balaji A, Goja S, Malik V. A review of the therapeutic management of multiple ventricular septal defects. J Card Surg 2022; 37:1361-1376. [PMID: 35146802 DOI: 10.1111/jocs.16289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/24/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM We showed in our anatomical review, ventricular septal defects existing as multiple entities can be considered in terms of three major subsets. We address here the diagnostic challenges, associated anomalies, the role and techniques of surgical instead of interventional closure, and the outcomes, including reinterventions, for each subset. METHODS We reviewed 80 published investigations, noting radiographic findings, and the results of clinical imaging elucidating the location, number, size of septal defects, associated anomalies, and the effect of severe pulmonary hypertension. RESULTS Overall, perioperative mortality for treatment of residual multiple defects has been cited to be between 0% and 14.2%, with morbidity estimated between 6% and 13%. Perioperative mortality is twice as high for perimembranous compared to muscular defects, with the need for reoperation being over four times higher. Perventricular hybrid approaches are useful for the closure of high anterior or apical defects. Overall, the results have been unsatisfactory. Pooled data reveals incidences between 2.8% and 45% for device-related adverse events. Currently, however, outcomes cannot be assessed on the basis of the different anatomical subsets. CONCLUSIONS We have addressed the approaches, and the results, of therapeutic treatment in terms of coexisting discrete defects, the Swiss-cheese septum, and the arrangement in which a solitary apical muscular defect gives the impression of multiple defects when viewed from the right ventricular aspect. Treatment should vary according to the specific combination of defects.
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Affiliation(s)
- Ujjwal K Chowdhury
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Robert H Anderson
- Institute of Biomedical Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | - Diane E Spicer
- Department of Pediatric Cardiology, University of Florida, Gainesville, Florida, USA.,Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Lakshmi K Sankhyan
- Department of Cardiothoracic Surgery, All India Institute of Medical Sciences, Bilaspur, India
| | - Niwin George
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Niraj N Pandey
- Department of Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Balaji
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shikha Goja
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Vishwas Malik
- Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
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Das D, Das T, Pramanik S, Bannerjee A, Kumar A. Moderator band calcification masquerading infrahisian conduction system disease. JOURNAL OF CLINICAL AND PREVENTIVE CARDIOLOGY 2022. [DOI: 10.4103/jcpc.jcpc_48_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Long-term surgical outcomes after repair of multiple ventricular septal defects in pediatrics. THE CARDIOTHORACIC SURGEON 2021. [DOI: 10.1186/s43057-021-00058-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Surgical closure of multiple ventricular septal defects (VSDs) is challenging and associated with a high complication rate. Several factors may affect the outcomes after surgical repair of multiple VSDs. We aimed to report the outcomes after surgical repair of multiple VSDs before and after 1 year and identify the factors affecting the outcomes. We have studied forty-eight patients between 2016 and 2017 who had surgical repair of multiple VSDs. We grouped them according to the age at the time of repair. Study outcomes were hospital complications, prolonged hospital stay, and reoperation.
Results
There were 18 females (60%) in group 1 and 13 (72.22%) in group 2 (P = 0.39). There were no differences in the operative outcomes between the groups. Prolonged postoperative stay was associated with group 1 (OR 0.23 (0.055–0.96); P = 0.04) and lower body weight (OR 0.76 (0.59–0.97); P = 0.03). Hospital mortality occurred in 2 patients (6.67%) in group 1 and 1 patient (5.56%) in group 2 (P > 0.99). Five patients had reoperations: two for residual VSDs, two for subaortic membrane resection, and one for epicardial pacemaker implantation. All reoperations occurred in group 1 (log-rank P = 0.08). Two patients had transcatheter closure of the residual muscular VSDs; both were in group 2.
Conclusions
Surgical repair of multiple VSDs was associated with good hospital outcomes. The outcomes were comparable in patients younger or older than 1 year of age. Young age at repair could lead to prolonged postoperative stay and a higher reoperation rate.
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Wu Q, Shi L, Chen R, Xing Q. Biventricular surgical repair of "Swiss Cheese" ventricular septal defects with two-patch and right ventricle apex excluding technique: preliminary experience and clinical results. J Cardiothorac Surg 2021; 16:33. [PMID: 33743761 PMCID: PMC7981800 DOI: 10.1186/s13019-021-01399-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 03/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background “Swiss Cheese” ventricular septal defects (VSDs) is a kind of rare and complex congenital heart defects and the surgical management remains controversial and a challenge. We reviewed our preliminary clinical experience on biventricular surgical repair of “Swiss Cheese” VSDs with two-patch and right ventricle apex excluding technique in 10 cases. Methods From May 2014 to December 2019, a series of 10 patients (M/F = 3/7) were admitted in our center. Nine cases underwent one-stage surgical repair with two-patch and right ventricle apex excluding technique and 1 case received two-stage surgical repair with the same technique. Surgical repair was done with cardiopulmonary bypass (CPB) in all cases. Two fresh autologous pericardium patches were used to close defects of the outflow tract area and the apex trabecular area respectively and as a result, the right ventricular apex was excluded from the right ventricular inflow tract. Results All operations were successful. Median CPB time and aortic clamping time were 96 min and 68 min respectively. Delayed chest closure was performed in 2 cases within 48–72 h postoperatively. The Median time of mechanical ventilation and ICU stay were 131.3 h and 8 days respectively. Median length of hospital stay after operation was 11 (9–42) days. There was no mortality and major complication except for 2 cases of ventilator associated pneumonia. There was no death and major complication during a median follow-up time of 3.2 years.. The latest echocardiography results showed the left and right heart function was normal in all the cases. Conclusions Biventricular surgical repair of “Swiss Cheese” VSDs with two-patch of fresh autologous pericardium and right ventricle apex excluding technique in infants is safe and feasible with favorable early and mid-term results. Long term results need to be evaluated with more cases.
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Affiliation(s)
- Qin Wu
- Heart Center, Qingdao Women and Children's Hospital, Qingdao University, No.6 Tongfu Road, 266034, Qingdao, People's Republic of China
| | - Lei Shi
- Pediatric Echocardiography Lab, Qingdao Women and Children's Hospital, Qingdao University, No.6 Tongfu Road, 266034, Qingdao, People's Republic of China
| | - Rui Chen
- Heart Center, Qingdao Women and Children's Hospital, Qingdao University, No.6 Tongfu Road, 266034, Qingdao, People's Republic of China
| | - Quansheng Xing
- Heart Center, Qingdao Women and Children's Hospital, Qingdao University, No.6 Tongfu Road, 266034, Qingdao, People's Republic of China.
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Sakurai H, Nonaka T, Sakurai T, Ohashi N, Nishikawa H. Swiss-cheese ventricular septal defect closure by combination sandwich patch. Asian Cardiovasc Thorac Ann 2020; 29:555-557. [PMID: 33231480 DOI: 10.1177/0218492320976245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 7-year-old boy with a history of neonatal pulmonary artery banding underwent almost complete closure of a sieve-like "Swiss-cheese" ventricular septal defect, using a combination sandwich patch technique through a right ventriculotomy. Although defects existed in the high-, mid-, and low-trabecular septa, a right ventriculotomy and division of the muscle trabeculations continuing the septal and moderator bands helped delineate the edges of the defects. Although patients with "Swiss-cheese" ventricular septal defects may be candidates for a Fontan operation conventionally, a combination patch technique could be considered the procedure of choice.
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Affiliation(s)
- Hajime Sakurai
- Department of Cardiovascular Surgery, Japan Community Healthcare Organization Chukyo Hospital, Nagoya, Japan
| | - Toshimichi Nonaka
- Department of Cardiovascular Surgery, Japan Community Healthcare Organization Chukyo Hospital, Nagoya, Japan
| | - Takahisa Sakurai
- Department of Cardiovascular Surgery, Japan Community Healthcare Organization Chukyo Hospital, Nagoya, Japan
| | - Naoki Ohashi
- Department of Pediatric Cardiology, Japan Community Healthcare Organization Chukyo Hospital, Nagoya, Japan
| | - Hiroshi Nishikawa
- Department of Pediatric Cardiology, Japan Community Healthcare Organization Chukyo Hospital, Nagoya, Japan
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Lee JY, Hur MS. Morphological classification of the moderator band and its relationship with the anterior papillary muscle. Anat Cell Biol 2019; 52:38-42. [PMID: 30984450 PMCID: PMC6449581 DOI: 10.5115/acb.2019.52.1.38] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/03/2018] [Accepted: 12/11/2018] [Indexed: 11/27/2022] Open
Abstract
This study investigated and classified the various types of moderator band (MB) in relation to the anterior papillary muscle, with the aim of providing anatomical reference information and fundamental knowledge for use when repairing the congenital defects and understanding the conduction system. The study investigated 38 formalin-fixed human hearts of both sexes obtained from donors aged 38–90 years. The MB was evident in 36 of the 38 specimens (94.7%). The morphology of the MB and its connection with the APM took various forms. The MBs that had a distinct shape were classified into three types according to their shape: cylindrical column, long and thin column, and wide and flat column. Types 2 and 3 were the most common, appearing in 15 (41.7%) and 14 (38.9%) of the 36 specimens, respectively, while type 1 was observed in seven specimens (19.4%). Type 3 was divided into subtypes based on their length. The MB usually originated from a single root (91.7%), with the remainder exhibiting double roots. The pairs of roots in the latter cases had different shapes. The originating point of the MB ranged from the supraventricular crest to the apex of the ventricle. The most-common originating point was in the middle (25 of 36 specimens, 69.4%), followed by the upper third (13.9%), the lower third (11.1%), and the top fifth (5.6%) of the interventricular septum. This study has produced fundamental anatomical and clinical information that will be useful when designing cardiac surgical procedures.
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Affiliation(s)
- Ju-Young Lee
- Department of Biomedical Engineering, College of Medical Convergence, Catholic Kwandong University, Gangneung, Korea
| | - Mi-Sun Hur
- Department of Anatomy, Catholic Kwandong University College of Medicine, Gangneung, Korea
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Mendez A, Gomez-Ciriza G, Raboisson MJ, Rivas J, Ordoñez A, Poirier N, Valverde I. Apical Muscular Ventricular Septal Defects: Surgical Strategy Using Three-Dimensional Printed Model. Semin Thorac Cardiovasc Surg 2018; 30:450-453. [PMID: 30012368 DOI: 10.1053/j.semtcvs.2018.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 07/06/2018] [Indexed: 11/11/2022]
Abstract
To evaluate the utility of a three-dimensional printed model (3D-model) for surgical decision planning in a complex case of multiple ventricular septal defect (VSD) (so-called Swiss-cheese septum). A 3 month-old-girl with diagnosis of multiple apical VSDs in the trabecular septum, perimembranous VSD, and atrial septal defect that resulted in congestive heart failure was referred for surgical intervention. Due to inconclusive understanding of the total number, openings and locations of the apical VSDs, there were concerns regarding the best surgical approach. Using computed tomography images, a 3D-model was fabricated by fused deposition modeling of polyurethane filament. The 3D model helped identifying the total number of VSD, their origins and exits as well as the minimum number of septal bands to resect, the optimal patch size and morphology to completely close all VSDs without reducing significantly the RV cavity. The procedure was successfully replicated in the patient by right atrial approach, resulting in good RV cavity size, function and no residual VSDs evaluated by transesophageal echocardiography. Direct evaluation of the 3D printed replica anatomy and surgical simulation may help optimizing surgical approach, patch size and location and therefore it might reduce complications and residual defects.
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Affiliation(s)
- Ana Mendez
- Paediatric Cardiology and Technological Innovation Group, Hospital Virgen del Rocio, Seville, Spain.; Cardiovascular Pathology Unit, Institute of Biomedicine of Seville (IBIS), CIBER-CV, Hospital Virgen de Rocio/CSIC/University of Seville, Seville, Spain.; Division of Paediatric Cardiology, Department of Paediatrics, Sainte-Justine University Hospital Center, Montreal, Quebec, Canada
| | - Gorka Gomez-Ciriza
- Paediatric Cardiology and Technological Innovation Group, Hospital Virgen del Rocio, Seville, Spain
| | - Marie-Josée Raboisson
- Division of Paediatric Cardiology, Department of Paediatrics, Sainte-Justine University Hospital Center, Montreal, Quebec, Canada
| | - Jose Rivas
- Paediatric Cardiology and Technological Innovation Group, Hospital Virgen del Rocio, Seville, Spain
| | - Antonio Ordoñez
- Cardiovascular Pathology Unit, Institute of Biomedicine of Seville (IBIS), CIBER-CV, Hospital Virgen de Rocio/CSIC/University of Seville, Seville, Spain
| | - Nancy Poirier
- Division of Paediatric Cardiology, Department of Paediatrics, Sainte-Justine University Hospital Center, Montreal, Quebec, Canada
| | - Israel Valverde
- Paediatric Cardiology and Technological Innovation Group, Hospital Virgen del Rocio, Seville, Spain.; Cardiovascular Pathology Unit, Institute of Biomedicine of Seville (IBIS), CIBER-CV, Hospital Virgen de Rocio/CSIC/University of Seville, Seville, Spain.; Division of Imaging Sciences and Biomedical Engineering, King's College London, The Rayne Institute, St. Thomas' Hospital, London, UK..
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Daley M, Brizard CP, Konstantinov IE, Brink J, Kelly A, Jones B, Zannino D, d'Udekem Y. Outcomes of Patients Undergoing Surgical Management of Multiple Ventricular Septal Defects. Semin Thorac Cardiovasc Surg 2018; 31:89-96. [PMID: 29601908 DOI: 10.1053/j.semtcvs.2018.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2018] [Indexed: 11/11/2022]
Abstract
Surgical treatment of multiple ventricular septal defects (VSDs) has advanced significantly in recent years, yet remains technically challenging. With high rates of complications and reoperations, we sought to assess the outcomes of patients undergoing a variety of management techniques for multiple VSDs. From 1988 to 2015, 157 consecutive patients underwent surgical management of multiple VSDs at a median age of 2.2 months (2 days-16 years). Sixty-nine patients (44%) had exclusively multiple VSDs, 62 patients (39%) had multiple VSDs with concomitant intracardiac anomalies, and 26 patients (17%) had multiple VSDs with aortic arch anomalies. The predominant techniques used at the initial operations were patch closure (84 patients), pulmonary artery band (83 patients), suture closure (37 patients), and sandwich technique (13 patients). Eighteen patients underwent ventriculotomies. There were 3 hospital deaths (2%). Mean follow-up time was 8.6 ± 6 years (1 day-22 years). Four patients died during follow-up, whereas freedom from reoperations was 52% (95% confidence interval 42-61%) at 16 years. Freedom from reoperation was significantly lower in the 1988-2002 era than in the post-2002 era (38% vs 73%, P = 0.016). Pacemaker implantation was ultimately required in 9% (14 of 150) of patients. No deleterious impact of a ventriculotomy could be detected. Surgical treatment of multiple VSDs can be performed with excellent short- and long-term survival, and normal late functional outcome, however, carries a significant rate of reoperation. The recent inclusion of absorbable pulmonary artery bands and the sandwich technique appear safe and are useful adjuncts in these patients.
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Affiliation(s)
- Michael Daley
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Christian P Brizard
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Igor E Konstantinov
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Johann Brink
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Andrew Kelly
- Department of Cardiology, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Bryn Jones
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Diana Zannino
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Yves d'Udekem
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.
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Holzer RJ, Sallehuddin A, Hijazi ZM. Surgical strategies and novel alternatives for the closure of ventricular septal defects. Expert Rev Cardiovasc Ther 2016; 14:831-41. [PMID: 27007884 DOI: 10.1586/14779072.2016.1169923] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A variety of therapies are available to close ventricular septal defects (VSDs). These include surgical closure on bypass, percutaneous device closure, as well as perventricular hybrid closure. Due to the incidence of heart block (1-5%) associated with percutaneous device closure of perimembranous VSDs, surgical closure presently remains the gold standard and preferred therapy for these defects. Therapeutic options are more varied for muscular VSDs. Beyond infancy, transcatheter closure offers excellent results with low morbidity and mortality, without the need for cardiopulmonary bypass. Infants however have a higher incidence of adverse events using a percutaneous approach. Large mid-muscular VSDs in infants can be treated successfully using a hybrid approach, surgical closure on bypass or a percutaneous approach. However, VSDs located apically or anteriorly are difficult to identify surgically and for these infants, perventricular hybrid closure should be considered as the preferred therapeutic modality. However, some VSD's also can be closed percutaneously.
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Affiliation(s)
- Ralf J Holzer
- a Division Chief Cardiology (Acting) , Sidra Medical and Research Center , Doha , Qatar
| | - Ahmad Sallehuddin
- b Cardiothoracic Department , Hamad Medical Corporation , Doha , Qatar
| | - Ziyad M Hijazi
- c Department of Pediatrics , Sidra Medical and Research Center , Doha , Qatar
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Yoshimura N, Fukahara K, Yamashita A, Doki Y, Takeuchi K, Higuma T, Senda K, Toge M, Matsuo T, Nagura S, Aoki M, Sakata K, Sakai M. Current topics in surgery for multiple ventricular septal defects. Surg Today 2015; 46:393-7. [DOI: 10.1007/s00595-015-1180-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 03/30/2015] [Indexed: 11/25/2022]
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Koneti NR, Verma S, Bakhru S, Vadlamudi K, Kathare P, Jagannath B. Epicardial deployment of right ventricular disk during perventricular device closure in a child with apical muscular ventricular septal defect. Ann Pediatr Cardiol 2014; 6:176-8. [PMID: 24688240 PMCID: PMC3957452 DOI: 10.4103/0974-2069.115275] [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
We report a successful perventricular closure of an apical muscular ventricular septal defect (mVSD) by a modified technique. An eight-month-old infant, weighing 6.5 kilograms, presented with refractory heart failure. The transthoracic echocardiogram showed multiple apical mVSDs with the largest one measuring 10 mm. perventricular device closure using a 12 mm Amplatzer mVSD occluder was planned. The left ventricular disk was positioned approximating the interventricular septum; however, the right ventricular (RV) disk was deployed on the free wall of the RV due to an absent apical muscular septum and a small cavity at the apex. The RV disk of the device was covered using an autologous pericardium. His heart failure improved during follow-up.
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Affiliation(s)
| | - Sudeep Verma
- Department of Pediatric Cardiology, Care Hospital, Hyderabad, India
| | - Shweta Bakhru
- Department of Pediatric Cardiology, Care Hospital, Hyderabad, India
| | | | - Pallavi Kathare
- Department of Pediatric Cardiology, Care Hospital, Hyderabad, India
| | - Br Jagannath
- Department of Pediatric Cardiac Surgery, Care Hospital, Hyderabad, India
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Koneti NR, Verma S, Bakhru S, Vadlamudi K, Kathare P, Penumatsa RR, Qureshi S. Transcatheter trans-septal antegrade closure of muscular ventricular septal defects in young children. Catheter Cardiovasc Interv 2013; 82:E500-6. [PMID: 23704080 DOI: 10.1002/ccd.25020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 05/10/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Surgical or transcatheter closure of muscular ventricular septal defects (mVSDs) in young children may be technically challenging and associated with significant complications. OBJECTIVE To assess the feasibility of trans-septal antegrade closure of mVSD in a selected subset of young children. METHODS This is a prospective study from a single centre from July 2011 to March 2013. Nine infants and children with single or multiple mVSDs were included in the study. The median age and weight were 6 months (range 4-18 months) and 4.5 kg (range 3.8-6.2 kg), respectively. Trans-femoral trans-septal antegrade technique was used in eight children. One child was excluded from the study because of abnormally tortuous anatomy of both the femoral veins and subsequently underwent VSD device closure by the trans-jugular approach. The follow-up evaluation included chest X-ray, ECG, and echocardiogram at 1 month, 3 months, 6 months, and 1 year. RESULTS The defects were closed successfully in all eight patients using Amplatzer mVSD device in 5 and Amplatzer Duct Occluder II in 3. Moderate mitral regurgitation due to entrapment of the anterior mitral leaflet occurred in one patient with a posteriorly located mVSD, necessitating removal of the device, and surgical closure of the mVSD. The small additional residual mVSD in one other patient closed spontaneously during the follow-up. CONCLUSIONS Transcatheter trans-septal antegrade closure of mVSD in young children is technically feasible and merits further consideration. Symptomatic relief in multiple mVSD can be achieved after closing larger defects.
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Affiliation(s)
- Nageswara Rao Koneti
- Care Hospital, The Institute of Medical Sciences, Road No. 1, Banjara Hills, Hyderabad, 50034, Andhra Pradesh, India
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Matsuhisa H, Yoshimura N, Higuma T, Misaki T, Onuma Y, Ichida F, Oshima Y, Okita Y. Ventricular Septal Dysfunction After Surgical Closure of Multiple Ventricular Septal Defects. Ann Thorac Surg 2013; 96:891-7. [DOI: 10.1016/j.athoracsur.2013.05.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 05/03/2013] [Accepted: 05/06/2013] [Indexed: 12/01/2022]
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Kitagawa T, Kitaichi T, Sugano M, Kurobe H. Techniques and results in the management of multiple muscular trabecular ventricular septal defects. Gen Thorac Cardiovasc Surg 2013; 61:367-75. [PMID: 23737104 DOI: 10.1007/s11748-013-0267-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Indexed: 10/26/2022]
Abstract
The management of patients with multiple muscular trabecular ventricular septal defects (VSDs) remains controversial. In the past two decades, innovative techniques including a right ventricular apical infundibulotomy and transcatheter, intraoperative and perventricular device closure have been exploited, and essential right atrial approach and limited apical left ventriculotomy have also been refined. However, specific management guidelines for this difficult disease have not been established. In this article, the benefits and drawbacks of each technique are reviewed and discussed. Primary repair for infants with multiple muscular trabecular VSDs was associated with good late outcomes. The right atrial approach was satisfactory for all muscular VSDs, excluding apical defects that were well seen through a limited apical ventriculotomy. Surgical closure of apical defects could be achieved safely and completely in early infancy through a limited apical left ventriculotomy or a right ventricular apical infundibulotomy. Further follow-up and prudent evaluations of ventriculotomy-associated morbidities are needed. Pulmonary artery banding should be limited to a small infant with complex associated defects. Percutaneous device closure, the most desirable option, is impractical due to limitations between the delivery system and access route. Intraoperative device closure appears less successful than device closure in the catheterization laboratory. Perventricular device closure has a significant advantage of being a non-bypass procedure approach. A less invasive strategy for "true" Swiss cheese septum is needed. All may have an important role, and results obtained by using these techniques are encouraging. These hybrid approaches will promise future success on management guidelines of multiple muscular trabecular VSDs.
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Affiliation(s)
- Tetsuya Kitagawa
- Department of Cardiovascular Surgery, Institute of Health Biosciences, The University of Tokushima Graduate School, 3-18-15 Kuramoto, Tokushima 770-8503, Japan.
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Gu Q, Zhou J, Gu H, Lu F, Zhang Y. Surgical Management of Apical Muscular Ventricular Septal Defects Using the Sandwich Technique. J Card Surg 2013; 28:301-5. [PMID: 23675683 DOI: 10.1111/jocs.12104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Qun Gu
- Department of Pediatric Cardiothoracic Surgery; Jiangsu Province Hospital; Nanjing China
| | - Jie Zhou
- Department of Pediatric Cardiothoracic Surgery; Jiangsu Province Hospital; Nanjing China
| | - Haitao Gu
- Department of Pediatric Cardiothoracic Surgery; Jiangsu Province Hospital; Nanjing China
| | - Fengxia Lu
- Department of Pediatric Cardiothoracic Surgery; Jiangsu Province Hospital; Nanjing China
| | - Yongshen Zhang
- Department of Pediatric Cardiothoracic Surgery; Jiangsu Province Hospital; Nanjing China
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Anderson BR, Stevens KN, Nicolson SC, Gruber SB, Spray TL, Wernovsky G, Gruber PJ. Contemporary outcomes of surgical ventricular septal defect closure. J Thorac Cardiovasc Surg 2013; 145:641-7. [DOI: 10.1016/j.jtcvs.2012.11.032] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 09/28/2012] [Accepted: 11/09/2012] [Indexed: 11/30/2022]
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Hofmeyr L, Pohlner P, Radford DJ. Long-term complications following surgical patch closure of multiple muscular ventricular septal defects. CONGENIT HEART DIS 2013; 8:541-9. [PMID: 23350905 DOI: 10.1111/chd.12038] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Multiple muscular ventricular septal defects (VSDs) in children can be difficult to treat and a range of techniques has been advocated. These include pulmonary artery banding, interventional catheter closure, and a variety of surgical approaches. When there are apical muscular defects and associated coarse trabeculations in the right ventricle (RV) producing a "Swiss cheese" pattern, a large patch extending on to the RV free wall and excluding part of the apex has been used. METHODS We assessed four adult patients who had surgery 22 to 45 years ago to treat muscular VSD by patches which excluded the RV apex. RESULTS Ages ranged from 22 to 50 years. Re-presentations were for polycythemia, cyanosis, syncope, and atrial flutter. Echocardiography showed bidirectional flow from left ventricle to apex of RV, no pulmonary hypertension, small-sized RV with diastolic dysfunction, enlarged right atria, reopening of patent foramen ovale (PFO) in three, and positive bubble studies with right to left shunting in two. Catheterization confirmed elevated right atrial and RV end diastolic pressures. Two patients had evidence of hepatic cirrhosis. One woman had device closure of PFO, but has right heart failure. One man had redo surgical closure of VSD and PFO. Another patient is being considered for a Glenn shunt to take some load off RV. CONCLUSIONS Surgical closure of muscular VSD by large patch with RV apical exclusion gives good early results. However, long term in adult life, the reduced size of RV, and diastolic dysfunction cause problems. These include reopening of PFO with cyanosis, right heart failure, cirrhosis, and arrhythmias.
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Affiliation(s)
- Lou Hofmeyr
- Adult Congenital Heart Disease Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia
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Corno AF, Kandakure PR, Dhannapuneni RRV, Gladman G, Venugopal P, Alphonso N. Multiple ventricular septal defects: a new strategy. Front Pediatr 2013; 1:16. [PMID: 24400262 PMCID: PMC3860893 DOI: 10.3389/fped.2013.00016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 07/16/2013] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION A multicenter prospective study was conducted to evaluate a new strategy for multiple Ventricular Septal Defects (VSDs). MATERIALS AND METHODS From 2004 to 2012 17 consecutive children (3 premature, 14 infants), mean age 3.2 months (9 days-9 months), mean body weight 4.2 kg (3.1-6.1 kg), with multiple VSDs underwent Pulmonary Artery Banding (PAB) with an adjustable FloWatch-PAB(®). Associated cardiac anomalies included patent ductus arteriosus (1), aortic coarctation (2), hypoplastic aortic arch (2), and left isomerism (3). Five patients (5/17 = 29.4%) required pre-operative mechanical ventilation, with a mean duration of 64 days (7-240 days) RESULTS There were no early or late deaths during a mean follow-up of 48 months (7-98 months), with either FloWatch removal or last observation as end-points. FloWatch-PAB(®) adjustments were required in all patients: a mean of 4.8 times/patient (2-9) to tighten the PAB, and a mean of 1.1 times/patient (0-3) to release the PAB with the patient's growth. After a mean interval of 29 months (8-69 months) 10/17 (59%) patients underwent re-operation: 7/10 PAB removal, with closure of a remaining unrestrictive VSD in 6 (peri-membranous in 3 patients, mid-muscular in 2, and inlet in 1) and Damus-Kaye-Stansel, bi-directional Glenn, and atrial septectomy in 1; 3/9 patients required only PAB removal. All muscular multiple VSDs had closed in all 10 patients. PA reconstruction was required in 1/10 patient. In 5/7 of the remaining patients with the PAB still in situ, all muscular VSDs had already closed. The only 2 patients with persistent muscular multiple VSDs are the 2 patients with the shortest follow-up. CONCLUSION This reproducible new strategy with an adjustable PAB simplifies the management of infants with multiple VSDs and provides the following advantages: (a) good results (0% mortality), delayed surgery with a high incidence (15/17 = 88%) of spontaneous closure of multiple muscular VSDs, and facilitated closure of residual unrestrictive VSD (peri-membranous, mid-muscular, or inlet) at an older age and higher body weight; PAB with FloWatch-PAB(®) and its subsequent removal can potentially be the only procedure required for Swiss cheese multiple VSDs without an associated peri-membranous unrestrictive VSD.
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Kosiński A, Kozłowski D, Nowiński J, Lewicka E, Dąbrowska-Kugacka A, Raczak G, Grzybiak M. Morphogenetic aspects of the septomarginal trabecula in the human heart. Arch Med Sci 2010; 6:733-43. [PMID: 22419933 PMCID: PMC3298343 DOI: 10.5114/aoms.2010.17089] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Revised: 08/05/2010] [Accepted: 08/27/2010] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The septomarginal trabecula is a constant element of the anatomy of the human heart, which connects the interventricular septum and the anterior wall of the right ventricle. Considering the diversity of opinions about the structure and numerous studies suggesting its important role in haemodynamics and conduction of electrical impulses in the heart, we decided to study this element in detail. MATERIAL AND METHODS The research was conducted on 220 human hearts. Attention was mainly paid to the structure and topography of the trabecula. Its relation to the anterior papillary muscle was also a part of the study. RESULTS The presence of this morphologically diverse element was confirmed in each of the studied hearts. In most cases the trabecula originated from the upper part of the interventricular septum, separating at an angle increasing proportionally to the number of branches of the crista supraventricularis as well as the number of secondary trabeculae. The criteria established for the study, which included the course of the trabecula in the lumen of the right ventricle and its relation to the anterior papillary muscle, let us distinguish 4 types of septomarginal trabecula (I, II, III, IV). The most common was type III, the undivided trabecula, tightly connecting with the anterior papillary muscle. CONCLUSIONS Based on the results of the following study we propose a hypothesis on the genesis of respective parts of the septomarginal trabecula and a plausible sequence of changes they undergo during human ontogenesis and phylogenesis of the primates.
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Affiliation(s)
- Adam Kosiński
- Department of Clinical Anatomy, Medical University of Gdansk, Poland
| | - Dariusz Kozłowski
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
| | - Janusz Nowiński
- Department of Clinical Anatomy, Medical University of Gdansk, Poland
| | - Ewa Lewicka
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
| | | | - Grzegorz Raczak
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
| | - Marek Grzybiak
- Department of Clinical Anatomy, Medical University of Gdansk, Poland
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Graham TP. The Year in Congenital Heart Disease. J Am Coll Cardiol 2010; 55:147-55. [DOI: 10.1016/j.jacc.2009.08.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Revised: 08/17/2009] [Accepted: 08/24/2009] [Indexed: 11/25/2022]
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