Evolution of aortic regurgitation following simple patch closure of doubly committed subarterial ventricular septal defect

Outflow Ventricular Septal Defect with Aortic Regurgitation: Optimal timing of Surgery?

BACKGROUND

Ideal time of surgery still remains controversial in outflow ventricular septal defect (VSD) with aortic regurgitation (AR). We aimed to identify the prevalence and predictors of postoperative AR progression.

METHODS

154 patients with outflow-VSD and AR who underwent VSD surgery between 2006 and 2012 were studied retrospectively.

RESULTS

Total 80 patients with subpulmonic-VSD and 74 with subaortic-VSD were followed-up for mean 6.32+/-2.27 years (range 3-12 years). Of them, 100 had trivial to mild (group-A) and 54 had moderate to severe preoperative-AR (group-B). At follow-up, There was no significant worsening of mean residual AR in group-A (p=0.16) and subpulmonic-VSD of group-B (p=0.083). However, it worsened significantly in subaortic-VSD (1.85+/-0.87 vs 2.21+/-1.08, p=0.005) of group-B. Only 2 (both had subaortic-VSD) patients of group-A developed moderate AR and none required aortic valve replacement (AVR), while 23 (42.60%) of group-B patients developed moderate or severe AR and 7 (30.4%) of them required AVR. Moreover, all who needed AVR had subaortic-VSD and had undergone valvuloplasty during VSD-closure. The 10 years freedom from moderate or severe-AR was significantly lower in group-B than group-A in both VSDs (subaortic-VSD 42.5+/-10.7% vs 89.3+/-8.1%, p<0.01; subpulmonic-VSD 66.7+/-10.3% vs 100%, p<0.01). On multiple regression analysis, postoperative residual-AR was the only predictor of AR-progression (standardized coefficients =0.48; p<0.001) at follow-up.

CONCLUSIONS

Mild preoperative-AR rarely progressed after VSD-repair. However, worsening of AR could not be prevented effectively, even with valvuloplasty, after the development of moderate or severe AR. Mild or more postoperative residual-AR need close follow-up, especially in subaortic-VSD.

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.

Surgery for doubly committed ventricular septal defects

OBJECTIVES

Doubly committed ventricular septal defects (VSDs) account for up to almost one-third of isolated ventricular septal defects in Asian countries, compared with only 1/20th in western populations. In our surgical experience, this type of defect accounted for almost three-quarters of our practice. To date, patch closure has been considered the gold standard for surgical treatment of these lesions. Our objectives are to evaluate the indications and examine the outcomes of surgery for doubly committed VSDs.

METHODS

Between October 2013, when our service of paediatric cardiac surgery was opened, and December 2014, 24 patients were referred for surgical closure of VSDs. Among them, 17 patients (71%), with the median age of 6 years, ranging from 2 to 9 years, and with a median body weight of 19 kg, ranging from 11 to 56 kg, underwent surgical repair for doubly committed defects. In terms of size, the defect was considered moderate in 4 and large in 13. Aortic valvular regurgitation (AoVR) was present in 11 patients (65%) preoperatively, with associated malformations found in 14 (82%), with 5 patients (29%) having two or more associated defects.

RESULTS

After surgery, there was trivial residual shunting in 2 patients (12%). AoVR persisted in 6 (35%), reducing to trivial in 5 (29%) and mild in 1 (6%). Mean stays in the intensive care unit and hospital were 2.6 ± 1.2 days, ranging from 2 to 7 days, and 6.8 ± 0.8 days, ranging from 6 to 9 days, respectively. The mean follow-up was 14 ± 4 months, ranging from 6 to 20 months, with no early or late deaths and without clinical deterioration.

CONCLUSIONS

The incidence of doubly committed lesions is high in our experience, frequently associated with AoVR and other associated malformation. Early detection is crucial to prevent further progression of the disease. Patch closure remains the gold standard in management, not least since it allows simultaneous repair of associated intracardiac defects.

Doubly committed ventricular septal defect: single-centre experience and midterm follow-up

BACKGROUND

Doubly committed ventricular septal defect (dcVSD) is the least common type of VSD. Because published studies are rather scarce, this study aimed at evaluating the midterm outcome of dcVSDs.

METHODS

The records of all patients registered in the database of Paediatric and Congenital Cardiology, University Hospitals Leuven, with a dcVSD at 16 years of age were reviewed. Clinical, electrocardiographic and transthoracic echocardiographic changes from baseline, defined as of the age of 16 years, until the latest follow-up were compared.

RESULTS

Thirty-three patients (20 males, median age 26 years, interquartile range 12) were followed for a median time of 7.9 years (interquartile range 9.8, time range 2-25.9). No deaths occurred. In 15 patients (45%), the defect remained patent at baseline. During follow-up, two spontaneous closures (13%) occurred. Eighteen patients (55%) required closure before the age of 16 years. Five (28%) needed reoperation. In the dcVSD closure group, left ventricular ejection fraction decreased from 69 ± 12 to 61 ± 6% (p = 0.028). No significant changes in pulmonary arterial hypertension were noticed.

CONCLUSIONS

Patients with persistently patent dcVSD remained nearly event free during follow-up. Event-free survival after dcVSD closure was markedly lower. These patients developed reduced left ventricular function and had a high risk of reintervention.

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.

Ventricular septal defect closure in right coronary cusp prolapse and aortic regurgitation complicating VSD in the outlet septum: which treatment is most appropriate?

BACKGROUND

There is currently not a standardized technique for the sizing and shaping of surgical closure of the ventricular septal defect (VSD) patch in patients with right coronary aortic cusp prolapse and aortic regurgitation (AR) complicating VSD in the outlet septum.

METHODS

Forty-six VSD patients who had aortic valve prolapse were divided into groups DC (direct closure, n=19), and SPC (small patch closure, n=27). Preoperative and postoperative echocardiography with Doppler color flow interrogation was performed on all patients.

RESULTS

In the DC group, among seven patients who had aortic valve prolapse but no AR preoperative, one patient developed AR during postoperative follow-up period. In the remaining 12 patients who had mild AR associated with aortic valve prolapse prior to the procedure, AR was diminished in four and unchanged in six patients. However, AR was aggravated in two patients who required further operations for AV repair or replacement. In the SPC group, among the eight patients who had no preoperative AR, AR progressed in one patient postoperatively. In the remaining 19 patients who had mild AR, AR was diminished in 15 and unchanged in four. The outcome from the operative procedure was significantly better in the SPC group than DC group with mild preoperative AR (chi(2)=7.82; P<0.05).

CONCLUSIONS

Small patch closure for this type of VSD is safer and more reliable in improving mild AR than that of direct closure, especially in patients with mild AR.

Ventricular septal defect and aortic valve regurgitation: pathophysiology and indications for surgery

As the velocity of a fluid increases a low-pressure zone is created, this is the Venturi effect and it explains the pathogenesis of aortic valve prolapse (AVP) and aortic insufficiency (AI) that is observed in a subset of patients with a ventricular septal defect (VSD). The VSDs complicated by AI are restrictive with high velocity shunting through the VSD, creating a low-pressure zone that impacts the adjacent aortic valve cusp resulting in AVP and subsequent AI. AVP and AI are therefore acquired lesions. AI is absent at birth because the forces necessary to create the low-pressure zone within the restrictive VSD do not exist in utero. The risk of development of AI increases during childhood, peaking at 5 to 10 years of age. VSD closure eliminates the low-pressure zone that is the cause of ongoing aortic valve cusp deformity and, if performed early, prevents development of AI. Patients with a subarterial VSD and AVP should undergo surgery to prevent the development of AI because this complicates about half of subarterial VSDs with AVP and spontaneous closure is rare. Patients with perimembranous VSDs with AVP should be followed with serial echocardiography and undergo VSD closure if more than trivial AI develops.

Impact of noncoronary cusp prolapse in addition to right coronary cusp prolapse in patients with a perimembranous ventricular septal defect

BACKGROUND

Few data are available with regard to the impact of aortic cusp herniation on the evolution of aortic regurgitation (AR) in patients with a perimembranous ventricular septal defect (VSD).

METHODS

One hundred and two patients with a perimembranous ventricular septal defect with right coronary cusp prolapse were divided to two groups depending on the development of aortic regurgitation. The original defect diameter, the right coronary cusp deformity index (RCCD), and the right coronary cusp imbalance index were obtained as we reported previously.

RESULTS

Mild aortic regurgitation was detected in 35 patients, and moderate in three. No aortic regurgitation was observed in 64 patients. A significantly larger number of patients had noncoronary cusp prolapse and the right coronary cusp imbalance index >/=1.30 in the aortic regurgitation group than in the no regurgitation group. Relative risk and odds ratio of noncoronary cusp prolapse and the right coronary cusp imbalance index >/=1.30 for development of aortic regurgitation were 3.69 (95% CI, 0.91-15.03) and 27.90 (95.94-130.85), and 2.23 (0.83-5.98) and 4.70 (1.44-15.27), respectively. Surgical closure was performed in 29 patients. All patients with no noncoronary cusp prolapse underwent simple patch closure of the ventricular septal defect, while five patients with noncoronary cusp prolapse and aortic regurgitation underwent aortic valvuloplasty. Among these, one patient needed aortic valve replacement.

CONCLUSIONS

The additional complication of noncoronary cusp prolapse is a strong risk factor for the development of aortic regurgitation in patients with a perimembranous ventricular septal defect with right coronary cusp prolapse.

Severity Indices of Right Coronary Cusp Prolapse and Aortic Regurgitation Complicating Ventricular Septal Defect in the Outlet Septum-Which Defect Should Be Closed?-

BACKGROUND

The factors that may determine the evolution of right coronary cusp prolapse (RCCP) and regurgitation (AR) associated with a ventricular septal defect in the outlet septum (outlet VSD) have not been clarified.

METHODS AND RESULTS

The Doppler echocardiograms of 316 patients were grouped according to both the development of RCCP, and the values of the right coronary cusp deformity index (RCCD) and the right coronary cusp imbalance index (R/L). All detected AR was </= slight, and not progressive in patients with both RCCD <0.30 and R/L <1.30. Moderate AR was detected in patients with either RCCD >/=0.30 or R/L >/=0.30. Rupture of the sinus of Valsalva was identified in patients with RCCD >/=0.30. A significantly large number of patients with both RCCD >/=0.30 and R/L >/=1.30 (p<0.01), and a few patients with either RCCD >/=0.30 or R/L >/=0.30 underwent aortic valvuloplasty or replacement. Operative outcome for AR </= slight was good.

CONCLUSIONS

There is no need to close an outlet VSD with RCCP when the RCCD <0.30 and R/L <1.30 as long as the AR remains trivial, but such defects should be closed when the RCCD is >/=0.30 or R/L >/=1.30.

Eccentric aortic regurgitation in patients with right coronary cusp prolapse complicating a ventricular septal defect

To analyze the clinical significance of eccentric aortic regurgitation (AR) complicating the right coronary cusp prolapse associated with a ventricular septal defect (VSD), the Doppler echocardiograms of 129 patients were reviewed. In 102 patients, AR was classified as mild and in 27 patients it was classified as moderate. Eccentric AR was defined as the jet distributing in an eccentric direction. In 15 patients of the moderate group, AR was already moderate at the initial examination and of these, the AR was eccentric in 14 and central in 1. In 12 patients who initially had mild AR, it became moderate during follow-up. In 7 patients with mild, central AR, 6 worsened to central moderate AR and 1 evolved to eccentric moderate AR. Eccentric mild AR patients all developed eccentric moderate AR. Within the mild AR group, 5 of 9 patients with eccentric AR progressed from mild to moderate, whereas only 7 of 105 patients with central AR did so (p<0.01). In conclusion, eccentric AR may be an advanced finding of the AR associated with right coronary cusp prolapse in some patients, but in others eccentric AR is highly likely to progress and is malignant.

[Aortic valve complications associated with subarterial infundibular ventricular septal defect. Echocardiograpic follow-up]

INTRODUCTION AND OBJECTIVES

Interventricular fibromuscular septal defects of the outlet tract are subarterial infundibular ventricular septal defects (VSDs). This anatomical situation predisposes to aortic cusp prolapse (AoP) and/or regurgitation (AoR).

METHODS

In order to determinate the frequency of VSDs and the presence or development of aortic valve alterations detected by two-dimensional echocardiography, we studied 35 patients with VSDs. The defect area and presence, severity, and evolution of AoP and/or AoR were evaluated. Ten anatomic specimens were studied to verify the echocardiographic correlation.

RESULTS

Subarterial infundibular defect was present in 6.9% of all ventricular septal defects. The average age at time of diagnosis was 5,8 years. VSDs diameter and gradient did not change during follow-up. At time of diagnosis, 30 patients (87%) did not have AoR, but during an average follow-up of 8 years, 11 (32%) developed it. By the end of the study, 46% had AoR. When the time to progression of AoR was compared in the group that developed it versus the group that did not, the median values were similar in both groups. There was a greater tendency to development and/or progression of regurgitation in small VSDs. The echo-anatomic correlation was precise.

CONCLUSIONS

Aortic valve damage was a frequent finding in VSD. Most cases did not progress to more severe AoR. Small VSDs developed more severe regurgitation in less time. Surgery must be considered when AoR is detected. Regular evaluation by echocardiography is important in follow-up.

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.

Imbalance of cusp width and aortic regurgitation associated with aortic cusp prolapse in ventricular septal defect

The Doppler echocardiograms of the aortic valve and associated aortic regurgitation (AR) were reviewed in 72 patients with a ventricular septal defect (VSD). Group I comprised 13 patients without any deformity of the aortic cusp for > or = 10 years, group 2 included 35 patients who did not develop AR for > or = 10 years after right coronary cusp prolapse (RCCP) was first detected, group 3 comprised 11 patients with RCCP and AR in whom the AR remained subclinical for > or = 10 years, and group 4 was 13 patients who underwent surgical treatment because of moderate to severe AR. The cusp imbalance index [width of right (R) or non- (N) coronary cusp/width of left coronary cusp (L)] was compared among the 4 groups. R/L or N/L was larger in group 4 than in groups 1-3; R/L exceeded 1.30 in all the patients in group 4, whereas it was less than 1.30 in all the atients in groups 1-3. Two patients in group 4 with non-coronary cusp prolapse had an N/L greater than 1.50. No other patients in any group had an N/L larger than 1.20. An imbalance of cusp width may predict possible progressive deterioration of AR.