Surgical treatment of large ventricular septal defect with pulmonary hypertension in the first 24 months of life

Mortality from congenital cardiovascular malformations in Japan, 1968 through 1997

Long-term mortality from congenital cardiovascular malformations (CCVM) remains unknown in most countries. Age- and sex-specific mortality rates from CCVM in Japan from 1968 through 1997 were determined from analyses, with official permission, of individual death records held by the Japanese Government. CCVM with chromosomal anomalies were not included. The number of deaths analyzed was 82,919. The mortality rate declined by 64% from 3.36 per 100,000 population in 1968 to 1.22 in 1997, largely because of a decrease in mortality among patients under 20 years of age. Infant mortality remained high until 1978, then sharply declined from 1979 to 1987 with the advent of 2-dimensional echocardiographic diagnosis and prostaglandin El therapy. The cumulative mortality rates in the first 20 years of life were expected to decline among cohort members born after 1978. In contrast, the mortality rates for subjects over 20 years of age increased during the 30-year study period. Mortality rates were higher for males than for females. The mortality rate among young patients with CCVM is expected to decline still further, suggesting that many if not most children with CCVM will survive to adulthood.

Long-term results of primary closure for ventricular septal defects in the first year of life

The long-term results of primary closure for large ventricular septal defects (VSDs) in infants under 1 year of age with severe symptoms were studied over a period of more than 10 years. Between January, 1971 and March, 1982, 49 infants underwent primary closure of a VSD through a right ventriculotomy using complete cardiopulmonary bypass with mild hypothermia. There were four hospital deaths but no late deaths. Two of four infants with residual shunts had a left ventricular-right atrial shunt which necessitated reoperation. Surgical heart block occurred in two infants who recovered sinus rhythm in the late period. The cardiothoracic ratio decreased from 60.5% preoperatively to 50.6% in the late postoperative period. Examination by cardiac catheterization revealed that the pulmonary-to-systemic pressure ratio (Pp/Ps) of 23 patients with a Pp/Ps of over 0.75 fell from 0.89 +/- 0.09 preoperatively to 0.42 +/- 0.12 by 1 month postoperatively, then to 0.27 +/- 0.05 in the late postoperative period. The latest values for the cardiac index and left ventricular ejection fraction were 3.4 l/min per m2 and 64.4%, respectively. More than 10 years after their operation, all the survivors were growing normally and maintaining a good quality of life, which supports our recommendation that primary repair should be performed in the first year of life for infants with large VSDs.

Pulmonary hypertension and platelet function

Platelet number and function were measured in patients (n = 45) who underwent open-heart surgery with cardiopulmonary bypass (CPB). The study showed that platelet adhesion and aggregation were higher in the patients who suffered from congenital heart disease with pulmonary hypertension than in those in the control group, i.e. without pulmonary hypertension. Platelet number and function gradually increased in the experimental group after the operation and postoperative blood loss was greater than that in the control group. The reason for this may have been platelet hyperfunction in patients with pulmonary hypertension, which resulted in platelet destruction and severe depletion during operation. Therefore, it is difficult to achieve haemosttasis and prevent blood loss.

Repair of large ventricular septal defects in infants and small children

It is possible to achieve excellent results for primary closure of ventricular septal defects regardless of the age of the patients when surgical intervention is required. Thirty-two severely symptomatic patients, age 1-24 months, with large ventricular septal defects (m Qp/Qs = 3.4, m R VSD = 4.0), had primary repair of the defects with one (3%) hospital death. Seven patients (22%) had increased pulmonary vascular resistance ranging from 5.4 to 12 units/m2. It was possible to close the ventricular septal defect through the right atrium in 26 patients (81%). Pulmonary artery banding was not performed in any patient with isolated ventricular septal defect during the period of this study. The 31 survivors have been followed an average of four years, and 30 of them are remarkably improved and remain New York Heart Association Class I or II. Only one patient, with obstructive pulmonary vascular disease (pulmonary resistance = 12 U/m2), died suddenly 16 months after operation. Follow-up catheterization was offered to all patients, and to date, 18 (60%) have been restudied. These hemodynamic data show that pulmonary vascular resistance after surgery is usually normal or only minimally elevated; except for one patient with a large residual ventricular septal defect, functionally significant left to right shunts were eliminated. These results and the analysis of results of combined series reported in the literature for primary and staged operations for the continued practice of primary repair of isolated large ventricular septal defects in infants and children who require surgery.