Outcome of ventricular septal defect repair in a developing country

Preoperative Malnutrition Increases Risk of In-Hospital Mortality, Major Infection, and Longer Intensive Care Unit Stay After Ventricular Septal Defect Closure

BACKGROUND

High energy requirements and poor feeding can lead to growth failure in patients with ventricular septal defect (VSD), but effects of preoperative malnutrition on surgical outcomes are poorly understood, especially in low-resource settings.

METHODS AND RESULTS

We analyzed a cohort of children <5 years of age undergoing VSD closure at 60 global centers participating in the International Quality Improvement Collaborative for Congenital Heart Disease, 2015 to 2020. We calculated adjusted odds ratios (ORs) for in-hospital death and major infection and adjusted coefficients for duration of intensive care unit stay for 4 measures of malnutrition: severe wasting (weight-for-height Z score, <-3), moderate wasting (-3

CONCLUSIONS

Malnutrition was associated with mortality, infection, and longer intensive care unit stay in a global cohort of children undergoing VSD closure.

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Key Words

• congenital heart disease
• global health
• malnutrition
• mortality
• ventricular septal defect

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MESH Headings

• Humans
• Heart Septal Defects, Ventricular/surgery
• Heart Septal Defects, Ventricular/mortality
• Heart Septal Defects, Ventricular/complications
• Male
• Female
• Infant
• Hospital Mortality
• Child, Preschool
• Length of Stay/statistics & numerical data
• Malnutrition/mortality
• Malnutrition/epidemiology
• Malnutrition/diagnosis
• Risk Factors
• Cardiac Surgical Procedures/adverse effects
• Intensive Care Units/statistics & numerical data
• Nutritional Status
• Postoperative Complications/epidemiology
• Postoperative Complications/mortality
• Retrospective Studies
• Risk Assessment
• Time Factors

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Grants

• P30 DK040561 NIDDK NIH HHS
• National Institutes of Health

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Affiliation(s)

Rachel E. Wittenberg Harvard Medical SchoolBostonMAUSA
Kimberlee Gauvreau Harvard Medical SchoolBostonMAUSA Boston Children’s HospitalBostonMAUSA
Christopher P. Duggan Harvard Medical SchoolBostonMAUSA Boston Children’s HospitalBostonMAUSA
Xinwei Du Shanghai Children’s Medical CenterShanghaiChina
Do Giang Nhi Dong 1Ho Chi Minh CityVietnam
Kishore Jayanthi Star HospitalHyderabadIndia
Nestor Sandoval Fundación Cardioinfantil y LaCardioBogotáColombia
Sivakumar Sivalingam Institut Jantung NegaraKuala LumpurMalaysia
Xiaolei Zhao TEDA International Cardiovascular HospitalTianjinChina
Kathy J. Jenkins Harvard Medical SchoolBostonMAUSA Boston Children’s HospitalBostonMAUSA

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Prevalence of Malnutrition in Children with Congenital Heart Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the global prevalence of malnutrition in children with congenital heart disease (CHD).

STUDY DESIGN

A systematic review and meta-analysis were performed. Web of Science, PubMed, Embase, Wanfang Database, China National Knowledge Infrastructure, and China Biology Medicine disc databases were searched for studies published through April 2021. Random-effect model meta-analyses were performed to derive the pooled the prevalence of preoperative underweight, stunting, and wasting in children with CHD. Time-trend analyses of postoperative malnutrition prevalence were undertaken. Subgroup and sensitivity analyses were conducted to explore sources of heterogeneity. Egger test and funnel plots were used to explore public bias.

RESULTS

A total of 39 studies were included in this meta-analysis. The pooled estimates of preoperative malnutrition in children with CHD were 27.4% (95% CI, 21.7-34.0) for underweight, 24.4% (95% CI, 19.5-30.0) for stunting, and 24.8% (95% CI, 19.3-31.3) for wasting. Catch-up growth was found in the postoperative period among some children. Different continents were identified as heterogeneity moderators by subgroup analyses.

CONCLUSIONS

Children with CHD have a high prevalence of preoperative malnutrition and some show catch-up growth postoperatively. These data can be used as benchmarks in efforts to improve the nutritional status of children with CHD.

Underweight, Stunted, and Wasted among Children with Congenital Heart Disease: Acyanotic versus Cyanotic

BACKGROUND Congenital heart disease (CHD) is the most common of all congenital lesions and is the most common type of heart diseases among children. Children with congenital heart disease are at increased risk of underweight, stunted and wasted. Wasted is a reflection of acute malnutrition, stunted is a reflection of chronic malnutrition while underweight is a reflection of both. OBJECTIVE To describe the prevalence of underweight, stunted and wasted among children with acyanotic and cyanotic CHD, in tertiary center in Bali, Indonesia. METHODS An observational study with cross sectional approach was conducted in children under 5 years old with newly diagnosed CHD in Sanglah Hospital, Bali. Data were collected from medical records.  Anthropometric z-scores based on WHO 2006 reference ranges were generated for each child including weight-for-age, height-for-age and weight-for-height z-scores. Diagnosis of CHD was retrieved based on echocardiography examination. The significance of the anthropometric status differences between acyanotic and cyanotic group were assessed using Pearson’s Chi Square. RESULTS From January 2017-December 2020, we found total 200 cases of CHD which 160 (80%) cases were acyanotic CHD with predominantly ventricle septal defect (38%) and 40 (20%) cases were cyanotic CHD with predominantly Tetralogy of Fallot with all variant (40%). The prevalence of underweight, stunted and wasted in acyanotic vs cyanotic CHD were: underweight (57.5% vs 40.0%, p=0.047), stunted (47.5% vs 65%, p=0.048) and wasted (67.5% vs 50%, p=0.039). CONCLUSION The prevalence of underweight, stunted and wasted among children with acyanotic and cyanotic CHD were high. Proportion of underweight and wasted were significantly higher in acyanotic CHD, while stunted was significantly higher in cyanotic CHD.

Long-term surgical outcomes after repair of multiple ventricular septal defects in pediatrics

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.

Risk factors of nosocomial infection after cardiac surgery in children with congenital heart disease

Background

The aim of our study was to analyze the risk factors of nosocomial infection after cardiac surgery in children with congenital heart disease (CHD).

Methods

We performed a retrospective cohort study, and children with CHD who underwent open-heart surgeries at Shanghai Children’s Medical Center from January 1, 2012 to December 31, 2018 were included. The baseline characteristics of these patients of different ages, including neonates (0–1 months old), infants (1–12 months old) and children (1–10 years old), were analyzed, and the association of risk factors with postoperative nosocomial infection were assessed.

Results

A total of 11,651 subjects were included in the study. The overall nosocomial infection rate was 10.8%. Nosocomial infection rates in neonates, infants, and children with congenital heart disease were 32.9, 15.4, and 5.2%, respectively. Multivariate logistic regression analysis found age (OR 0798, 95%CI: 0.769–0.829; P < 0.001), STS risk grade (OR 1.267, 95%CI: 1.159–1.385; P < 0.001), body mass index (BMI) <5th percentile (OR 1.295, 95%CI: 1.023–1.639; P = 0.032), BMI >95th percentile (OR 0.792, 95%CI: 0.647–0.969; P = 0.023), cardiopulmonary bypass (CPB) time (OR 1.008, 95%CI: 1.003–1.012; P < 0.001) and aortic clamping time (OR 1.009, 1.002–1.015; P = 0.008) were significantly associated with nosocomial infection in CHD infants. After adjusted for confounding factors, we found STS risk grade (OR 1.38, 95%CI: 1.167–1.633; P < 0.001), BMI < 5th percentile (OR 1.934, 95%CI: 1.377–2.715; P < 0.001), CPB time (OR 1.018, 95%CI: 1.015–1.022; P < 0.001), lymphocyte/WBC ratio<cut off value (OR 3.818, 95%CI: 1.529–9.533; P = 0.004) and AST>cut off value (OR 1.546, 95%CI: 1.119–2.136; P = 0.008) were significantly associated with nosocomial infection in CHD children.

Conclusion

Our study suggested STS risk grade, BMI, CPB duration, low lymphocyte/WBC or high neutrophil/WBC ratio were independently associated with nosocomial infection in CHD infant and children after cardiac surgery.

Early weight trends after congenital heart surgery and their determinants

BACKGROUND

Early weight trends after cardiac surgery in infants from low- and middle-income countries where the majority are undernourished have not been defined. We studied the early post-operative weight trends to identify specific factors associated with early weight loss and poor weight gain after discharge following congenital heart surgery in consecutive infants undergoing cardiac surgery at a referral hospital in Southern India.

METHODS

This was a prospective observational study. Weights of the babies were recorded at different time points during the hospital stay and at 1-month post-discharge. A comprehensive database of pre-operative, operative, and post-operative variables was created and entered into a multivariate logistic regression analysis model to identify factors associated with excessive early weight loss after cardiac surgery, and poor weight gain following hospital discharge.

RESULTS

The study enrolled 192 infants (mean age 110.7 ± 99.9 days; weight z scores - 2.5 ± 1.5). There was a small but significant (p < 0.001) decline in weight in the hospital following surgery (1.6% decline (interquartile range -5.3 to +1.7)); however, there was substantial growth following discharge (26.7% increase (interquartile range 15.3-41.8)). The variables associated with post-operative weight loss were cumulative nil-per-oral duration and cardiopulmonary bypass time, while weight gain following discharge was only associated with age.

CONCLUSION

Weight loss is almost universal early after congenital heart surgery and is associated with complex surgery and cumulative nil-per-oral duration. After discharge, weight gain is almost universal and not associated with any of the perioperative variables.

Totally endoscopic ventricular septal defect repair using bilateral femoral arterial cannulation in an 8-year-old girl

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The scope of totally endoscopic cardiac surgery in children is limited.

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Femoral cannulation has risks which increase in small children.

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Bilateral femoral arterial cannulation helped to avoid vessel complication in small children.

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Four small trocars (5–12 mm) were suitable for totally endoscopic VSD closure.

Introduction

There are few reports on applying totally endoscopic surgery (TES) for repairing ventricular septal defect (VSD), especially in children.

Case presentation

We described an 8-year-old girl, weighing 17 kg, who was diagnosed with peri-membranous VSD and patent ductus arteriosus (PDA). The patient had undergone trans-catheter PDA closure first, and 3 weeks later, TES was performed for VSD repair through 4 small trocars (one 12 mm trocar and three 5 mm trocars) without robotic assistance. Arterial line was set up indirectly to the right femoral artery (FA) through a graft with an additional line to the left side for reducing arterial pressure.

Discussion

FA cannulation in small children induce some risks, such as: FA trauma, critical lower limb ischaemia, and iliac or femoral arterial stenosis. Our new method of FA cannulation was safe with 13 months of follow-up. The major concerns in this case were repairing VSD through small trocars in a small child.

Conclusion

Bilateral FA cannulation and the way to set up small trocars may facilitate totally endoscopic VSD repair in small children. However, the safety and efficacy of these approaches needs to be validated by larger studies preferably randomised controlled trials.

Management of undernutrition and failure to thrive in children with congenital heart disease in low- and middle-income countries

Poor growth with underweight for age, decreased length/height for age, and underweight-for-height are all relatively common in children with CHD. The underlying causes of this failure to thrive may be multifactorial, including innate growth potential, severity of cardiac disease, increased energy requirements, decreased nutritional intake, malabsorption, and poor utilisation of absorbed nutrition. These factors are particularly common and severe in low- and middle-income countries. Although nutrition should be carefully assessed in all patients, failure of growth is not a contraindication to surgical repair, and patients should receive surgical repair where indicated as soon as possible. Close attention should be paid to nutritional support - primarily enteral feeding, with particular use of breast milk in infancy - in the perioperative period and in the paediatric ICU. This nutritional support requires specific attention and allocation of resources, including appropriately skilled personnel. Thereafter, it is essential to monitor growth and development and to identify causes for failure to catch-up or grow appropriately.

Wasting, underweight and stunting among children with congenital heart disease presenting at Mulago hospital, Uganda

BACKGROUND

Children with congenital heart disease are at increased risk of malnutrition. The aim of this study was to describe the prevalence of wasting, underweight and stunting among children with congenital heart disease attending Mulago National Referral Hospital, Uganda.

METHODS

A cross-sectional study among 194 children aged 0-15 years was conducted between August 2013 and March 2014. Anthropometric measurements and clinical assessments were carried out on all children. Anthropometric z-scores based on WHO 2007 reference ranges were generated for each child. Weight-for-height z-scores were generated for children 0-5 years, weight-for-age z-scores for children 0-10 years, and height-for-age and BMI-for-age z-scores for all children. Risk factors associated with malnutrition were determined by Poisson regression.

RESULTS

One hundred and forty five (74.7%) children were aged 0-5 years; and 111 of 194 (57.2%) were female. Forty five of 145 (31.5%) children aged 0-5 years were wasted; 77 of 181 (42.5%) children aged 0-10 years were underweight; 88 of 194 (45.4%) children were stunted; and 53 of 194 (27.3%) children were thin (BMI for age z score < -2). Moderate to severe anaemia (RR 1.11, 95% CI: 1.01-1.22) and moderate to severe heart failure (RR 1.24, 95% CI: 1.13-1.36) were associated with wasting and underweight respectively. Stunting was associated with moderate to severe heart failure (RR 1.11, 95% CI: 1.01-1.21) while thinness was associated with moderate to severe heart failure (RR 1.12, 95% CI: 1.04-1.21) and moderate to severe anaemia (RR 1.15, 95% CI: 1.06-1.25).

CONCLUSION

Malnutrition is common in children with congenital heart disease, and is associated with anaemia and heart failure. There is need to integrate strategies to identify and manage malnutrition during the care of children with congenital heart disease.

Global Perspectives On Pediatric Cardiac Critical Care

OBJECTIVES

The objectives of this review are to discuss the global epidemiology of cardiovascular disease, emphasizing congenital heart disease; to discuss the concept of epidemiologic transition and its role in studying the evolving epidemiology of disease; and to assess and address the global burden of congenital heart disease including its prevention and treatment.

DATA SOURCE

MEDLINE and PubMed.

CONCLUSIONS

Despite impressive reductions in mortality from congenital and acquired cardiovascular disease in high-income countries, these reductions have not been observed on a global scale. It will be necessary to continue our attempts to extend rational programs of care to middle- and low-income countries based on community empowerment, economics, and population health. The specialist in pediatric cardiac critical care can be a central driver of these programs.

Preoperative Determinants of Outcomes of Infant Heart Surgery in a Limited-Resource Setting

We studied the effect of preoperative determinants on early outcomes of 1028 consecutive infant heart operations in a limited-resource setting. Comprehensive data on pediatric heart surgery (January 2010-December 2012) were collected prospectively. Outcome measures included in-hospital mortality, prolonged ventilation (>48 hours), and bloodstream infection (BSI) after surgery. Preoperative variables that showed significant individual association with outcome measures were entered into a logistic regression model. Weight at birth was low in 224 infants (21.8%), and failure to thrive was common (mean-weight Z score at surgery was 2.72 ± 1.7). Preoperatively, 525 infants (51%) needed intensive care, 69 infants (6.7%) were ventilated, and 80 infants (7.8%) had BSI. In-hospital mortality (4.1%) was significantly associated with risk adjustment for congenital heart surgery-1 (RACHS-1) risk category (P < 0.001). Neonatal status, preoperative BSI, and requirement of preoperative intensive care and ventilation had significant individual association with adverse outcomes, whereas low birth weight, prematurity, and severe failure to thrive (weight Z score <-3) were not associated with adverse outcomes. On multivariable logistic regression analysis, preoperative sepsis (odds ratio = 2.86; 95% CI: 1.32-6.21; P = 0.008) was associated with mortality. Preoperative intensive care unit stay, ventilation, BSI, and RACHS-1 category were associated with prolonged postoperative ventilation and postoperative sepsis. Neonatal age group was additionally associated with postoperative sepsis. Although severe failure to thrive was common, it did not adversely affect outcomes. In conclusions, preoperative BSI, preoperative intensive care, and mechanical ventilation are strongly associated with adverse outcomes after infant cardiac surgery in this large single-center experience from a developing country. Failure to thrive and low birth weight do not appear to adversely affect surgical outcomes.

Eisenmenger ventricular septal defect: classification, morphology, and indications for surgery

This study aimed to examine the definition and indications for surgery, to elucidate the morphologic substrate of aortic regurgitation, and to extrapolate the pathologic mechanisms of subpulmonary stenosis in Eisenmenger ventricular septal defect (EVSD). The study enrolled 160 patients. Preoperative respiratory symptoms and poor growth were present in 41 patients (26%), and 21 patients (13%) required mechanical ventilation. Perimembranous ventricular septal defect (pVSD) had been diagnosed previously for 136 of the patients (85%) at other institutions. Of the 160 patients, 51 (32%) had muscular posteroinferior rims. Aortic regurgitation was experienced by 36 patients (23%), found to be mild in 31 cases (19%) and moderate in 5 cases (3%). None of the patients had severe regurgitation. No aortic valvuloplasty was performed. The significant risk factors for aortic regurgitation were subpulmonary stenosis (p = 0.001) and a muscular posteroinferior rim (p = 0.000). Subpulmonary stenosis was seen in 57 patients (35%), found to be mild to moderate in 42 cases (26%) and severe in 15 cases (9%). Adequacy of the stenosis band was repaired through the tricuspid valve for 57 of these patients. The definition of EVSD should identify it as a subgroup different from pVSD, and it should be closed as soon as it is identified in developing countries. Aortic regurgitation occurs rarely, and aortic valvoplasty should be performed if it exceeds a moderate level. The subpulmonary stenosis can be repaired through the tricuspid valve.

Growth after ventricular septal defect repair: does defect size matter? A 10-year experience

AIM

To evaluate whether the ventricular septal defect (VSD) size, along with the degree of preoperative growth impairment and age at repair, may influence postoperative growth, and if VSD size can be useful to identify children at risk for preoperative failure to thrive.

METHODS

Sixty-eight children submitted to VSD repair in a Brazilian tertiary-care institution were evaluated. Weight and height measurements were converted to Z-scores. Ventricular septal defect size was normalized by dividing it by the aortic root diameter (VSD/Ao ratio).

RESULTS

Twenty-six patients (38%) had significantly low weight-for-height, 10 patients (15%) had significantly low height-for-age and 13 patients (19%) had both conditions at repair. Catch-up growth occurred in 82% of patients for weight-for-age, in 75% of patients for height-for-age and in 89% of patients for weight-for-height. Weight-for-height Z-scores at surgery were significantly lower in patients who underwent repair before 9 months of age. The VSD/Ao ratio did not associate with any other data. On multivariate analysis, weight-for-age Z-scores and age at surgery were independent predictors of long-term weight and height respectively.

CONCLUSION

The VSD/Ao ratio was not a good predictor of preoperative failure to thrive. Most patients had preoperative growth impairment and presented catch-up growth after repair. Preoperative growth status and age at surgery influenced long-term growth.

What determines nutritional recovery in malnourished children after correction of congenital heart defects?

BACKGROUND

Malnutrition is common in children with congenital heart disease (CHD), especially in developing countries.

OBJECTIVE

To examine the impact of corrective intervention on the nutritional status of children with CHD and identify factors associated with suboptimal recovery.

METHODS

Consecutive patients with CHD in a tertiary center in South India were evaluated for nutritional status before and 2 years after corrective intervention. Anthropometry was performed at presentation and every 6 months for 2 years, and z scores were compared. Malnutrition was defined as a weight-for-age, height-for-age, and weight/height z score <-2. Determinants of malnutrition were entered into a multivariate logistic regression analysis model.

RESULTS

Of 476 patients undergoing corrective intervention (surgical: 344; catheter-based: 132) z scores of less than -2 for weight for age, height for age, and weight/height were recorded in 59%, 26.3%, and 55.9% of patients, respectively, at presentation. On follow-up (425 patients [92.5% of survivors; 20.63 +/- 13.1 months of age]), z scores for weight for age and weight/height improved significantly from the baseline (weight: -1.42 +/- 1.03 vs -2.19 +/- 1.16; P < .001; weight/height: -1.15 +/- 1.25 vs -2.09 +/- 1.3; P < .001). Height-for-age z scores were not significantly different. Malnutrition persisted in 116 (27.3%) patients on follow-up and was associated with a birth weight of <or=2.5 kg, nutritional status at presentation, and height of parents and not with type of cardiac lesion, dietary intake, or socioeconomic factors.

CONCLUSIONS

This study from South India demonstrates severe malnutrition in over half of the patients with CHD and is not always reversed by corrective surgery or intervention. Persistent malnutrition after corrective intervention is predicted by nutritional status at presentation, birth weight, and parental anthropometry.

Pediatric cardiac surgery in developing countries

Pediatric cardiac surgery in developing countries is a major challenge. It is a challenge to employ evolving methods to cater to the surgical needs of a very large number of children with congenital heart defects while dealing with severe budgetary constraints, finding funding to maintain the program, and maintaining quality in the backdrop of constant turnover of trained medical, nursing, and other paramedical personnel. Choosing the best procedure to achieve maximum palliation at lower cost and, when possible, giving priority for one-stage corrective procedures, albeit at a higher risk, calls for practice modifications. Despite improved infrastructure and surgical skills in recent years, in some developing countries, logistics, affordability, late presentation, nutritional issues, staffing, and unfavorable economics continue to negatively influence the overall results compared to those of developed nations.

Somatic growth after ventricular septal defect in malnourished infants

OBJECTIVE

To assess somatic growth after ventricular septal defect (VSD) repair in severely malnourished infants.

STUDY DESIGN

Ninety consecutive infants (age at surgery: 7.2 +/- 3.2 months) were followed after VSD closure at a referral center in southern India to evaluate somatic growth.

RESULTS

At surgery, 44% and 30% of patients had weight and height Z score <-3, respectively. On follow-up (age 5.4 +/- 0.8 years), despite a significant improvement from baseline (Z score -1.8 +/- 1.2 vs -2.8 +/- 1.3, P <.001), weight was significantly lower compared with healthy Indian children, particularly for boys. Height Z score improved significantly only in girls (-0.8 +/- 1.3 vs -1.8+/-2.1, P = .01). Weight, height, and combined weight and height Z scores (failure to thrive) of <-2 were observed in 42%, 27%, and 18 % of patients, respectively. On multivariate analysis, weight Z score <-2 on follow-up was predicted by weight Z score at surgery and male sex, height Z score <-2 by maternal height and male sex, and failure to thrive by maternal height and caloric intake.

CONCLUSIONS

There is suboptimal recovery of somatic growth after repair of VSD in severely malnourished infants. Preoperative malnutrition affected only weight on follow-up, whereas height recovery and failure to thrive were influenced by constitutional factors.

Management of infants with large, unrepaired ventricular septal defects and respiratory infection requiring mechanical ventilation

OBJECTIVES

We sought to describe the hospital management and early outcome of critically ill infants presenting with large ventricular septal defects and pneumonia requiring mechanical ventilation at a referral center in a developing country. Infants with large ventricular septal defects who have pneumonia might present with respiratory failure requiring mechanical ventilation. In the developing world this presentation is relatively common, but few data exist describing patient management strategies.

METHODS

Hospital data of consecutive infants admitted with large ventricular septal defects and pneumonia requiring mechanical ventilation were reviewed and analyzed.

RESULTS

We identified 18 infants (mean age, 3.6 +/- 3.0 months). On admission, all the infants were significantly malnourished, and echocardiography showed bidirectional shunting (predominantly right-to-left shunting) in 6 infants. Thirteen (72%) patients improved with intensive medical management that included mechanical ventilation for 1 to 16 days (median, 6.5 days); unequivocal left-to-right shunting was subsequently documented by means of echocardiography in all 13 patients. Twelve patients underwent surgical repair, and 11 (91.6%) were discharged after median mechanical ventilation of 100 hours (range, 42-240 hours) and intensive care unit stay of 8 days (range, 4-15 days). Five of 6 unoperated patients died, 4 of them within a few hours of admission. One child with multiple ventricular septal defects was discharged and subsequently underwent pulmonary artery banding.

CONCLUSION

Corrective cardiac surgery for selected critically ill infants with large ventricular septal defects, severe malnutrition, and pneumonia requiring mechanical ventilation is feasible and should be considered a viable management strategy.