Ventricular septal defect with pulmonary stenosis and aortic regurgitation

Ventricular septal defect and aortic regurgitation

We have reviewed our experience of 29 patients with the association of ventricular septal defect and aortic regurgitation, 27 of whom have been treated surgically. Our present approach to the surgical management is outlined and the embryology and pathological anatomy are reviewed. The most common cause of aortic regurgitation was a prolapsed aortic valve cusp, which occurred in 19 patients. Aneurysmal dilatation of an aortic sinus accounted for the regurgitation in three patients, and two patients had both abnormalities. In two patients no cause for the aortic regurgitation was found. Those patients with aortic cusp prolapse commonly had large ventricular septal defects, of which nearly a third were supracristal. Because of cusp prolapse into the ventricular septal defect, and sometimes into the right ventricular outflow tract, the findings at cardiac catheterization often suggested erroneously that the ventricular septal defect was small and that infundibular obstruction was present. Characteristic angiographic features have been demonstrated, in particular the deformed and prolapsed aortic cusp. The various techniques of surgical correction which were used are described, the majority of patients having had a patch closure of the ventricular septal defect and repair of the aortic valve. Some residual aortic regurgitation was usual, but it was improved or minimized in 18 of the 23 survivors, and the more recent results have been particularly encouraging. Closure of the ventricular septal defect alone relieved heart failure in a 3-year-old child. There were four operative deaths (15% mortality) in patients with severe aortic regurgitation, three of whom were in heart failure before operation. The medical course was commonly of slowly increasing severity of the aortic regurgitation with progression to heart failure. However, the individual course was unpredictable and three children developed heart failure within a year of the onset of their aortic regurgitation. Infective endocarditis occurred in a quarter of the patients and usually followed the development of the aortic regurgitation. Despite the difficulties of surgical management it is felt that the unpredictable prognosis, high operative risk once cardiac failure has supervened, and the hazard of infective endocarditis make early operation desirable.

Ventricular Septal Defect with Aortic Regurgitation

Thirty-four patients with ventricular septal defect and aortic regurgitation, representing less than 5 per cent of our patients with ventricular septal defect, are discussed.

A loud, systolic murmur, characteristic of ventricular septal defect, is noted during infancy, whereas evidences of aortic regurgitation (protodiastolic murmur and wide pulse pressure) does not usually appear until sometime between 2 and 10 years of age.

Clinical and catheterization data indicate that the principal hemodynamic load is aortic regurgitation, whereas the ventricular septal defect does not usually result in a large pulmonary blood flow or high pulmonary arterial pressure. In about 50 per cent of the patients, a significant pressure gradient across the right ventricular outflow tract exists.

Detailed pathologic studies indicate that the ventricular septal defects are high and anterior and encroach to a greater or lesser degree on the membranous bulbar septum. The right coronary cusp is the one most severely involved, and, by its prolapse, causes aortic regurgitation; the noncoronary cusp is always less severely affected. The anatomic basis of the pressure gradient observed across the right ventricular outflow tract is not always clear.

Ventricular Septal Defect with Aortic Insufficiency

Eighteen patients with the combination of ventricular septal defect and aortic insufficiency were studied. Nine also had infundibular pulmonary stenosis. Seventeen were treated by open-heart operations.

The physical findings were those of a typical ventricular defect murmur and thrill together with an aortic insufficiency blow and a wide pulse pressure. A systolic murmur at the upper left sternal border with thrill is strongly suggestive of the additional lesion of infundibular pulmonary stenosis, but the presence or absence of infundibular pulmonary stenosis was indicated most accurately at cardiac catheterization and on inspection at operation. It was not of sufficient severity for signs of additional right ventricular hypertrophy to appear on the electrocardiogram.

Retrograde aortography serves to demonstrate the severity of the aortic regurgitation.

The problem of the surgical correction of these lesions will be the subject of a separate communication.