Patent Ductus Arteriosus with Pulmonary Hypertension Simulating Ventricular Septal Defect

Ventricular septal defect with patent ductus arteriosus. A clinical and hemodynamic study

Twenty-two patients with the combined lesions of ventricular septal defect and patent ductus arteriosus, proved at cardiac catheterization, are reviewed in detail in regard to their clinical profile, hemodynamic data, and indications for, and results of, surgical repair.

The incidence of this combination of lesions is not so uncommon as would be anticipated by the paucity of the reports in the medical literature. The diagnosis of both lesions is important for management and surgical technic.

The striking findings by physical examination are the gross undernourishment and the wide pulse pressure in the great majority. Almost all have harsh systolic murmurs along the mid left sternal border and only 2 had continuous Gibson murmurs. Consequently, auscultation is of little help in delineating the presence of an associated patent ductus arteriosus.

The electrocardiogram is of minor importance in the diagnosis of this combination of lesions. Roentgenograms in the majority show features common to either lesion alone although the frequency with which left atrial enlargement is found appears to be greater in this combination of lesions.

Careful hemodynamic studies are crucial in the diagnosis of these 2 lesions. At the ductal level passage of the catheter establishes the diagnosis, or an increase in oxygen saturation greater than 5 per cent in comparison to the right ventricular blood strongly suggests the presence of a patent ductus arteriosus. The great majority of the ventricular septal defects were diagnosed by an increase in the oxygen saturation of 10 per cent or greater at the ventricular level. Almost all had pulmonary artery hypertension.

Thirteen patients had surgical intervention; 9 had only closure of the patent ductus arteriosus alone and 4 had complete repair of the lesions. In the former group there were 2 deaths and 2 improved significantly. In the latter group there were 2 surgical deaths and 2 were markedly improved. The 2 surgical deaths appear to be directly related to the massive hemorrhage through the unsuspected patent ductus arteriosus while on cardiac bypass and the subsequent technical difficulty of closing both defects from an anterior thoracotomy.

The relationship of calculated pulmonary vascular resistance to surgical closure of the defects is discussed.

It is suggested that if the patent ductus arteriosus is diagnosed on the basis of a typical machinery murmur, correction of this lesion is indicated, irrespective of the associated ventricular defect. If, on the other hand, the clinical picture is suggestive of a ventricular defect alone and the presence of the combination of lesions is discovered only at catheterization, then simultaneous correction of the 2 lesions is recommended. In small infants in whom the combined operation is particularly difficult at the present time, a preliminary trial of medical management is recommended; only if this fails to accomplish the expected result should division of the ductus be undertaken.

The first open-heart repairs of ventricular septal defect, atrioventricular communis, and tetralogy of Fallot using extracorporeal circulation by cross-circulation: a 30-year follow-up

From March 26, 1954, to July 19, 1955, 45 patients with major cardiac malformations not previously correctable underwent open repair utilizing cross-circulation between patient and donor without donor deaths. All operations were carried out at normothermia with lowered flow rates based on azygos flow studies. Twenty-seven patients, more than half of them infants, had ventricular septal defects closed. There were 8 hospital deaths, and there have been only 2 late deaths in 30 years. Fourteen (87.5%) of 16 who underwent recatheterization have closed defects. The 17 30-year-survivors are all in New York Heart Association Functional Class I. Five patients 4 months to 10 years old were operated on for atrioventricular canal (complete form). All had intractable failure, and 4 had pulmonary hypertension. Two of the 3 hospital deaths were due to heart block. The long-term survivor, a 15-month-old infant at the time of operation (severe pulmonary hypertension, 90/50 mm Hg), underwent repair 31 years ago and is now married with 3 children. Recatheterization disclosed normal pulmonary pressure (20/4 mm Hg), no shunts, and mild mitral regurgitation. Ten cyanotic tetrads 13 months to 14 years old were operated on with 5 hospital deaths. Of the 3 late deaths, 1 was accidental at 17 years, 1 occurred suddenly at home 13 years after operation in infancy for atresia, and the third occurred at reoperation 10 years later. The 2 remaining patients (1 the first patient operated on) are in excellent health. The surgical methods used and the physiological advantages of cross-circulation (temporary placenta) that made these results possible at a time when surgical knowledge was primitive are described.

Intracardiac Phonocardiography in Ventricular Septal Defect

It has been demonstrated that intracardiac phonocardiography provides precise localization of the source of cardiovascular sounds. Can this technic be of practical help in the diagnosis of small or complicated ventricular septal defects? Is a ventricular septal defect ever silent? What mechanisms are responsible for the diastolic murmurs in ventricular septal defect? In an attempt to answer these problems, intracardiac phonocardiograms have been studied in 47 cases.