Syndrome of Ventricular Septal Defect and Aortic Regurgitation - A 22-Year Review of its Management

Introduction

The presence of aortic regurgitation (AR) in the setting of ventricular septal defect (VSD) has always been a management challenge.

Methods

This is a retrospective study looking at patients who underwent VSD closure with or without aortic valve intervention between January 1st, 1992 and December 31st, 2014 at the Institute Jantung Negara. This study looked at all cases of VSD and AR, where AR was classified as mild, moderate, and severe, the intervention done in each of this grade, and the durability of that intervention. The interventions were classified as no intervention (NI), aortic valve repair (AVr), and aortic valve replacement (AVR).

Results

A total of 261 patients were recruited into this study. Based on the various grades of AR, 105 patients had intervention to their aortic valve during VSD closure. The rest 156 had NI. All patients were followed up for a mean time of 13.9±3.5 years. Overall freedom from reoperation at 15 years was 82.6% for AVr. Various factors were investigated to decide on intervening on the aortic valve during VSD closure. Among those that were statistically significant were the grade of AR, size of VSD, age at intervention, and number of cusp prolapse.

Conclusion

We can conclude from our study that all moderate and severe AR with small VSD in older patients with more than one cusp prolapse will need intervention to their aortic valve during the closure of VSD.

A common variant near TGFBR3 is associated with primary open angle glaucoma

Primary open angle glaucoma (POAG), a major cause of blindness worldwide, is a complex disease with a significant genetic contribution. We performed Exome Array (Illumina) analysis on 3504 POAG cases and 9746 controls with replication of the most significant findings in 9173 POAG cases and 26 780 controls across 18 collections of Asian, African and European descent. Apart from confirming strong evidence of association at CDKN2B-AS1 (rs2157719 [G], odds ratio [OR] = 0.71, P = 2.81 × 10⁻³³), we observed one SNP showing significant association to POAG (CDC7–TGFBR3 rs1192415, OR_G-allele = 1.13, P_meta = 1.60 × 10⁻⁸). This particular SNP has previously been shown to be strongly associated with optic disc area and vertical cup-to-disc ratio, which are regarded as glaucoma-related quantitative traits. Our study now extends this by directly implicating it in POAG disease pathogenesis.

Coarctation of aorta repair at the National Heart Institute (1983-1994)

This retrospective study illustrates our approach to this problem over the years, from performing subclavian flap aortoplasty initially to the more accepted procedure now, which is resection and end-to-end anastomosis. Coarctation of aorta in our population is seen in a varying age groups and are also associated with other cardiac anomalies including both acyanotic and cyanotic congenital cardiac defects. Therefore a wide variety of surgical procedures were performed including resection of the coarcted segment and end-to-end anastomosis, subclavian flap aortoplasty, patch aortoplasty and synthetic tube graft interposition. Subclavian flap aortoplasty is not widely practised anymore in favour of resection with end-to-end anastomosis. Fifty four point four percent of patients had isolated coarctation, 10.5% had associated valvular defects, 28.1% had other simple congenital defects and 7.0% had associated complex cyanotic congenital defects. Perioperative mortality was 5.26% and is correlated with the younger age of patients at time of surgery and severity of cardiac failure at time of presentation. We did not see any difference in mortality for patients with complex congenital disease or between the different surgical procedures. However, we did find that in the early period when resection with end-to-end anastomosis was performed, there was a significantly higher incidence of morbidities.

Obstruction of mechanical heart valve--diagnosis, surgical treatment and outcome

From 1982 till 1999, our department performed a total of 2970 heart valve replacements--92% of which were with mechanical heart valves. During this period, there were 8 patients who came to our department with mechanical heart valve obstruction. All these patients presented with signs of heart failure or compromised haemodynamic. Confirmatory tests included transthoracic or transoesophageal echocardiography and cine fluoroscopy. Seven patients were operated upon urgently. Four of the patients had valve thrombosis. The time interval between the initial implantation and presentation varies from 4 months to 11.3 years. Six of the seven patients who were operated on recovered well from the surgery.

Mediastinal teratoma in a neonate

A neonate with severe respiratory distress due to a benign mediastinal teratoma (MT) is reported. Despite early and easy surgical excision of the tumor, the child died due to poor cardiac function. Only ten cases of MT in neonates have been reported in the literature so far. While the tumor has been known to interfere with lung development in utero, postnatal myocardial dysfunction due to poor heart development has not been previously documented.