Aspects of surgery for congenital ventricular septal defect

In chapter 1, an outline of the thesis is given. This thesis focuses on aspects of surgical closure of a congenital ventricular septal defect. In Chapter 2, the accuracy and the potential of 3-D echocardiography in the preoperative assessment of a congenital VSD were evaluated. 3-D echocardiography can be considered a valuable diagnostic tool, which may accurately identify the location, size, and spatial relations of a VSD. Chapter 3 presents a surgical alternative by temporary tricuspid valve detachment, in the approach for the repair of a congenital VSD in patients in whom transatrial exposure of the VSD is inadequate. The procedure was significantly associated with patients that were younger, lighter in weight, shorter and more often on diuretic therapy. Regardless of the age, size and preoperative clinical condition of the patients, and regardless of the right ventricular load, temporary detachment of the tricuspid valve in closure of a congenital VSD can be performed safely, without any negative effect on growth or function of the valve at medium-term follow-up. Chapter 4 comments on temporary chordal detachment as an alternative to temporary detachment of the anterior or septal tricuspid leaï¬,et from the tricuspid annulus in repairing a congenital VSD in patients in whom transatrial exposure of the VSD is incomplete. This technique may be useful in selected cases; however, arguments in favour should preferably come from obvious advantages or from careful follow-up. Chapter 5 focuses on the differences between mild (32°C) and moderate (28°C) systemic hypothermia during the reconstruction of a congenital ventricular septal defect in paediatric patients. No differences were found regarding organ preservation and adequacy of cardio pulmonary bypass, nor in surgical exposure and clinical outcome. Chapter 6 demonstrates the clinical application of real time 3-D echocardiography in patients with a surgically corrected congenital ventricular septal defect. With I-Space technology, the complex postoperative cardiac anatomy of the closed congenital VSD can be appropriately visualised in virtual reality and provides a unique resource for postoperative quality control as well as for education with regard to the intracardiac repair of a congenital VSD. Chapter 7 provides a long-term follow-up study after surgical closure of a congenital ventricular septal defect. To enhance surgical exposure of the congenital ventricular septal defect in selected patients, the tricuspid valve was temporary detached from the tricuspid annulus and proved to be a safe method. Closure of a congenital ventricular septal defect can be performed with a low complication rate. Tricuspid valve detachment (TVD) results in less early postoperative tricuspid valve regurgitation and does not result in tricuspid valve dysfunction during follow-up. TVD results in comparable residual shunting as non-TVD. The incidence of trivial residual shunting is higher in small children irrespective of tricuspid valve detachment. Trivial residual shunting is expected to disappear spontaneously Chapter 8 provides a long-term follow-up study after surgical closure of a congenital ventricular septal defect at adult age with special emphasis to quality of life. The need for surgical closure of a congenital ventricular septal defect in adulthood is rare, but on the right indication, surgery is an adequate and safe procedure, with good results on long-term follow up. Quality of life of this adult VSD group is comparable with general population. In 10 out of twelve domains of the TAAQOL-questionnaire they had an equal score. Merely in 2 domains, cognitive functioning and sleep, our population differed from the general population with regard to the quality of life. Chapter 9 contains a general discussion regarding aspects of surgery of a co

Heparin as a risk factor for perigraft seroma complicating the modified Blalock-Taussig shunt

OBJECTIVE: The purpose of this study was to determine the risk factors associated with the occurrence of perigraft seromas complicating systemic-to-pulmonary polytetrafluoroethylene grafts. METHODS: Clinical and perioperative variables were reexamined, blinded for the outcome variable perigraft seroma, in 60 patients undergoing 67 consecutive graft procedures in a 3.5-year period. RESULTS: Eight cases of perigraft seroma were diagnosed in six patients. Univariate analysis revealed age (p = 0.02), a diagnosis of pulmonary atresia with ventricular septal defect and systemic-pulmonary collaterals (p = 0.001), reimplantation of collaterals during the procedure (p < 0.001), and intravenous heparin administered after operation (p < 0.0001) as risk factors for symptomatic perigraft seroma. Multivariable analysis defined heparin as the only significant factor associated with symptomatic perigraft seroma. Consolidation of the upper lobe on chest radiograph, ipsilateral to the shunt, directly after operation (p = 0.01), but especially 8 to 10 days after operation (p < 0.0001), or the need for prolonged drainage of pleural fluid (p < 0.0001) were correlated with the occurrence of perigraft seroma. Perigraft seroma led to four early rethoracotomies in three patients and to accelerated corrective surgery in three cases. Consolidation and absent perfusion of lung segments persisted in two patients. CONCLUSIONS: Our data suggest that the use of heparin leads to an increased risk of perigraft seroma, complicating systemic-pulmonary polytetrafluoroethylene grafts. Prolonged pleural drainage and/or postoperative consolidation of the upper lobe indicate the development of symptomatic perigraft seroma. Treatment is controversial and results are unpredictable. Expectative management seems to be justified so long as permitted by the clinical condition

Virtual reality 3D echocardiography in the assessment of tricuspid valve function after surgical closure of ventricular septal defect

Background. This study was done to investigate the potential additional role of virtual reality, using three-dimensional (3D) echocardiographic holograms, in the postoperative assessment of tricuspid valve function after surgical closure of ventricular septal defect (VSD). Methods. 12 data sets from intraoperative epicardial echocardiographic studies in 5 operations (patient age at operation 3 weeks to 4 years and bodyweight at operation 3.8 to 17.2 kg) after surgical closure of VSD were included in the study. The data sets were analysed as two-dimensional (2D) images on the screen of the ultrasound system as well as holograms in an I-space virtual reality (VR) system. The 2D images were assessed for tricuspid valve function. In the I-Space, a 6 degrees-of-freedom controller was used to create the necessary projectory positions and cutting planes in the hologram. The holograms were used for additional assessment of tricuspid valve leaflet mobility. Results. All data sets could be used for 2D as well as holographic analysis. In all data sets the area of interest could be identified. The 2D analysis showed no tricuspid valve stenosis or regurgitation. Leaflet mobility was considered normal. In the virtual reality of the I-Space, all data sets allowed to assess the tricuspid leaflet level in a single holographic representation. In 3 holograms the septal leaflet showed restricted mobility that was not appreciated in the 2D echocardiogram. In 4 data sets the posterior leaflet and the tricuspid papillary apparatus were not completely included. Conclusion. This report shows that dynamic holographic imaging of intraoperative postoperative echocardiographic data regarding tricuspid valve function after VSD closure is feasible. Holographic analysis allows for additional tricuspid valve leaflet mobility analysis. The large size of the probe, in relation to small size of the patient, may preclude a complete data set. At the moment the requirement of an I-Space VR system limits the applicability in virtual reality 3D echocardiography in clinical practice

Intraoperative device closure of perimembranous ventricular septal defects in the young children under transthoracic echocardiographic guidance; initial experience

<p>Abstract</p> <p>Objectives</p> <p>This study aimed to assess the safety and feasibility of intraoperative device closure of perimembranous ventricular septal defects (VSD) in young children guided by transthoracic echocardiography (TTE).</p> <p>Methods</p> <p>We enrolled 18 patients from our hospital to participate in the study from June 2011 to September 2011. A minimal inferior median incision was performed after full evaluation of the perimembranous VSD by real-time TTE, and a domestically made device was inserted to occlude the perimembranous VSD. The proper size of the device was determined by means of transthoracic echocardiographic analysis.</p> <p>Results</p> <p>Implantation was ultimately successful in 16 patients using TTE guidance. In these cases, the complete closure rate immediately following the operation and on subsequent follow-up was 100%. Symmetric devices were used in 14 patients, and asymmetric devices were used in two patients. Two patient were transformed to surgical treatment, one for significant residual shunting, and the other for unsuccessful wire penetration of the VSD. The follow-up periods were less than nine months, and only one patient had mild aortic regurgitation. There were no instances of residual shunt, noticeable aortic regurgitation, significant arrhythmia, thrombosis, or device failure.</p> <p>Conclusions</p> <p>Minimally invasive transthoracic device closure of perimembranous VSDs is safe and feasible, using a domestically made device under transthoracic echocardiographic guidance, without the need for cardiopulmonary bypass. This technique should be considered an acceptable alternative to surgery or device closure guided by transesophageal echocardiography in selected young children. However, a long-term evaluation of outcomes is necessary.</p

The Effect of Temperature Management During Cardiopulmonary Bypass on Clinical Outcome in Pediatric Patients Undergoing Correction of Ventricular Septal Defect

Moderate hypothermia of 28°C is widely accepted in cardiac surgery with cardiopulmonary bypass (CPB). Recently, however, several studies suggested that normothermic or “tepid” bypass techniques may improve the clinical outcome for patients undergoing cardiac operations. To assess the effect of bypass temperature management strategy in pediatric patients undergoing correction of ventricular septal defect, 26 patients with body weight under 10 kg were randomly assigned to two treatment groups: Group 1, mild hypothermia, patients cooled to nasopharyngeal temperature of 32°C during the bypass; or Group 2, moderate hypothermia of 28°C. Clinical parameters were recorded, and blood samples were obtained just before, during, and 24 hours after operation. All the population characteristics and intraoperative variables were similar in the two groups. Hematologic data after CPB and protamine administration revealed a significantly (p < .05) longer activated partial thromboplastin time in the 32°C group; however, the difference in blood loss did not reach significance. Our study shows that both perfusion temperatures equally well facilitated CPB for this type of intracardiac surgery

Aortic root reoperations after pulmonary autograft implantation

Objective: To report the results of aortic root reoperations after pulmonary autograft implantation. Methods: All consecutive patients in our prospective Ross research database were selected for analysis, and additional information for patients requiring reoperation was obtained from the hospital records. Results: From 1988 to 2009, 155 pulmonary autograft operations were performed. During this period, 41 patients required reoperation for aortic root dilatation and/or autograft valve insufficiency, in 8 patients combined with pulmonary allograft dysfunction. The freedom from autograft reoperation rate was 86% (standard error, 3.3%) after 10 years and 52% (standard error, 6.6%) after 15 years. The median interval to reoperation was 15.3 years. During reoperation, 39 patients underwent aortic root replacement (mechanical conduit, 31; stentless root, 2; allograft, 3; and valve sparing, 3), and 2 patients underwent valve replacement. In 8 patients this was combined with pulmonary allograft replacement. The technical difficulties encountered included bleeding at the sternal re-entry in 5 patients. No 30-day mortality occurred. The postoperative complications included reexploration for persistent blood loss in 3 patients and cerebrovascular accident in 3 patients. Two patients died during the follow-up period. The survival rate after reoperation was 94% (standard error, 4.1%) at 5 years. Conclusions: An increasing number of patients requires reoperation after pulmonary autograft implantation. These reoperations can be done with very low mortality and morbidity and excellent follow-up results