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

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

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

How should I treat impaired systolic function and clinical deterioration after surgery of type A aortic dissection?

BACKGROUND: A 50-year-old male with diagnosis of acute type A aortic dissection underwent surgical repair. Immediately after surgery the patient had transient ECG changes, a raise in serum cardiac markers and physical signs of heart failure. INVESTIGATION: Physical examination, electrocardiography, echocardiography (transthoracic and transoesophageal), coronary angiography, intravascular ultrasound. DIAGNOSIS: Type A aortic dissection. MANAGEMENT: Surgical repair, coronary angiography, percutaneous coronary intervention