Flap Valve Double Patch Closure of Ventricular Septal Defects in Children With Increased Pulmonary Vascular Resistance

doi:10.1016/j.athoracsur.2004.06.107

The Annals of Thoracic Surgery

Volume 79, Issue 1, January 2005, Pages 21-28

Presented at the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26–28, 2004.

https://doi.org/10.1016/j.athoracsur.2004.06.107 Get rights and content

Background

Closure of a large ventricular septal defect (VSD) in children with elevated pulmonary vascular resistance (PVR) is associated with significant morbidity and mortality. Sophisticated medications and circulatory assist devices may not be available to assist in the care of children with elevated PVR undergoing VSD closure. We designed a fenestrated flap valve double VSD patch to decrease the morbidity and mortality associated with the closure of a large VSD in this high-risk group.

Methods

Ninety-one children (median age 4.0 ± 3.1 years) with a large VSD and elevated PVR (10.5 ± 4.9 Wood units) underwent double patch VSD closure. The routine VSD patch was fenestrated (4 to 8 mm), and on the left ventricular side of the patch, a second smaller patch was attached to the upper third of the fenestration before VSD patch placement.

Results

Fifty-six children with a VSD as the primary lesion, 16 with complete atrioventricular canal, 10 with double outlet right ventricle/VSD, 2 with interrupted aortic arch/VSD, 2 with truncus arteriosus, and 1 each with transposition/VSD, corrected transposition/VSD, total anomalous pulmonary venous connection/VSD, VSD/left pulmonary artery atresia, and aortopulmonary window underwent operation; the overall early mortality rate was 7.7% (7 of 91). There have been 7 late deaths: 2 VSD and 5 complex defects.

Conclusions

Closure of a large VSD with elevated PVR can be performed with reasonable mortality and morbidity.

Section snippets

Patient Demographics and Sites of Operation

Ninety-one patients with a large VSD and pulmonary hypertension underwent VSD closure between May 1996 and February 2003. Fifty-two patients (57%) were female. The age of the patients ranged from 5 months to 17 years with a median age of 4.0 ± 3.1 years. The cities in which the operations were performed were Kyiv, Ukraine (21), Minsk, Belarus (15), Zagreb, Croatia (13), Santander, Colombia (11), Bogotá, Columbia (9), Lima, Peru (6), Nanjing, China (4), Memphis, Tennessee (4), Managua, Nicaragua

Preoperative Data

No significant difference was found in the sex mix between the simple and the complex groups. The median age for the simple group was 5.1 ± 3.4 and for the complex group, 2.3 ± 2.2 (p = 0.005). Median weight similarly differed significantly between the two groups (simple 16.0 ± 5.9, complex 10.7 ± 4.5; p < 0.03).

For the entire study population, the preoperative room air SpO₂ obtained at cardiac catheterization was 90% ± 4%, and the ratio of pulmonary artery systolic to systemic systolic

Comment

Pulmonary hypertension after closure of a large VSD continues to cause significant morbidity and mortality even in industrialized countries [6]. The use of nitric oxide and ECMO rescue has reduced the mortality, but with significant cost and patient morbidity. These expensive and sophisticated modalities are not available in many countries throughout the world. Even the additional expense of a hemoconcentrator precluded the use of the relatively inexpensive device in some of the sites

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Delayed diagnosis in children with a ventricular septal defect (VSD) is common in low- and middle-income countries. Consequently, these children present with elevated pulmonary vascular resistance (PVR) and pulmonary arterial hypertension (PAH). The study investigators introduced the double-flap valve VSD patch closure technique (DFV) in 1996 to reduce early postoperative risk. Long-term results are presented in this report.
This was a retrospective single-institution study of patients who underwent DFV between May 1996 and July 2015. Beginning in 2005, all candidates for DFV received sildenafil preoperatively and postoperatively. Preoperative catheterization data and operative, postoperative, hospital, and follow-up data were analyzed.
A total of 40 patients underwent the DFV procedure. Patients’ demographics were comparable between the sildenafil and nonsildenafil groups. One of 39 patients (2.6%) was lost to follow-up. Early mortality was 2.5% (1 of 40), and late mortality was 2.6% (1 of 38). Sildenafil improved preoperative oxygen saturation, improved preoperative hemodynamics, and shortened postoperative ventilation time. In both groups, abnormal hemodynamic values improved with a 100% oxygen challenge. The median age at late follow-up was 26.3 years (interquartile range [25%, 75%], 20.9, 29.9 years), and the median time since operation was 19.2 years (interquartile range, 11.4, 22.7 years). Current discharge survival was 97.3%. A total of 18% of patients had severe PAH in late follow-up. Multivariate analysis revealed only a baseline PVR-to–systemic vascular resistance ratio of 0.8 or greater as a significant predictor of late severe PAH.
Long-term follow-up demonstrated that 60% of the patients will achieve normal or nearly normal pulmonary artery pressures. Furthermore, the study demonstrated that sildenafil improves preoperative hemodynamics and postoperative management. Children with VSD, elevated PVR, and PAH should not be denied operation.
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The purpose of the present study was to study the midterm hemodynamic outcomes of unidirectional valved patch closure of ventricular septal defects (VSDs) in patients with VSD and pulmonary arterial hypertension (PAH).
From January 2006 to January 2012, 20 patients with VSD with PAH and a pulmonary vascular resistance index >8 Wood units underwent VSD closure with a unidirectional valved patch using the technique previously described by us. Of these, 13 patients agreed to follow-up cardiac catheterization and were studied at a mean follow-up of 34.7 ± 18.6 months (range, 2-56). The mean age of these 13 patients was 8.5 ± 4.4 years (range, 2-19; median, 9), and the mean preoperative systemic saturation was 94.1% ± 3.4% (range, 87-99; median, 95.0) The mean preoperative pulmonary artery systolic pressure was 96.2 ± 13.6 mm Hg (range, 75-115; median, 103.0), and the mean preoperative pulmonary vascular resistance index was 10.0 ± 2.1 Wood units (range, 8.0-15.1; median, 9.3).
At follow-up cardiac catheterization, the mean systemic saturation had increased to 98.92%. The pulmonary vascular resistance index had decreased significantly to 5.8 ± 2.1 Wood units (P = .02). A significant decrease was seen in the pulmonary artery systolic, diastolic, and mean pressures (P = .000), and none of the patients had severe PAH. No patients died, and all patients were in New York Heart Association class I.
Unidirectional valved patch closure of VSD is a promising technique for patients with a large VSD and severe PAH. It had a favorable effect on the immediate, early, and midterm clinical outcomes and hemodynamic parameters.

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Original articleCardiovascularFlap Valve Double Patch Closure of Ventricular Septal Defects in Children With Increased Pulmonary Vascular Resistance

Background

Methods

Results

Conclusions

Section snippets

Patient Demographics and Sites of Operation

Preoperative Data

Comment

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Progr Pediatr Cardiol

Progr Pediatr Cardiol

Progr Pediatr Cardiol

J Thorac Cardiovasc Surg

Nitric oxide is superior to prostacyclin for pulmonary hypertension after cardiac operations

Ann Thorac Surg

Early extubation: the initial Croatian experience

Cardiovasc Eng

Double patch closure of ventricular septal defect with increased pulmonary vascular resistance

Ann Thorac Surg

Long-term outcome of patients operated for large ventricular septal defects with increased pulmonary vascular resistance

Indian Heart J

Failed extubation after cardiac surgery in young children: incidence, etiology, risk factors

Pediatr Crit Care Med

Original article
Cardiovascular
Flap Valve Double Patch Closure of Ventricular Septal Defects in Children With Increased Pulmonary Vascular Resistance