Repair of ventricular septal defect in infants without ventriculotomy

Repair Of Ventricular Septal Defect In Infants Without Ventriculotomy Shu-Min

Kuo, Pei-Leun

Kang,

Jyuhn-Jung

Lyu,

Kwok-Dei

Cheng,

Kai-Sheng

Hsieh*

Cardiovascular Surgery, Pediatric Cardiology*, National Yang-Ming Medical College, Taipei and Veterans General Hospital, Kaohsiung, Taiwan, Republic of China

E

ighty-nine infants with clinical evidence of a large ventricular septal defect (VSD), refractory to conventional medical treatment, underwent surgical closure within the first 12 months of life from August 1987 to December 1991. There were 54 males and 35 females. The ages of the patients ranged from 2 to 12 months, with a mean age of 6.4 months. The mean body weight of the patients was 5.2 kg (range 2.3 to 10 kg). Surgery was performed because of intractable heart failure in 38 infants (43%), failure to thrive in 49 (55%), repeated pneumonia in 53 (60%) and prolonged endotracheal intubation in 10 (11%). There were 27 patients with a supracristal VSD (30%), and 62 patients with perimembranous VSD (70%). Eleven patients (12%) had pre-operative cardiac catheterization. Transatrial repair of perimembranous VSDs and transpulmonary repair of supracristal VSDs was used exclusively without ventriculotomy in our institution. Surgically induced heart block did not occur in any of the patients. Only 2 patients (2.2%) died during the early post-operative period. Diagnosis in most cases was confirmed by the present advanced integrated colour Doppler echocardiographic technology which is widely used by paediatric cardiologists. There is no need to perform cardiac catheterization in most patients with VSD. The morbidity and mortality were low. We strongly suggest that transatriai or transpuimonary primary repair without ventricuiotomy can be successfully accomplished in almost all infants with a large VSD. Key words: ventricular septal defect, infant, surgery. (AustralAs J Cardiac Thorac Surg 1992; l(2): pp.27-30) Introduction

we report our experience with transatrial repair of perimembranous VSDs and transpulmonary repair of supracristal VSDs without ventriculotomy during the first 12 months of life.

Ventricular septal defect (VSD) is the most common form of congenital heart disease (CHD) in Chinese. It accounts for 31% of all CHD’. Those infants younger than 12 months of age with a large VSD and recurrent pulmonary infections, failure to thrive or intractable congestive heart failure unresponsive to intensive medical therapy require prompt surgical intervention, because the medical mortality rate for this group is estimated to be as high as 25% despite intensive medical therapyzv3.

Materials and Methods Eighty-nine infants with a large VSD were operated on at Veterans Genera1 Hospital, Kaohsiung and Taipei, from August 1987 to December 1991. There were 54 male and 35 female infants. The mean age was 6.4 months (range 2-12 months). The mean body weight of the infants was 5.2 kg (range 2.3-10 kg). The body weight of the majority of patients was lower than the third percentile. Clinical evidence of a large VSD in this series was defined by the following criteria: (1) cardiomegaly and increased pulmonary blood flow on chest x-ray examination; (2) ventricular hypertrophy on ECG; (3) quantitative colour flow mapping of VSD jet compatible with QP/QS 51.5:1”. Repeated pu lmonary infections were present in 53 patients (60%), which was the most common indication for surgery. Failure to thrive was noted in 49 patients (55%), and intractable heart failure despite intensive medical treatment was present in 38 patients (43%). Prolonged endotracheal intubation was another indication for early operation in 10 patients (11%) (Table 1).

The previously preferred method of surgical management for these infants was to band the pulmonary artery followed later by repair for the VSD and pulmonary artery debanding. This two-stage surgical procedure has been abandoned by most medical centres, because the morbidity and mortality rates are higher than for one-stage primary repair of VSD 4-9. It is now standard practice in our institution to repair all VSDs without ventriculotomy, using transatrial or transpulmonary artery repair. In this paper, Presented at the 10th Bienniel Congress at the Asian Association of Thoracic and Cardiovascular Surgeons, November 1991, Bali, Indonesia.

27

Kuo, Kay, Lyu,,Cheng, Hsieh

AustralAs J Cardiac Thorac Surg 1992; l(2): pp.27-30 Ventricular

Table

1: Indications

for primary

repair

of VSD in infancy

N

%

Repeat pneumonia Failure to thrive Intractable heart failure Prolonged endotracheal intubation

53 49 38 10

60 55 43 11

The clinical diagnosis of VSD was confirmed mainly by integrated colour Doppler echocardiography at our paediatric cardiology department. Seventy-eight patients (88%) were operated upon with a diagnosis of VSD by echocardiography only, without cardiac catheterisation. Cardiac catheterisation was performed in 11 patients (12%) during the early period of this series or for associated cardiac anomalies. Twenty-seven infants were of the supracristal type of VSD (30%), and 62 infants were of the perimembranous type of VSD (70%). Associated cardiac anomalies included patent ductus arteriosus (PDA) in 8 patients (9%), coarctation of the aorta (CoA) in 10 patients (ll%), atria1 septal defect (ASD) in 6 patients (7%), type A interrupted aortic arch (IAA) in 4 patients (.5%), corrected transposition of the great arteries (c-TGA) in 2 patients (2%) and car triatriatum in 1 patient (1%). Previous pulmonary artery banding (PAB) had been performed in 5 patients (Table 2). 2: Associated

cardiac

N

%

Coarctation of aorta Patent ductus arteriosus Atrial septal defect Pulmonary artery banding Interrupted aortic arch Corrected TGA Cotriatriatum

10 8 6 5 4 2 1

11 9 7 6 5 2 1

surgery

There were two hospital deaths among the 89 infants, making a mortality rate of 2.2% (Table 3). One of these patients was 11 months old at the time of op-

Table

anomalies.

Anomaly

Infant,

Results

Age Table

efect,

chordae and medial papillary muscle of the tricuspid valve. In cases of total absence of infundibular septum in supracristal VSD, the stitches of the superior margin of the VSD were sutured in the annulus of the pulmonary valve on the pulmonary site. The associated atria1 septal defects were repaired by direct suture. The PDAs were ligated intrapericardially. The previous PAB was removed before starting cardiopulmonary bypass. The associated car triatriatum was repaired at the same time. In cases of VSD associated with CoA or IAA, the CoA or IAA was corrected first through a left thoracotomy without PAB, then the VSD was repaired 1 week to 6 months later depending on the patient’s condition. In cases of VSD with c-TGA, the VSD was repaired using the same method as simple VSD. Postoperative management included the use of a central venous pressure line inserted through the internal jugular vein, a radial arterial line and a Foley’s catheter.

(N=89).

Indication for operation

sepal

3: Hospital

mortality

for primary

repair

of VSD

in infancy.

Hospital death

(months)

N

N

%

<3 3-6 6- 12

11 35 43

0 1 1

0 3 2

Total

89

2

2.2

eration. After repair to the VSD, the patient’s hemodynamic condition was stable, but intractable hypoglycaemic episodes occurred during the early postoperative period. A brain CT scan revealed saggital sinus thrombosis. The patient died on the 15th postoperative day from multiple organ failure. The other patient also died from a similar condition. Postoperative blood transfusions were needed in 6 infants. Inotropic support (dopamine 3 20 12g/kg/min) was required in 5 patients. Eleven patients developed post-operative pulmonary insufficiency which needed endotracheal intubation and mechanical respiratory support for longer than 3 days. Seven trivial residual VSDs were noted by post-operative echocardiograms. There were no instances of post-operative complete heart block, nor re-exploratory sternotomy for bleeding in this series. Temporary A-V dissociation occurred in 15 patients (Table 4). All infants were followed up regularly after discharge from hospital and showed rapid weight gain without any cardiac medication.

Operative repair was performed with cardiopulmonary bypass and moderate hypothermia (25 28°C). Crystalloid cardioplegia and topical cooling using saline slush were used routinely for myocardial protection. No deep hypothermic circulatory arrest was used in this series. The VSD was exposed through a right atria1 approach for perimembranous VSD and a transpulmonary approach for supracristal VSD without right ventriculotomy. The defects were closed with a dacron patch and 5-O prolene interrupted mattress sutures with teflon pledgets. Frequently, the annulus of the septal leaflet of the tricuspid valve was on the right lateral side of the inferior rim of the perimembranous VSD, so the stitches were placed on the annulus of the septal leaflet at the right atria1 site. The septal leaflet of the tricuspid valve was detached from the annulus in 3 patients because of interference from the 28

Kuo, Kay.Lyu,,Cheng.

AustralAs J Cardiac Thorac Surg 1992; l(2): pp.27-30

Table 4: Post-operative VSD in infancy.

complications

following

primary

Ventricular

repair

Complication

N

%

Pulmonary insufficiency Residual VSD Low cardiac output Tracheal stenosis Neurologic deficit Bleeding Complete A-V block Temporary A-V dissociation

11

12 8 6 3 2 1 0 17

7 5 3 2 1 0 15

septal

efect,

mnfant,

Hsieh surgery

atria1 method and the supracristal VSDs by the transpulmonary method. Refinements of this operative technique, improvements in perfusion and hypothermic manipulation, and precise peri-operative management of infants with intracardiac defects have resulted in a very low operative mortality in infants with large VSDs. The transatrial approach for perimembranous VSDs and the transpulmonary approach for supracristal VSDs clearly exposes the margin of the VSD and the AV node, which eliminates the risk of significant post-operative residual VSDs and heart block. Another advantage of these two approaches is that there is little post-operative bleeding and almost no need for post-operative transfusion. The main pulmonary artery pressure was measured routinely before cannulation and after repair in the non-catheterised group during the early period of this series, and we found that the pulmonary artery pressure dropped to normal immediately after the operation, especially in infants. The post-operative intensive care of these small patients is very important, and any minor negligence may cause serious complications The right atria1 pressure, systolic arterial pressure and arterial blood saturation were monitored in all patients during the first 24 hours. All intranveous infusions as well as the inotropic agents, were accurately controlled by infusion pumps. Assisted post-operative ventilation was provided for all patients, and extubation was usually done during the afternoon following the operation or the next morning, according to the patient’s individual needs. Most of the infants were extubated early.

of

Discussion

VSD is the most common congenital heart defect. It is found in about 31% of all patients with CHD. Frequent pulmonary infections, congestive heart failure and failure to thrive are the major clinical symptoms in infants with a large VSD. Medical treatment alone, in these critically ill infants, carries a high mortality rate I’ . Therefore, su r gical intervention is frequently indicated. In the past, two-stage correction with initial PAB was popular because of the high mortality rate for primary repair of VSD in infants, especially in critically ill infants. However, although there are numerous criteria for adequate banding to decrease pulmonary overflow’2-15, none of these is entirely reliable. Even if the pulmonary artery is properly banded at the time of the operation, the future of the band is unpredictable. PAB is also unsatisfactory because of the significant early and late mortality and the development of band-related complications’6W20. In recent years, we have tried to repair large VSDs in infants with major clinical symptoms, especially critically ill infants with prolonged intubation due to respiratory failure or persistent congestive heart failure, despite intensive medical treatment. The diagnosis in this series was confirmed in most cases by a pre-operative integrated echocardiogram, which was used to locate the VSD, determine its size, estimate the pulmonary artery pressure and assess associated anomalies. Echocardiography can provide an accurate and non-invasive assessment of VSD in infants and children21-22. Cardiac catheterisation was done only in cases with complicated cardiac anomalies or incompatibility between the clinical and echocardiographic diagnosis. The major anatomical type of VSD in our infant series was perimembranous VSD (70%) which always presented early with severe symptoms and signs. There were no muscular VSDs in this series. The muscular VSD is very uncommon in Chinese (0.3-0.6%). In supracristal VSD (30%), the anatomical size of the VSD did not usually correspond to its functional size, because the actual size of the supracristal VSD is partially or totally obliterated by prolapse of the aortic cusp, usually the right coronary aortic cusp. All the perimembranous VSDs were repaired by the trans-

Previous experimental studies have demonstrated that a right ventriculotomy can depress right ventricular function, and the shorter the ventriculotomy, the less is the degree of depression23*24. Based on this concept we try to avoid right ventriculotomy in all cases of VSD in our institution, as well as in repair of tetralogy of Fallot2’. The transatrial exposure for perimembranous VSD and transpulmonary for supracristal VSD is excellent. At the same time, right ventricular function is well preserved by avoiding right ventriculotomy. Conclusion

Infants with VSD complicated by medically intractable heart failure, failure to thrive or repeated pneumonia should be treated early with surgical repair. The surgical morbidity and mortality are very low. The surgical repair of a VSD in infancy can be done safely with pre-operative echocardiographic evaluation and without cardiac catheterisation. The supracristal type of VSD should be repaired early to avoid further aortic regurgitation due to aortic cusp prolapse. PA banding should be reserved for infants with complex congenital heart defects. Precise surgical technique, proper intra-operative perfusion, hy29

AustralAs .I Cardiac Thorac Surg 1992; l(2): pp.27-30

Kuo, Kay, Lyu,,Cheng, Hsieh Ventricular septal efect, mnfant, surgery

pothermic manipulation and diligent post-operative care are mandatory. Transatrial repair of perimembranous VSD and transpulmonary repair of supracristal VSD can be successfully performed without ventriculotomy.

13. Grainger RG, Nagle RE, Pawidapha C, et al. Pulmonary artery banding for ventricular septal defect. Br Heart J 1967; 29:289-98.

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