32.1.32 Early Outcome of Surgical Closure of 200 Ventricular Septal Defects: Single Surgeon Experience

Original Article

 

Surgical Closure of Ventricular Septal Defects

Early Outcome of Surgical Closure of 200 Ventricular Septal Defects: Single Surgeon Experience

Faiz Rasool

ABSTRACT

Objective: To see the early outcome of surgical closure of 200 ventricular septal defects

Study Design: Retrospective study

Place and Duration of Study: This study was conducted at the children’s Hospital Lahore, Hameed Latif Hospital Lahore and University of Lahore Teaching Hospital Lahore from January 2018 to October 2020.

Materials and Methods: Files of the patients who underwent VSD closure by a single surgeon (author) were reviewed. Age, weight, presenting symptoms, indication for surgery, associated lesions, cardiopulmonary bypass time, cross clamp time, duration of mechanical ventilation, mortality, risk factors for mortality, and complications were studied.

Results: 200 patients underwent VSD closure from January 2018 to October 2020. Mean age was 11 months, mean weight was 7 kg. Pulmonary hypertension was the most common indication for VSD closure. Average cardiopulmonary bypass time was 48 minutes; average cross clamp time was 32 minutes. Peri operative mortality was 3.5%.

Conclusion: In a resource limited country like Pakistan where there are only few centers are performing pediatric cardiac surgery, our series of 200 VSD closures represent reasonable outcome.

Key Words: ventricular septal defect. VSD closure, heart block

Citation of article: Rasool F. Early  Outcome of Surgical Closure of 200 Ventricular Septal Defects: Single Surgeon Experience. Med Forum 2021;32(1):132-135.

 

 

INTRODUCTION

Ventricular septal defect (VSD) is the most common congenital cardiac anomaly in children.  Isolated VSD accounts for 37% of all congenital heart disease in children. The incidence of isolated VSD is about 0.3% of newborns. 1 The interventricular septum is a  curved structure because of  the pressure difference in right and left ventricles. It is composed of five parts: the membranous, muscular, infundibular, atrioventricular and the inlet.2,3  Failure of one of these components to form will result in ventricular septal defect. There are mainly 4 types of VSD. Type 1 is outlet VSD, type 2 is membranous VSD, type 3 is inlet VSD and type 4 is muscular VSD.4

The physiologic consequences of any hole between the ventricles are related to its size, and to the relative resistances produced in the pulmonary and systemic vascular beds.

 

 

Department of Pediatric Cardiac Surgery, Children hospital. Lahore.

 

 

Correspondence: Dr. Faiz Rasool, Assistant Professor of Pediatric Cardiac Surgery, Children hospital. Lahore.

Contact No: 03009454461

Email: faiz03009454461@gmail.com

 

 

Received:  November, 2020

Accepted:  December, 2020

Printed:      January, 2021

 

 

Left ventricular volume overload, pulmonary hypertension, infective endocarditis, aortic regurgitation, and eisenmenger syndrome are the potential complications.5

It is estimated that every year 42000 babies are born with CHD in Pakistan.6

According to cardiothoracic surgeon registry there are 0.52 (0-25.97) pediatric cardiac surgeons per million population globally. Large disparities exists between regions, ranging from 0.08 pediatric cardiac surgeons per million population (sub-Saharan Africa) to 2.08 pediatric cardiac surgeons (North America).7 In Pakistan, ratio is same as that of Africa, that is 0.08/million.

In most of the patients, VSD closure is required in infancy. In this article, author has retrospectively reviewed the results of 200 ventricular septal defects that were closed in the period of last three years.

MATERIALS AND METHODS

Study type: Retrospective; case series

Study duration:  Study was done from January 2018 to October 2020.

Setting: Surgeries were performed at children’s Hospital Lahore, Hameed Latif Hospital Lahore and University of Lahore Teaching Hospital Lahore.

Inclusion criteria: all the patients undergoing VSD closure.

Exclusion criteria: Patients undergoing VSD closure as a part of treatment for other diseases like tetralogy of fallots, truncus srteriosis, transposition of great
arteries etc.

Files of the patients who underwent VSD closure by a single surgeon (author), from January 2018 to October 2020, were reviewed. Age, weight, presenting symptoms, indication for surgery, associated lesions, cardiopulmonary bypass time, cross clamp time, duration of mechanical ventilation, mortality,  risk factors for mortality, and complications were studied.

Patents who had VSD closure during operation for other diseases like Tetrology of fallot, complete AV canal defects, transposition of  great  arteries,  and truncus arteriosis, were not included in the study..

RESULTS

200 patients underwent VSD closure from January 2018 to October 2020.  160 at Children’s Hospital Lahore, 32 at Hameed Latif Hospital Lahore and 28 at university of Lahore teaching hospital Lahore.

Age: Age of the patients ranged from 3 months to 14 years with the mean of 11 months

Weight: weight ranged from 2.5kg to 42 kg with mean of 7kg

Indication For Surgery:  table 1 shows the indications for surgery. Pulmonary hypertension was the most common indication for VSD closure.

Concomitant Surgical Procedures:  table 2 shows the concomitant surgical procedures

Cardiopulmonary Bypass Time:  Cardiopuomonary bypass time ranged from 35 minutes to 285 minutes with the mean of 48 minutes

Cross Clamp Time:  cross clamp time ranged from 21 minutes to 200 minutes with the mean of 32 minutes

Types of VSDs: type 2 VSD was the most common type of VSD. Detail is provided in table 3

Mortality:  7 patients died. All of these died of ventilator associated pneumonia leading to sepsis and multi organ failure. 4 patients were having weight less than 3.5 kg. They could not be weaned from mechanical ventilation. 4 were having persistent pulmonary hypertension.

Complications: fig 1 shows the detail of  complications.

 

Table No.1: indication for surgery

Indications for surgery

n

%

Pulmonary hypertension

152

76%

Right coronary cusp prolapsed

17

8.5%

Aortic regurgitation

13

6.5%

RVOT obstruction

12

6.%

Failure to thrive

3

1.5%

LV volume overload

3

1.5%

 

 

 

Table No.2: Concomitant procedures

Concomitant procedures

N

%

PDA ligation

45

22.5%

Right ventricular outflow tract muscle resection

10

5%

Pulmonary valvotomy

2

1%

PA debanding

2

1%

Aortic valve repair

6

3%

Creation of flap valve in VSD patch

3

1.5%

Closure of additional muscular VSD

2

1%

Coarctation of aorta repair

1

0.5%

Table No.3 Miscellaneous details

Total number of patients

200

 

Age

3months - 14 years (mean 11months)

 

Weight

2.5 – 41 kg( mean 7kg)

 

CPB time

35-285 (mean 48 minutes)

 

Cross clamp time

21-200 minutes( mean 32miutes)

 

Type 1 VSD

35

18.5%

Type 2 VSD

148

74%

Type 3VSD

8

4%

Type 4 VSD

9

4.5%

 

 

 

 

Figure No. 1 complication after VSD closure

DISCUSSION

The outcomes after surgical closure of VSD have  improved  over time with the advance in  surgical techniques, cardiopulmonary bypass, anaesthesia and postoperative care8. However, the disturbance of conduction system like complete heart block and  right bundle branch block, residual ventricular shunt, neurologic injury, and postoperative mortality are important  postoperative problems, more frequent  in infants with malnutrition. 9

 

 

Mortality after VSD closure in developed countries is 0.5-1.7% 10-12, but it is still high in developing countries like Pakistan. Mortality rate in our series is comparable to other studies in Pakistan 13,14, which had mortality rate of 3.4% to 6%. Weight less than 3.5kg and persistent pulmonary hypertension were identified as the risk factors for mortality in our series.  Another study by kamal saleem15 had mortality of 11%. Body weight less than 5 kg,  young age, high pulmonary artery to systemic pressure ratio  and presence of additional left to right shunt were identified as  risk factors for adverse outcome.

A study by Jamal Abdul Nasir 16 had incidence of aortic valve repair associated with VSD was 30%, while in our series, only 3 percent of the patients with VSD required aortic valve repair.

While in most of the recent studies,17-20 show device closure of the VSD, but in Pakistan most of the centers are doing surgical closure of the VSDs.

Incidence of complete heart block after VSD closure is less than 1% in international literature. But a study from Pakistan 21 had 10% incidence of heart block after VSD closure. In that study all patients with perimembranous ventricular septal defect, aged 5 years to 25 years were included. Results showed complete heart block in the perimembranous ventricular septal defect after surgical closure was 10(9.71%).

In our series 2% of the patients developed complete heart block that required permanent pace maker in peri operative period. 1 of them developed sinus rhythm 2 days after the permanent pace maker insertion.

CONCLUSION

In a resource limited country like Pakistan where there are only few centers are performing pediatric cardiac surgery, our series of 200 VSD closures represent reasonable outcome. We have not mentioned about the follow up of those patients which is shortcoming in this series.

Author’s Contribution:

Concept & Design of Study:

Faiz Rasool

Drafting:

Faiz Rasool

Data Analysis:

Faiz Rasool

Revisiting Critically:

Faiz Rasool

Final Approval of version:

Faiz Rasool

Conflict of Interest: The study has no conflict of interest to declare by any author.

REFERENCES

1.     Pinto NM, Waitzman N, Nelson R, Minich LL, Krikov S, Botto LD. Early Childhood Inpatient Costs of Critical Congenital Heart Disease. J Pediatr 2018;203:371-379.e7.

2.     Patel ND, Kim RW, Pornrattanarungsi S, Wong PC. Morphology of intramural ventricular septal defects: Clinical imaging and autopsy correlation. Ann Pediatr Cardiol 2018;11(3):308-311. 

3.     Lopez L, Houyel L, Colan SD, Anderson RH, Béland MJ, Aiello VD, et al. Classification of Ventricular Septal Defects for the Eleventh Iteration of the International Classification of Diseases-Striving for Consensus: A Report From the International Society for Nomenclature of Paediatric and Congenital Heart Disease. Ann Thorac Surg 2018;106(5):1578-1589.

4.      Mostefa-Kara M, Houyel L, Bonnet D. Anatomy of the ventricular septal defect in congenital heart defects: a random association? Orphanet J Rare Dis 2018;13(1):118.

5.     Spicer, Diane & Hsu, Hao & Co-Vu, Jennifer & Anderson, Robert & Fricker F. Ventricular septal defect. Orphanet J Rare Diseases 2014;9. 144.

6.     Christianson AHC, Modell B. March of Dimes. Global report on birth defect. The hidden toll of dying and disabled children. New York; 2006.

7.     Vervoort D, et al. Global cardiac surgery: Access to cardiac surgical care around the world doi.org/10.1016/j.jtcvs.2019.04.039.

8.     Aydemir NA, Harmandar B, Karaci AR, et al. Results for surgical closure of isolated ventricular septal defects in patients under one year of age. J Card Surg 2013;28:174-9.

9.     Shi G, Chen H, Sun Q, Zhang H, Zheng J. Mattress Stitch--A Modified Shallow Stitching in the Surgical Closure of Large Perimembranous Ventricular Septal Defect in Infants. Ann Thorac Cardiovasc Surg 2015;21(3):282-8.

10.            Scully BB, Morales DL, Zafar F, McKenzie ED, Fraser CD Jr, et al. Current expectations for surgical repair of isolated ventricular septal defects. Ann Thorac Surg 2010;89:544-549.

11.            Nygren A, Sunnegårdh J, Berggren H. Preoperative evaluation and surgery in isolated ventricular septal defects: a 21 year perspective. Heart 2000;83:
198-204.

12.            Anderson BR, Stevens KN, Nicolson SC, Gruber SB, Spray TL, et al. Contemporary outcomes of surgical ventricular septal defect closure. J Thorac Cardiovasc Surg 2013;145:641-647.

13.            Khan IU, Ahmed I, Mufti WA, Rashid A, Khan AA, Ahmed SA, et al. Ventricular septal defect in infants and children with increased pulmonary vascular resistance and pulmonary hypertension--surgical management: leaving an atrial level communication. J Ayub Med Coll Abbottabad. 2006;18(4):21-5.

14.            Bushra O, Muneer AM, Mehnaz A. Surgical Outcomes of Pediatric Patients with Ventricular Septal Defects in a Tertiary Referral Center in Pakistan: A Retrospective Cohort Study. J Clin Exp Cardiolog 2013;4:269.

15.            Saleem K, Ahmad SA, Rashid A, Khan AA, Zameer M, Naqvi S, et al. Outcome of ventricular septal defect closure. J Coll Physicians Surg Pak 2004;14(6):351-4.

16.            Nasir JA. Outcome of surgery for aortic regurgitation associated with ventricular septal defects. J Rawal Med Coll 2011;15:10-12.

17.            Shyu TC, Lin MC, Quek YW, Lin SJ, Saw HP, Jan SL, et al. Initial experience of transcatheter closure of subarterial VSD with the Amplatzer duct occluder. J Chin Med Assoc 2017;80(8):487-491.

18.            Yang L, Tai BC, Khin LW, Quek SC. A systematic review on the efficacy and safety of transcatheter device closure of ventricular septal defects (VSD). J Interv Cardiol 2014;27(3):260-72.

19.            Ali YA, Hassan MA, El Fiky AA. Assessment of left ventricular systolic function after VSD transcatheter device closure using speckle tracking echocardiography. Egypt Heart J 2019;71(1):1.

20.            Cinteză EE, Butera G. Complex ventricular septal defects. Update on percutaneous closure. Rom J Morphol Embryol 2016;57(4):1195-1205.

21.            Shah SMA, et al. Frequency of complete heart  block after surgical closure of perimembranous ventricular septal defects. J postgrad Med Inst 2015;29:308-12.