Spontaneous Closure of Small Residual Ventricular Septal Defects After Surgical Repair

doi:10.1016/j.athoracsur.2006.09.086

The Annals of Thoracic Surgery

Volume 83, Issue 3, March 2007, Pages 902-905

https://doi.org/10.1016/j.athoracsur.2006.09.086 Get rights and content

Background

Residual shunts may be detected by intraoperative or postoperative echocardiography after surgical closure of a ventricular septal defect (VSD). The hemodynamic relevance and rate of late closure are unknown.

Methods

Between 1994 and 2005, 198 consecutive patients underwent surgical correction of an isolated VSD (n = 100), tetralogy of Fallot (n = 52) or atrioventricular septal defect (n = 46). Intraoperative transesophageal echocardiography (TEE) was routine, and postoperative transthoracic echocardiography was performed in the intensive care unit, at hospital discharge, and during follow-up. Residual defects were graded as absent, between 1 and 2 mm, or greater than 2 mm.

Results

Shunt-related discrepancy was observed between intraoperative TEE and intensive care unit transthoracic echocardiographic findings; significantly so after Fallot repair (p < 0.0001). After discharge, 83% of all residual defects less than 2 mm closed. Of nine residual defects greater than 2 mm, only three closed after a median follow-up of 3.1 years. In patients with residual shunts, they were hemodynamically insignificant, required no medication, and no endocarditis was noted. At last follow-up, there was no significant difference between the percentage of residual shunts among the three groups (p = 0.135).

Conclusions

Postsurgical residual VSDs less than 2 mm closed spontaneously in the majority within a year. Defects greater than 2 mm are unlikely to close spontaneously. Residual shunts after atrioventricular septal defect repair almost always close, whereas one third will remain open after Fallot or isolated VSD repair. At midterm follow-up, residual shunts remained hemodynamically and clinically irrelevant. Revision of a residual defect greater than 2 mm on cardiopulmonary bypass at initial repair, guided by TEE, may spare late redo surgery and lifelong antibiotic prophylaxis.

Section snippets

Material and Methods

The Institutional Review Board of our hospital approved the study. Retrospective chart and echocardiography report analysis were anonymously performed, whereby patient consent was waived. Between 1994 and 2005, 198 consecutive patients underwent surgery for closure of an isolated perimembranous VSD (n = 100), a malalignment TOF VSD (n = 52), or an inlet AVSD (n = 46). Standard surgical technique using cardiopulmonary bypass with moderate hypothermia, cross-clamping, and cold blood cardioplegia

Results

Median follow-up was 3.1 years (range, 0.5 to 9.7 years), and was similar in all three diagnostic groups. Discrepancy was observed between the intraoperative TEE findings and those of the first TTE performed in the intensive care unit, either on the same day as the operation or one day afterward. As seen in Table 1, the first TTE on the ICU disclosed a 30% rate of residual VSD versus only 20% on intraoperative TEE in patients after AVSD repair; 46% versus 15% after repair of tetralogy, and 30%

Comment

Surgical closure of an isolated VSD is a routinely performed operation, using standardized surgical techniques and postoperative care management. Outcomes are excellent, with mortality and morbidity rates approaching zero in almost all centers internationally [1]. When a VSD is part of a more complex congenital heart disease, such as tetralogy of Fallot or complete atrioventricular septal defect, they are routinely closed, with surgical mortalities ranging from 1% to 5% and 3% to 16%,

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There are more references available in the full text version of this article.

Cited by (53)

Is It a Residual Ventricular Septal Defect?
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2020, Progress in Pediatric Cardiology
A ventricular septal defect (VSD) is one of the most common congenital cardiac lesions. Echocardiography is the primary mode for evaluation of ventricular septal defects. Echocardiographic evaluations of ventricular septal defects are easily reproducible, can be done in a timely fashion, and do not require a complex set up. They give detailed information needed for the diagnosis, treatment and long term follow up. Although diagnosis can now be made prenatally, a more detailed evaluation with confirmation of the diagnosis is not made until after birth with transthoracic echocardiography. With a combination of 2D, color Doppler and spectral Doppler, the VSD location, size, and hemodynamic components can be established. Additionally, sequelae from the VSD and other associated congenital cardiac lesions can also be identified. A review of the standard components of a thorough transthoracic echocardiogram to evaluate the different types of ventricular septal defects will be discussed in this article.
Intraoperative echocardiography in congenital heart surgery: What the surgeon wants to know
2020, Progress in Pediatric Cardiology
Intraoperative transesophageal echocardiography (TEE) plays an integral role in the modern era of congenital heart surgery. Pre- and post-repair imaging obtained in the operating room by a pediatric cardiologist is now routine for most cardiac operations. This intraoperative collaboration is unique among the subspecialties, and, in many cases, influences the next step of the operation. Although TEE is an invaluable tool for providing detailed anatomical information, the surgical decisions based on that information are a reflection of the working relationship between the surgeon and the echocardiographer. As equally-invested stakeholders, pediatric cardiologists and surgeons share the responsibility for outcomes in congenital heart surgery. Optimizing communication in the operating room between surgeons and physicians performing echocardiograms is critical to providing the best possible outcomes for patients. Although published guidelines describe the technical conduct of TEE, they fail to describe what the surgeon is looking for and why. Just as surgeons may be unfamiliar with the technical aspects of echocardiography, cardiologists may be unfamiliar with the technical aspects of certain cardiac surgery procedures, and generally do not observe the entire operation. Because the surgeon looks at the echocardiogram from the unique perspective of having recently handled the involved structures, he or she will place priority on some aspects over others. Common priorities can be described by operation type. Herein, we provide an overview of intraoperative TEE for six benchmark operations, from the perspective of the surgeon.
Guidelines for Performing a Comprehensive Transesophageal Echocardiographic: Examination in Children and All Patients with Congenital Heart Disease: Recommendations from the American Society of Echocardiography
2019, Journal of the American Society of Echocardiography
Citation Excerpt :
Assessment for a residual VSD should always occur in more than one view and the decision to return to bypass should take into account several factors, including associated aortic regurgitation, outflow tract obstruction, and hemodynamic significance. Most residual VSDs ≤ 2 mm will spontaneously resolve with time.181 Residual VSDs ≤ 3 mm are typically not hemodynamically significant and some will spontaneously resolve.
Septal Leaflet Versus Chordal Detachment in Closure of Hard-to-Expose Ventricular Septal Defects
2018, Annals of Thoracic Surgery
Citation Excerpt :
Despite the initial presence of 20% and 23% small residual VSDs (≤2 mm) in the immediate postoperative transesophageal echocardiography in the CD and LD group respectively, there were no residual VSDs in the CD and only 2 in the LD group in the follow-up studies. It is not unusual for small residual shunts to close spontaneously in postoperative follow-up [17]. No patients from the CD or the LD group required reintervention or reoperation for closure of a residual VSD.
Different techniques have been used for exposure of ventricular septal defect (VSD) margins when there is crowding of the VSD anatomy by tricuspid valve subvalvar apparatus. This study compared surgical outcomes for the two techniques of tricuspid valve leaflet detachment and the rarely described tricuspid valve chordal detachment for hard-to-expose VSDs.
Patients undergoing transatrial VSD repair were identified from our institutional database. Follow-up echocardiography and patient data were obtained from medical records. Between January 2005 and August 2016, 130 isolated conoventricular VSDs were repaired. Among these, 26 patients underwent leaflet detachment, 15 underwent chordal detachment, and 89 underwent regular VSD repair (reference group).
The groups did not differ significantly in age, weight, postoperative length of stay, genetic/syndromic abnormalities, time to extubation, and left and right ventricular systolic function. The cardiopulmonary bypass and cross-clamp time were significantly longer in the leaflet detachment group than in the reference group (118 ± 28 vs 102 ± 32 minutes [p = 0.02] and 73 ± 20 vs 61 ± 23 minutes [p = 0.01], respectively). Echocardiographic follow-up was available for 87 patients at a mean of 2.6 years (range, 1 month to 11 years). Tricuspid regurgitation was rated as none or trivial in 66 (76%), mild in 20 (23%), and moderate in 1 reference group patient. There was no difference in presence of residual VSD or degree of tricuspid regurgitation among the three groups. There was no reoperation for tricuspid regurgitation.
Tricuspid valve leaflet and chordal detachment techniques provide an equally viable and safe alternative to closure of hard-to-expose VSDs while maintaining appropriate tricuspid valve function. Their use in our series did not lead to increased tricuspid valve dysfunction at early-to-midterm echocardiographic assessment.
Detachment of the tricuspid valve for ventricular septal defect closure in infants younger than 3 months
2016, Journal of Thoracic and Cardiovascular Surgery
Although several previous studies have reported that a ventricular septal defect (VSD) can be closed safely through the detached tricuspid valve (TV) without impairing TV function, this has not been demonstrated for infants younger than 3 months.
We enrolled 296 infants younger than 3 months who underwent VSD closure through the right atrium between January 2004 and December 2013. In the study group of 49 patients (16.6%), the TV was detached for better exposure of the defect.
The median age and weight were 63.5 days (14-90 days) and 4.4 kg (2.1-6.7 kg), without intergroup differences. Abnormal chordal attachment of the TV in preoperative echocardiography was associated with detachment of the TV during surgery (P = .001). Cardiopulmonary bypass (P = .001) and aortic crossclamp (P < .001) times were significantly longer in the study group. A permanent pacemaker was required for 2 patients in the control group. Follow-up echocardiography was available for 282 patients at a median of 21 months (1-108 months) after the operation. On final echocardiography, tricuspid regurgitation greater than grade 2 was observed in 1 patient in the study group and residual VSD existed in 4 patients (1 in the study group), without statistical significance.
Detachment of the TV can be used safely for better exposure of the VSD without increased risk of tricuspid regurgitation in infants younger than 3 months. Preoperative echocardiography might be useful for predicting the possibility of detachment of the TV for enhancing exposure of the VSD.

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Original articleCardiovascularSpontaneous Closure of Small Residual Ventricular Septal Defects After Surgical Repair

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

J Am Coll Cardiol

J Am Soc Echocardiogr

Ventricular septal defect

Evaluation of ventricular septal defect repair using intraoperative transesophageal echocardiography: frequency and significance of residual defects in infants and children

Echocardiography

Original article
Cardiovascular
Spontaneous Closure of Small Residual Ventricular Septal Defects After Surgical Repair