Ventricular septal defect surgery
Ventricular septal defect Microchapters
Ventricular septal defect surgery On the Web
American Roentgen Ray Society Images of Ventricular septal defect surgery
- Muscular and membranous defects usually close spontaneously
- Perimembranous VSD is repaired on cardiopulmonary bypass with ischemic arrest. Device closure is rarely used in the United States because of the reported incidence of early and late onset complete heart block after device closure, presumably secondary to device trauma to the AV node.
- Surgical exposure is achieved through the right atrium. The tricuspid valve septal leaflet is retracted or incised to expose the defect margins.
- Several patch materials are available, including native pericardium, bovine pericardium, PTFE (Goretex(tm) or Impra(tm), or dacron.
- Suture techniques include horizontal pledgeted mattress sutures, and running polypropylene suture.
- Critical attention is necessary to avoid injury to the conduction system located on the left ventricular side of the interventricular septum near the papillary muscle of the conus.
- Care is taken to avoid injury to the aortic valve with sutures.
- The heart is extensively deaired by venting blood through the aortic cardioplegia site, and by infusing carbon dioxide into the operative field to displace air.
- Intraoperative transesophageal echocardiography is used to confirm secure closure of the VSD, function of the aortic valve, ventricular function, and the elimination of all air from the left side of the heart.
- The sternum is closed, with potential placement of a local anesthetic infusion catheter under the fascia, to stabilize postoperative pain control.
- Subaortic and subpulmonary defects even if small should be closed to prevent aortic regurgitation and pulmonary regurgitation.
- Shown below is a video of perimembranous VSD repair, including the operative technique, and the daily postoperative recovery.
AMPLATZER Muscular Occluder VSD is delivered through a catheter. The physician deploys the occluder discs on either side of the defect, closing off the defect.
2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines
Therapeutic Recommendations for Ventricular Septal Defect
|1. "Adults with a VSD and evidence of left ventricular volume overload and hemodynamically significant shunts (Qp:Qs ≥1.5:1) should undergo VSD closure, if PA systolic pressure is less than 50% systemic and pulmonary vascular resistance is less than one third systemic.(Level of Evidence: B-NR) "|
|"1. Surgical closure of perimembranous or supracristal VSD is reasonable in adults when there is worsening aortic regurgitation (AR) caused by VSD(Level of Evidence: C-LD)|
|1."Surgical closure of a VSD may be reasonable in adults with a history of IE caused by VSD if not otherwise contraindicated. (Level of Evidence: C-LD)"|
|2."Closure of a VSD may be considered in the presence of a net left-to-right shunt (Qp:Qs ≥1.5:1) when PA systolic pressure is 50% or more than systemic and/or pulmonary vascular resistance is greater than one third systemic(Level of Evidence: C-LD) "|
The extent of the shunt and the afterload to the ventricles are closely related to the hemodynamic impact of ventricular septal defects (VSDs), which initially place a volume load on the left heart. In children, isolated VSDs are the most typical type of congenital heart disease. The majority of isolated muscle and perimembranous VSDs are small and close spontaneously.
2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)
Recommendations for Surgical Ventricular Septal Defect Closure (DO NOT EDIT)
|"1. Surgeons with training and expertise in congenital heart disease (CHD) should perform VSD closure operations.(Level of Evidence: C) "|
|"2. Closure of a VSD is indicated when there is a Qp/Qs (pulmonary–to–systemic blood flow ratio) of 2.0 or more and clinical evidence of left ventricular (LV) volume overload. (Level of Evidence: B) "|
|"3. Closure of a VSD is indicated when the patient has a history of infective endocarditis (IE). (Level of Evidence: C) "|
|"1. VSD closure is not recommended in patients with severe irreversible PAH.(Level of Evidence: B) "|
|"1. Closure of a VSD is reasonable when net left-to-right shunting is present at a pulmonary blood flow/systemic blood flow (Qp/Qs) greater than 1.5 with pulmonary artery pressure less than two thirds of systemic pressure and PVR less than two thirds of systemic vascular resistance.(Level of Evidence: B)|
|"2. Closure of a VSD is reasonable when net left-to-right shunting is present at a Qp/Qs greater than 1.5 in the presence of LV systolic or diastolic failure.(Level of Evidence: B) "|
- Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM; et al. (2019). "2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". J Am Coll Cardiol. 73 (12): 1494–1563. doi:10.1016/j.jacc.2018.08.1028. PMID 30121240.
- Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (23): e1–121. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.