Ann Thorac Surg 1996;61:1838-1839
© 1996 The Society of Thoracic Surgeons
Case Report
Ventricular Septal Aneurysm After Atrioventricular Septal Repair With Pericardium
Harold M. Burkhart, MD,
Stephanie A. Moody, BS,
Greg J. Ensing, MD,
John W. Brown, MD
Section of Cardiothoracic Surgery, Department of Surgery, and Section of Cardiology, Department of Pediatrics, Indiana University Medical Center, Indianapolis, Indiana
Accepted for publication December 26, 1995.
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Abstract
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A 2-month-old infant underwent a two-patch repair of a type C atrioventricular septal defect using autologous pericardium. Several months later a large, symptomatic aneurysm of the ventricular septal patch developed, requiring resection. The use of untreated autologous pericardium for large, congenital ventricular septal defects is unpredictable and should be avoided.
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Introduction
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Autologous pericardium continues to be widely used in the repair of numerous types of cardiac lesions. Since Sauvage and associates [1] reported their experience in using pericardium for ventricular septal defect (VSD) repair almost three decades ago, little has been reported regarding its use for this application. The purpose of this report is to present a rare case of a large, symptomatic ventricular septal aneurysm after repair of an atrioventricular septal defect with untreated autologous pericardium. This article will also review existing literature concerning the use of autologous pericardium in repairing ventricular defects.
A 3.9-kg, 2-month-old male infant presented in congestive heart failure. Echocardiography revealed a complete atrioventricular septal defect characterized by a large, nonrestrictive VSD with low-velocity flow and a large primum-type atrial septal defect. Cineangiography showed a mildly dilated left ventricle with normal function, scalloping of the mitral valve, a typical goose-neck deformity of the left ventricular outflow tract, a large inlet VSD, a large primum atrial septal defect, and a large left-to-right shunt.
The patient was considered to be at moderate risk for pulmonary artery banding because of the large atrial shunt and was taken to operation for a complete repair of the defect. Intraoperatively, the patient was found to have a type C atrioventricular septal defect. Autologous pericardium was substituted for the routine Dacron or polytetrafluoroethylene material because of the extremely delicate (ie, transparent) nature of the bridging atrioventricular valve leaflets. Separate untreated autologous pericardial patches were used to close a 20 x 10-mm crescent-shaped VSD and a 20 x 20-mm atrial septal defect. The bridging atrioventricular valve leaflet tissue was attached to the pericardial VSD patch as well as the atrial septal patch. The procedure was concluded without complication. A postrepair transesophageal echocardiogram showed an excellent repair with minimal mitral insufficiency.
Approximately 3 months postoperatively, the patient presented in mild respiratory distress. Echocardiography revealed a large aneurysm of the VSD patch prolapsing from the posterior membranous inlet ventricular septum into the right atrium, anterior and superior to the tricuspid valve. Angiography showed a large aneurysm of the VSD patch partially obstructing the tricuspid valve orifice and nearly filling the right atrium as it flopped up and down through the tricuspid valve orifice (Fig 1
). Cardiac catheterization demonstrated a left ventricular pressure of 105/10 mm Hg, normal right ventricular pressures, and an ascending aortic pressure of 110/65 mm Hg.
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Fig 1. . Right oblique view of a cardiac cineangiogram after left ventricular injection. Note the large ventricular septal defect patch aneurysm obliterating the right atrium during systole.
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The patient was returned to the operating room 2 days later and a massively dilated, thin-walled VSD pericardial patch aneurysm was found bulging into the right atrium. The atrial septal defect patch was found to be intact, without aneurysm, and with normal-appearing endothelialization. The aneurysmal VSD patch was completely excised, leaving a 1.5-mm rim to attach a quarter-sized, crescent-shaped Dacron patch. Intraoperative transesophageal echocardiography revealed no significant shunting, mild tricuspid regurgitation, and mitral insufficiency at the cleft repair site. The procedure was tolerated well, and the patient was discharged home 7 days postoperatively. Ten months later he continues to do well and does not require digoxin or diuretics.
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Comment
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The use of autologous pericardium for congenital VSD repair continues to be a topic of controversy. Several centers continue to use it in infants with atrioventricular septal defects (personal communication: J. Meyers, MD, University of Pittsburg [50+ cases, glutaraldehyde treated]). Its use in many other cardiac repairs has been established, including repair of postinfarction ventricular aneurysms, repair of valvular defects, and enlargement of the right ventricular outflow tract and aortic root [2, 3]. Despite its numerous advantages and success in other repairs, surgeons continue to be reluctant to use this material because of its unpredictability secondary to the risk of patch aneurysm [3]. An exception to this is its widespread use in enlarging the aortic root, where patch aneurysm does not seem to be a problem [2]. The advantages of pericardium include its ready availability, seemingly good strength, handling ease, imperviousness, resistance to infection, and lower thrombogenicity than graft material [3, 4].
The predominant disadvantage of untreated pericardium is its unpredictable predilection for aneurysm formation. Several studies have illustrated the formation of aneurysms after the use of autologous pericardium to repair right ventricular outflow tracts. The rates of aneurysm formation between 4% and 25% have been related to a larger size of defect and to pressure overload on the right ventricular outflow tract [5].
Relatively few studies have reported on the use of autologous pericardium in the repair of VSDs. The first such study was by Sauvage and associates [1], in which satisfactory results were obtained in 13 congenital VSD repairs using autologous pericardium. The average size of the defects was reported as 14 mm. David and colleagues [3] reported the repair of six postinfarction VSDs using a double-layer pericardial patch, none of which had postoperative complications.
Other studies, however, have discussed repairs using autologous pericardium that were not so successful. Kawashima and associates [6] reported on a series of 9 children undergoing VSD repair with pericardium. More than half of the patches showed evidence of bulging or aneurysm. Kawashima and associates concluded that the predominant contributing factor to patch aneurysm formation is a defect of 12 mm or more. In this report, pathologic studies of the aneurysm tissue found thickened margins with newly developed vasculature. However, the central portions lacked tissue invasion and were atrophic. The findings reported by Sauvage and associates [4], based on animal and human studies of the viability of tissue and prosthetic grafts in cardiac repairs, supported these pathologic conclusions.
In addition to the size of the VSD and tissue invasion, proposals have been made in regard to other possible factors contributing to aneurysm formation. Because anatomic variation in the distensibility of pericardium has been evidenced in bovine pericardium [7], the location of the sample of pericardium excised may contribute to the likelihood of aneurysm formation. The age of the patient may also contribute in that adult pericardium may be intrinsically more resistant to aneurysm formation as evidenced by animal studies [8].
In conclusion, autologous pericardium continues to be an excellent tissue for the repair of various cardiac defects. However, its use in the repair of congenital VSDs is unpredictable and should be avoided for larger defects.
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Footnotes
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Address reprint requests to Dr Brown, Section of Cardiothoracic Surgery, Department of Surgery, Indiana University Medical Center, Emerson Hall 222, 545 Barnhill Dr, Indianapolis, IN 46202.
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References
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- Sauvage LR, Wood SJ, Deane PG, Merritt WH, Logan GA. Autologous pericardium as a graft for the ventricular septum. The Am Surg 1966;32:535–7.
- Piehler JN, Danielson GK, Pluth JR, et al. Enlargement of the aortic root or anulus with autogenous pericardial patch during aortic valve replacement. J Thorac Cardiovasc Surg 1983;86:350–8.[Abstract]
- David TE, Feindel CM, Ropchan GV. Reconstruction of the left ventricle with autologous pericardium. J Thorac Cardiovasc Surg 1987;94:710–4.[Abstract]
- Sauvage LR, Gross RE, Rudolf AM, Pontius RG, Watkins E. Experimental study of tissue and prosthetic grafts with selected application to clinical intracardiac surgery. Ann Surg 1961;153:321–43.[Medline]
- Seybold-Epting W, Chiariello L, Hallman GL, Cooley DA. Aneurysm of pericardial right ventricular outflow tract patches. Ann Thorac Surg 1977;24:237–45.[Abstract/Free Full Text]
- Kawashima Y, Nakano S, Kato M, Danno M, Sato K, Manabe H. Fate of pericardium utilized for the closure of ventricular septal defects: postoperative ventricular septal aneurysm. J Thorac Cardiovasc Surg 1974;68:209–18.
- Trowbridge EA, Roberts KM, Crofts CE, Lawford PV. Pericardial heterographs. J Thorac Cardiovasc Surg 1986;92:21–8.[Abstract]
- Hjelms E, Pohlner P, Barratt-Boyes BG, Gavin JB. Study of autologous pericardial patch grafts in the right ventricular outflow tract in growing and adult dogs. J Thorac Cardiovasc Surg 1981;81:120–3.[Abstract]
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Abstract
Introduction
