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Ann Thorac Surg 1997;63:288-289
© 1997 The Society of Thoracic Surgeons

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Updates

Repair of Large Muscular Ventricular Septal Defects in Infants Employing Left Ventriculotomy

As Originally Published in 1989:

Updated in 1996 by Robert L. Hannan, MD, Nancy McDaniel, MD, and Irving L. Kron, MD

Division of Thoracic and Cardiovascular Surgery and Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia

Since the publication of the original article [1] we have employed a left ventriculotomy to close a large muscular ventricular septal defect (VSD) in 1 additional infant. This patient was a 4-month-old infant with a large muscular VSD, coarctation of the aorta, congestive heart failure, and failure to thrive. The child did well postoperatively and is now almost 5 years old. The use of the technique only once in the interval does not reflect a new bias against the approach, but rather a dearth of patients presenting with this lesion in the first 4 months of life with intractable heart failure.

Follow-up of the 5 patients in the entire series ranges from 4 to almost 11 years. All are in excellent health. The older children participate in sports, and the oldest 2 have had exercise bicycle stress testing with normal results for age and no dysrhythmia or ischemia. All have had follow-up echocardiography: none have a residual VSD, 1 child has a subaortic ridge, and 2 have echocardiographic evidence of apical dyskinesia. Two patients have normal electrocardiograms; 2 children have evidence of right bundle-branch block and 1 has evidence of left ventricular hypertrophy. Three patients have had follow-up cardiac catheterization: there were no residual shunts by oximetry, and all had normal right ventricular and pulmonary artery pressures. All 3 were, however, noted to have apical dyskinesia (Fig 1).

View larger version (126K): [in this window] [in a new window]   Fig 1. . Left anterior oblique left ventriculogram demonstrating apical akinesis (arrows).

In our series of 5 patients all were 4 months of age or less at operation and all had congestive heart failure refractory to medical therapy at the time of operation. Three patients have evidence of apical dyskinesia by echocardiography or angiography; none have any physical limitations or other evidence of myocardial dysfunction. In this specific subset of patients, left ventriculotomy remains a rational approach to a difficult management problem, with excellent short-term and midterm results. Although the number of infants to whom this approach is applicable is limited, we continue to consider it an excellent approach, and it remains a standard part of our practice. We will continue to follow up these patients to determine the long-term effects of left ventriculotomy in infants.

Footnotes

Address reprint requests to Dr Hannan, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Box 3501, University of Virginia Health Sciences Center, Charlottesville, VA 22908 (e-mail: rhannan{at}Virginia.edu).

References

1. McDaniel N, Gutgesell HP, Nolan SP, Kron IL. Repair of large muscular ventricular septal defects in infants employing left ventriculotomy. Ann Thorac Surg 1989;47:593–4.
2. Bridges ND, Perry SB, Keane JF, et al. Preoperative transcatheter closure of congenital muscular ventricular septal defects. N Engl J Med 1991;324:1312–7.[Abstract]
3. Fishberger SB, Bridges ND, Keane JF, et al. Intraoperative device closure of ventricular septal defects. Circulation 1993;88 (Suppl 2):205–9.
4. Leca F, Karam J, Vouhé PR, et al. Surgical treatment of multiple ventricular septal defects using a biologic glue. J Thorac Cardiovasc Surg 1994;107:96–102.[Abstract/Free Full Text]
5. Serraf A, Lacour-Gayet F, Bruniaux J, et al. Surgical management of isolated multiple ventricular septal defects. Logical approach in 130 cases. J Thorac Cardiovasc Surg 1992;103:437–43.[Abstract]

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