Ann Thorac Surg 2006;81:1510-1512
© 2006 The Society of Thoracic Surgeons
Case report
Rupture of a Synthetic VSD Patch 28 Years After Total Correction of Fallot's Anomaly
Tobias Kühme, MD, PhD
*
,
Kåge Säfström, MD, PhD,
Niels Erik Nielsen, MD, PhD,
Eva Nylander, MD, PhD,
Christian Olin, MD, PhD
Linköping Heart Center, University Hospital, Linköping, Sweden
Accepted for publication March 18, 2005.
* Address correspondence to Dr Kühme, Department of Cardiovascular Surgery and Anaesthesia, Linköping Heart Center, University Hospital, Linköping, 581 85 Sweden (Email: tobias.kuhme{at}lio.se).
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Abstract
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Patients operated on for complex congenital heart malformations need continuous follow-up. We present a male patient born in 1948 with Fallot's anomaly. A total correction was performed when he was 21 years old. Twenty-eight years after the operation, at routine follow-up, he presented with a significant left-to-right shunt because of a new ventricular septal defect. During the operation we found the original patch to be fractured with a central perforation. The patient received a new patch and has been without any clinical symptoms since.
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Introduction
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Fallot's anomaly is the most common cyanotic congenital heart defect, characterized by a large ventricular septal defect (VSD), an aorta overriding the left and right ventricles, and an obstruction of the right ventricular outflow tract. Open correction of Fallot's anomaly using cardiopulmonary bypass has been performed since 1955. This constitutes a patch closure of the VSD and relief of the right ventricular outflow obstruction. We describe a patient who had his total correction as an adult and had a late complication develop that required reoperation after 28 years.
The patient was born in 1948 with Fallot's anomaly. At the age of 5 years he received a Blalock-Taussig shunt [1].
When the patient was 21 years old he underwent a total correction [2]. The VSD was closed with a 3 x 3 cm patch of synthetic material (Dacron, Dupon). A commissurotomy of the valvular pulmonary stenosis was performed, the infundibular stenosis was resected, and the right ventricular outflow tract was enlarged with a patch.
Twenty-five years after the operation, a postoperative follow-up study of all patients operated on for Fallot's anomaly was initiated. Echocardiography in our patient showed a VSD patch in place without any signs of shunting. There was a moderate residual outflow tract obstruction in the right ventricle (Table 1). Cardiac catheterization showed no signs of shunting and normal pressures in the left ventricle and pulmonary artery.
Three years later the patient returned for an outpatient control. At that time he felt well and worked full time. Echocardiography now showed a high intensity flow with a maximal velocity of 4 m/sec from the left to the right ventricle in the area of the patch in the VSD. We were able to detect a defect in the patch, with a left-to-right shunt and a small part of it moving forward and backward synchronously with the blood flow (Fig 1, top).
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Fig 1. (Top) Transoesophageal echocardiography shows the patch in the ventricular septum with a central rupture (arrow) where a small part moved forward and backward with the blood flow. (LV = left ventricle; RV = right ventricle.) (Bottom) Intraoperative photograph from the surgeon's view of the inside of the right ventricle and the fragmented patch. The area was exposed through an incision in the old right ventricular outflow patch.
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A new cardiac catheterization showed a significant shunt with a pulmonary systemic blood flow ratio of 2 to 1. The pressure in the right ventricle had risen from 65/13 mm Hg to 104/17 (Table 1). Because of the large shunt and the increased pressure-load and volume-load of the right ventricle, we decided to operate.
During the operation, we found a rupture of the patch. The fabric structure was destroyed and fragmented (Fig 1, bottom). We performed an excision of the fragmented area and a new Dacron patch was anchored onto the left side of the interventricular septum by sutures through the septum. At the same time, a subvalvular muscular protrusion was excised and an additional commissurotomy of the pulmonary valve was performed.
Early in the postoperative recovery stage, we could see a nonsignificant residual shunt at one edge of the new patch. The postoperative recovery was uncomplicated, and the patient noted an increased exercise capacity. Postoperatively, the patient has been checked every second year, and his condition has been stable ever since.
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Comment
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Late mortality from cardiac causes accounts for about two-thirds of all late deaths for this patient group. Between 40% and 60% of these are sudden and are presumed to be caused by arrhythmias or by heart blockage. Other causes like right ventricular outflow abnormalities (obstruction, pulmonary incompetence, aneurysm) and congestive heart failure, which is often related to residual VSDs. Residual VSD was reported in 1% to 8% of all operated patients in the early series. In the current era, residual VSDs are expected to occur in less than 5% of tetralogy repairs [3, 4]. Rupture of the VSD patch is very uncommon.
During the routine evaluation 25 years after surgery, our patient had a moderate residual right ventricular outflow obstruction that did not warrant reoperation. However, 3 years later when the shunt was present, the outflow gradient (as well as the filling pressure of the right ventricle) had increased. These signs of increased right ventricular pressure load, in combination with the shunt size, led to the decision to reoperate. At reoperation, attempts were also made to reduce the outflow obstruction. In a study of 163 patients by Murphy and colleagues [5], 16 patients required a late reoperation. The principal reason for reoperation was a recurrent or residual VSD (10 patients). However, there was no description of the hemodynamic consequences that led to the decision to reoperate. Five of the reported patients had a failure of the patch material originally used for reconstruction (ie, the "Ivalon sponge" [polyvinyl alcohol crosslinked with formaldehyde]). This material was observed to undergo early resorption, and its use was stopped at the beginning of the 1970s. The patch material in our case, Dacron, which is a polyester material, is still being used, and because synthetic material will probably age over time, the complication seen in our patient may not remain unique in the future. In addition, our patient was operated as an adult and therefore received a comparative large patch, which increased the mechanical stress on the material.
Adults with complex congenital heart disease represent a growing patient group that needs regular follow-up by specialists with particular interest in this area who are aware of the possible long-term complications after previous surgery.
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References
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- Blalock A, Taussig HB. The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia JAMA 1945;128:1342-1367.
- Lillehei CW, Varco RL, Cohen M, et al. The first open heart corrections of tetralogy of Fallot. A 26-31 year follow-up of 106 patients Ann Surg 1986;204(4):490-502.[Medline]
- Abramov D, Abramov Y, Raanani E, et al. Repeated repair of Tetralogy of Fallot. Report of 11 cases and review of the literature Scand J Thorac Cardiovasc Surg 1995;29:111-113.[Medline]
- Pome G, Rossi C, Colucci V, et al. Late reoperations after repair of Tetralogy of Fallot Eur J Cardiothorac Surg 1992;6:31-35.[Abstract]
- Murphy JG, Gersh BJ, Mair DD, et al. Long-term outcome in patients undergoing surgical repair of Tetralogy of Fallot NEJM 1993;329:593-599.[Abstract/Free Full Text]
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Abstract
Introduction
