Ann Thorac Surg 2007;83:906
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Kirk R. Kanter, MD
Division of Cardiothoracic Surgery, Emory University School of Medicine, 1365 Clifton Rd, Atlanta, GA 30322
(Email: kkanter{at}emory.edu).
Surgical closure of ventricular septal defects (VSDs), either in isolation or associated with tetralogy of Fallot or complete atrioventricular septal defect, constitutes one of the most common procedures performed by the congenital heart surgeon. With the ubiquitous application of intraoperative and postoperative echocardiography, the surgeon is commonly faced with the dilemma of a child who has undergone VSD closure but has a residual defect seen either in the operating room by transesophageal echocardiography or in the intensive care unit by transthoracic echocardiography. One must decide whether or not to go back on bypass in the operating room or return the patient to the operating room from the intensive care unit for closure of this apparently small residual ventricular septal defect.
This article by Dodge-Khatami and colleagues [1] helps us to decide what to do with these patients. The authors looked at 198 consecutive patients undergoing surgical correction of a VSD either isolated (n = 100), with tetralogy of Fallot (n = 52), or with atrioventricular septal defect (n = 46). They excluded patients with a residual VSD greater than 3.0 mm for whom cardiopulmonary bypass was reinstituted for residual VSD closure. Looking at those with small VSDs, they found a surprisingly high incidence of residual VSDs (21% by transesophageal echocardiography in the operating room, 34% by transthoracic echocardiography in the intensive care unit, and 36% at the time of hospital discharge). On median follow-up of 3.1 years, 83% of residual defects less than 2.0 mm closed entirely, whereas of the nine defects greater than 2.0 mm, three had closed. Despite this, none of these patients had symptoms of heart failure, evidence of pulmonary hypertension, or were taking cardiac medicines.
This article reassures us that it is not necessary to re-establish bypass or to return to the operating room for what seems to be a hemodynamically insignificant residual ventricular septal defect detected by echocardiography (defined by the authors as < 3.0 mm with a ratio of pulmonary blood flow to systemic blood flow [Qp:Qs] < 1.5). The vast majority of these defects smaller than 2.0 mm will close spontaneously. For those residual VSDs > 2.0 mm, only a third will close, but these patients will be asymptomatic. Therefore the only purpose for closing residual VSDs < 3.0 mm is to eliminate the need for chronic endocarditis prophylaxis. Although most likely this practice is already used by most congenital heart surgeons, it is reassuring to have affirmation as demonstrated in this article that the lack of reoperation on these patients is a reasonable course of action.
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References
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- Dodge-Khatami A, Knirsch W, Tomaske M, et al. Spontaneous closure of small residual ventricular septal defects after surgical repair Ann Thorac Surg 2007;83:902-906.[Abstract/Free Full Text]
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