VENTRICULAR SEPTAL DEFECT IN INFANTS AND CHILDREN WITH INCREASED PULMONARY VASCULAR RESISTANCE AND PULMONARY HYPERTENSION - SURGICAL MANAGEMENT: LEAVING AN ATRIAL LEVEL COMMUNICATION

Inam Ullah Khan, Iftikhar Ahmed, Waqar A. Mufti, Azhar Rashid, Asif Ali Khan, Syed Afzal Ahmed, Muhammad Imran

Abstract


Objective : To evaluate the surgical and medical efficacy of the patients operated for Ventricular
Septal Defect (VSD) with Pulmonary Hypertension and Pulmonary Vascular Resistance (PVR).
Infants and children with elevated PVR and Pulmonary Hypertension are associated with
significant mortality and morbidity after surgical closure. Circulatory assist devices and
sophisticated medicines may not be available to help in the management of infants and children
with elevated Pulmonary artery pressure and resistance. We left Patent Foramen Ovale (PFO) or
made atrial communication to decrease the morbidity and mortality associated with the closure of
large VSD in this risky group. Methods : Sixteen infants and children were operated with median
age of 12 months, operated by the same surgeon (IU), from January’ 2004 to December’ 2005 .
They were with large VSD of elevated PVR (3.9+0.3) and underwent VSD closure leaving PFO or
artificial ASD (5mm). Surgical approach was through right atrium. Post operatively, all the
patients were electively ventilated for 36 hours. They were given intravenous dilators (Glyceral
Trinitrate + Phentolamine) and oral Sildenafil up to 1mg /Kg, six hourly. Five cases went into
acute pulmonary hypertensive crisis postoperatively, and were rescued by Prostacycline
Nebulization. Results: Sixteen patients had VSD as the primary lesion that underwent operation.
The overall early mortality was 6.25% (1/16). There have been no late deaths. Conclusion:
Closure of large VSD with elevated PVR can be performed, leaving PFO or artificial ASD, with
acceptable mortality and morbidity.

References


Nygren A, Sunnegardh J, Berggren H. Preoperative

evaluation and surgery in iso lated ventricular septal defects:

a 21 year perspective. Heart 2000;83:198-204.

Bhatt M, Roth SJ, Kumar RK, Gauvreau K, Nair SG,

Chengode S et al. Management of infants with large,

unrepaired ventricular septal defects and respiratory infection

requiring mechanical ventilation. J Thorac Cardiovasc Surg

;127:1466-73.

Goldman AP, Delius RE, Deanfield JE, de Leval MR,

Sigston PE, Macrae DJ. Nitric oxide might reduce the need

for extracorporeal support in children with critical

postoperative pulmonary hypertension. Ann Thorac Surg

;62:750-5.

J Ayub Med Coll Abbottabad; 18(4)

Goldman AP, Delius RE, Deanfield JE, Marcae DJ. Nitric

oxide is superior to prostacyclin for pulmonary hypertension

after cardiac operations. Ann Thorac Surg 1995; 60:300-5;

Bando K, Turrentine MW, Sun K, Sharp TG, Ensing GJ,

Miller AP et al. Surgical management of complete

atrioventricular septal defects. A twenty year experience. J

Thorac Cardiovsac Surg 1995;110:1543-54.

Schulze-Neick I, Li Penny DJ, Redington AN. Pulmonary

vascular resistance after cardiopulmonalry bypass in infants:

effect on postoperative recovery. J Thorac Cardiovasc Surg

; 121:1033-9.

Carotti A, Marino B, Bevilacqua M, Marcelletti C, Rossi E,

Santoro G et al. Primary repair of Isolated Ventricular Septal

Defect in Infancy Guided by Echocardiography. Am J

Cardiol 1997;79:1498-1501.

Knott-Craig CJ, Elkins RC, Lane MM, Holz J, McCue C,

Ward KE.Knott-Craig CJ,Elkins RC, Lane MM, et al. A 26-

Year Experience with surgical management of Tetralogy of

Fallot: Risk Analysis for Mortality or Late Reintervention.

Ann Thorac Surg 1998;66:506-11

Novick WM, Sandoval N, Lazorhysynets VV, Castillo V,

Baskevitch A, Mo X. Flap Valve Double Patch Closure of

Ventricular Septal Defects in Children With Increased

Pulmonary Vascular Resistance. Ann Thorac Surg 2005;

:21-8.

Kannan BR, Sivasankaran S, Tharakan JA, Titus T, Ajith

Kumar VK, Francis B et al. Long-term outcome of patients

operated for large ventricular septal defects with increased

pulmonary vascular resistance. Indian Heart J.2003;55:161.

Wessel DL. Current and future strategies in the treatment of

childhood pulmonary hypertension. Progr Pediatr Cardiol

;12:289-318.

Trachte AL, Lobato EB, Urdaneta F, Hess PJ, Klodell CT,

Martin TD et al. Oral Sildenafil Reduces Pulmonary

Hypertension After Cardiac Surgery. Ann Thorac Surg 2005;

:194-7.

Moritz A, Ozaslan F, Dogan S, Abdel-Rahman U, Aybek T,

Wimmer-Greinecker G. Closure of atrial and ventricular

septal defects should be performed by the surgeon. J Interv

Cardiol.2005;1 8(6):523-7.


Refbacks

  • There are currently no refbacks.


Contact Number: +92-992-382571

email: [jamc] [@] [ayubmed.edu.pk]