Surgical Repair Of Multiple Muscular Ventricular Septal Defects. The Role Of Re-endocardialization
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Objective: Surgical repair of multiple ventricular septal defects (mVSDs) / Swiss cheese septum is associated with significant morbidity and mortality. Those having other associated defects have a further increased risk of mortality. We sought to evaluate if a new approach, trans-atrial re-endocardialization of the ventricular septum (TAR), mitigated risk.
Methods: Between Sep 1982 and Aug 2005, 133 patients underwent surgery for mVSDs. Fifty six (42%) had isolated mVSDs and 77 (58%) had associated cardiac defects (coarctation n=29, AVSD n=9, TOF n=7, TGA n=5, and DORV n=5). The last 27 consecutive patients (2002-05) underwent the TAR strategy. Median age was 0.54 years (range 15-7.2), and median weight 4.9 Kg (range 2.4 - 17.6). 14 had isolated mVSDs and 13 had associated cardiac defects. 3 had previous pulmonary artery band. The TAR strategy is based on the concept that there are a finite number of trabeculations and that deep suturing is a significant cause of ventricular dysfunction following closure of multiple VSDs. The trabeculations can all be sutured to each other with fine superficial endocardial running sutures thereby eliminating the Swiss cheese defects. Evaluation of repair was done by intra-operative TEE.
Results: There was no mortality in the TAR group, the median number of VSDs closed was 7 (range 3-22). Each patient had combined closure strategies as needed: TAR (median 5, range 2-21), patch (median 1, range 0-4) and device closure (range 0-1). Mean cardiopulmonary bypass and cardiac ischemic times were 146+52 and 112+38 minutes respectively. There was 1 intraoperative revision for a peridevice residual VSD. Ventricular function on post-repair TEE was moderately or severely reduced in 1 patient each. Median number of residual VSDs was 1.5 (range 0-3), and the median residual jet width on color Doppler was 2.3 mm (range 0-4.2). Intraoperative shunt fraction was measured when residual VSDs were identified and only one patient had significant Qp/Qs=2.1. One patient required permanent pacemaker. For the entire cohort, operative mortality was 8% (n=11, 3.6% and 11.7% for isolated and complex cases). Era mortality differs: mortality was 15% prior to 1990, 11% between 1990-1998 and 0% after 1999. Risk factors for operative mortality on multivariable logistic regression model were: associated DORV (OR 11.7, P=0.07), and the need for ventriculotomy (OR 4, P=0.07).
Conclusions: Outcome of surgical repair of mVSDs / Swiss cheese septum has improved. The technique of TAR enables complete or near complete obliteration of the Swiss cheese defects. The risk of mVSD's and associated lesions has been largely mitigated and the incidence of permanent heart block has improved. Early echocardiographic and clinical outcomes are promising and future follow up is needed to confirm the favorable results.
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