Pulmonary hypertensive vasculopathy--no indication for corrective operation of isolated ventricular septum defect in babyhood
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C Huth1, H E Hoffmeister, E Steil
1Department of Thoracic, Cardiac and Vascular Surgery, University of Tübingen, FRG.
Insights
Surgical closure of ventricular septum defects (VSD) in infants under 12 months has high mortality. Early VSD closure is not always necessary, as irreversible pulmonary hypertensive vasculopathy (PHVP) is rare in the first year.
Area of Science:
- Cardiology
- Pediatric Surgery
- Pulmonary Hypertension
Background:
- Surgical closure of ventricular septum defects (VSD) in infants under 12 months has increased significantly.
- Mortality rates for VSD correction in older children have decreased, but remain stagnant at 8% for early correction (≤12 months).
- Reasons for early VSD intervention include irreversible pulmonary hypertensive vasculopathy (PHVP) and heart failure with growth issues.
Purpose of the Study:
- To evaluate the outcomes of early VSD closure in infants with pulmonary hypertension (PH).
- To assess the development and reversibility of PHVP in infants with isolated VSD and PH.
- To determine the optimal timing for VSD correction in infants with PH.
Main Methods:
- Retrospective analysis of 31 infants undergoing VSD closure for PH within the first year of life.
- Comparison of preoperative and postoperative ventricular pressure ratios.
- Histopathological examination of pulmonary tissue to assess PHVP.
- Comparison with 120 children who underwent VSD closure after 12 months of age.
Main Results:
- Perioperative mortality was 9.7% (3/31) in the early VSD closure group.
- Mortality was 2.5% (3/120) in the later VSD closure group (after 12 months).
- PHVP was absent or mild (grade 0-II) in 46% of patients undergoing later closure, and was reversible.
Conclusions:
- Irreversible PHVP does not typically develop within the first year of life in isolated VSD with PH.
- VSD correction can be safely postponed to the second year of life if recurrent heart failure or growth disorders are not present.
- Early surgical VSD closure in infants with PH carries a higher perioperative risk without clear benefit regarding PHVP development.
Abstract:
The frequency of surgical closure of a ventricular septum defect (VSD) in the first year of life has risen from 10% to 30% in the last seven years in West Germany. Whereas there was a decrease of mortality in older children, mortality has stagnated at 8% for correction at age 12 months or less (early correction). Development of an irreversible pulmonary hypertensive vasculopathy (PHVP) and recurrent heart failure with growth disorders are given as reasons for operation in the first year of life. In the last six years, we have operated on 31 infants for isolated VSD with pulmonary hypertension (PH) and closed the VSD. In approximately equal preoperative pressure in the two ventricles with a pressure ratio of 0.88 +/- 0.16, there was an immediate fall in pressure in the right ventricle with pressure ratios of 0.43 +/- 0.24. Three patients (9.7%) died perioperatively. In the same period, a primary VSD closure was carried out in 120 children even after over 12 months with three deaths (2.5%). Pulmonary tissue removed in this operation did not show any PHVP in four patients (13%), grades 0 to I and I to II in 10 patients each (total 33%) and a PHVP grade II to III in six patients (20%). This PHVP is capable of full regression. An irreversible PHVP does not develop up to the end of the first year of life in isolated VSD with PH, so that the correction can be safely postponed to the beginning of the second year of life provided that recurrent heart failure with growth disorders does not compel earlier correction.(ABSTRACT TRUNCATED AT 250 WORDS)