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Surgical management of doubly committed subarterial ventricular septal defects
M R de Leval1, M Pozzi, V Starnes
1Hospital for Sick Children, London, England.
Insights
Doubly committed subarterial ventricular septal defects (DCVSD) require timely surgical closure. Treatment strategies vary based on defect size and associated aortic valve issues, impacting patient outcomes.
Area of Science:
- Cardiology
- Pediatric Surgery
- Congenital Heart Disease
Background:
- Doubly committed subarterial ventricular septal defects (DCVSD) are a subset of congenital heart defects.
- These defects can lead to significant clinical challenges, including heart failure and aortic valve complications.
Purpose of the Study:
- To analyze the clinical presentation, diagnosis, and surgical treatment outcomes for 63 patients with DCVSD.
- To stratify patients into groups based on defect severity and associated complications to guide treatment strategies.
Main Methods:
- Retrospective analysis of 63 patients diagnosed with DCVSD.
- Patients were categorized into three groups based on clinical presentation and defect characteristics.
- Surgical interventions and outcomes were reviewed for each group.
Main Results:
- Group 1 (large VSD, no regurgitation): 31 patients, 1 death (hypoplastic right ventricle), recommended early closure via transpulmonary approach.
- Group 2 (moderate/small VSD, aortic regurgitation): 19 patients, 1 late death (endocarditis), severe regurgitation required valve replacement.
- Group 3 (Tetralogy of Fallot): 13 patients, all survived radical repair, often requiring a transannular patch (76%).
Conclusions:
- Early surgical closure is crucial for large DCVSD presenting with severe heart failure.
- Timely intervention is necessary for DCVSD with developing aortic valve regurgitation.
- Radical repair with transannular patching is effective for DCVSD associated with Tetralogy of Fallot.
Abstract:
The clinical presentation, diagnosis, and surgical treatment of 63 patients with doubly committed subarterial ventricular septal defects (DCVSD) were analyzed retrospectively. The patients were divided into three groups. Thirty-one patients had severe congestive heart failure in infancy and presently have a large ventricular septal defect that has no tendency to close or to produce aortic valve regurgitation (Group 1). Ideally, these defects should be closed in infancy, and the transpulmonary approach is recommended to achieve closure. In the first group, there was one death in a patient with a hypoplastic right ventricle. In Group 2, nineteen patients had aortic valve prolapse or aortic valve regurgitation. The DCVSD were moderately large or small. A number of DCVSD in Group 2 patients had maintained the normal offsetting of the arterial valves. These defects must be closed by the time mild aortic valve regurgitation has occurred. In Group 2, there was one late death in a patient who developed subacute bacterial endocarditis. The two patients who had severe aortic valve regurgitation required aortic valve replacement and underwent multiple surgical procedures to replace calcified bioprostheses. Group 3 comprised 13 patients who were diagnosed with tetralogy of Fallot. All of these patients had a large DCVSD with aortic valve overriding. All Group 3 patients survived radical repair of the defect, which required a transannular patch in most cases (76%).