Transpulmonary Direct Surgical Closure of Restrictive Subarterial Ventricular Septal Defects

  • Dr Kelly Nagasawa, University of Hawaii School of Medicine, Honolulu, HI, United States
  • Dr Carlos Moreno-Cabral, University of Hawaii School of Medicine, Honolulu, HI, United States
  • Dr John Lamberti, Rady Children's Hospital of San Diego, San Diego, CA, United States
  • Dr Venu Reddy, Kapiolani Medical Center for Women and Children, Honolulu, HI, United States
  • Dr Lance Shirai, Kaiser Permanente Medical Center, Honolulu, HI, United States
  • Dr James Sim, Kapiolani Medical Center for Women and Children, Honolulu, HI, United States

    • Objective:
    Subarterial VSD are uncommon defects. Our preferred technique is direct closure through the pulmonary artery. We are reporting our updated surgical experience and its effect on aortic regurgitation (AR).

    Materials and Methods:
    From March 1993 through March 2008, 197 children underwent operations for isolated VSD. Thirty-eight (19%) had subarterial defects. Mean age was 6.2 years, 63% were male and 94% were Asian or Pacific Islanders. Preoperative echocardiograms showed mild AR in 24 patients (63%), trivial in 3 (8%), and none in 11 (29%). The operation is done through a longitudinal arteriotomy, pledgeted mattress sutures are placed at the crest of the VSD and exit at the annular insertion of the pulmonary valve. This results in direct approximation of the lower rim of the VSD to the intervalvar fibrous tissue.

    Results:
    There were no deaths, valve complications or reoperations. To assess the impact of the operation on the 24 patients with mild AR, post-discharge echocardiograms were evaluated. These were available in 22 patients. Of these, 13 patients (59%) showed improvement and 9 patients (41%) showed no change. We found a positive correlation between age and the presence of AR. Patients with AR were older (mean age 8.2 years; 24 patients) than the patients without AR (mean age 2.6 years; 11 patients) p <0.005.

    Conclusion:
    Transpulmonary closure of subarterial VSD is a safe and effective method that results in the improvement or elimination of AR in the majority of patients, effectively reversing the trend of progression of the aortic disease.