Original article: cardiovascular
Apical right ventriculotomy for closure of apical ventricular septal defects

https://doi.org/10.1016/j.athoracsur.2003.12.054Get rights and content

Abstract

Background

Apical ventricular septal defects (VSDs) are difficult to visualize through a transatrial approach, while the use of a left ventriculotomy may result in progressive ventricular dysfunction. Transcatheter closure has not been reliable, especially in small infants. Apical right ventriculotomy provides good exposure, preserves left ventricular function, and allows secure closure of apical VSDs.

Methods

From November 1994 through April 2002, nine children, median age 8 months (range, 74 days to 2.5 years) underwent 10 operations for VSD closure via apical right ventriculotomy (one patient with a residual defect underwent successful VSD closure via a second apical right ventriculotomy). Two patients were status post pulmonary artery banding and two patients had previous unsuccessful attempts at closure via a transatrial approach.

Results

There was no hospital mortality; there were 2 late deaths (78% survival; 95% confidence interval [CI], 45% to 94%), 3 months and 4 years postoperatively. Postoperative echocardiography demonstrated no residual VSDs in 3 and insignificant residual VSDs in 4 of the survivors. All survivors currently exhibit normal biventricular function during a median follow-up of 25 months (range, 11 to 104 months).

Conclusions

Apical right ventriculotomy provides excellent exposure allowing safe and effective closure of apical VSDs. The observed late morbidity and mortality reflects the complexity that often exists in these cases due to additional irreparable lesions.

Section snippets

Patients

A retrospective study was performed for a consecutive series of nine patients (median age, 8 months; range, 74 days–2.5 years and median weight 6.5 kg; range, 3 to 9.8 kg) who underwent an apical right ventriculotomy for apical VSD closure from November 1994 through April 2002. The study was approved by the Institutional Review Board of The Cleveland Clinic Foundation. All but one of the patients had associated congenital cardiac lesions; five patients had severe associated cardiac anomalies (

Results

The median duration of cardiopulmonary bypass was 103 minutes (range, 40 to 167 minutes) and the median cross clamp time was 61 minutes (range, 27 to 92 minutes). Additional procedures were performed in nine of the ten surgical cases (Table 2). Postoperatively, the median duration of intubation was 2 days (range, 1 to 17 days), the median time in the intensive care unit was 2 days (range, 2 to 17 days), and the median duration of hospitalization was 7 days (range, 4 to 56 days). One of the

Comment

The approach to patients with apical VSDs remains a substantial challenge due to difficult surgical access and the frequent occurrence of additional cardiac lesions. Treatment strategies must provide adequate exposure and then must allow definitive surgical closure in that residual VSDs are poorly tolerated, especially when associated with other significant lesions. In addition to these considerations, strategies for repair must preserve cardiac rhythm and should not unduly prolong ischemic

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