Surgical strategies for the management of multiple ventricular septal, defects

Abstract

Methods: An infant with right isomerism, single ventricle, left sided SVC and an anomalous pulmonary vein to the SVC presented with cyanosis. During surgery, the SVC was transected above the opening of the anomalous pulmonary vein and fully mobilized of all its tributaries leaving the anomalous drainage intact. The MPA was transected and the branch pulmonary arteries mobilized. This enabled us to perform the anastomosis between SVC and LPA without any kink or tension.Results: The patient made an uneventful recovery and postoperative echocardiography showed a functioning BCPS with good pulmonary flow. The patient is on follow up with a saturation of 90 on 3 month follow up Conclusions: The technique adopted by us ensured approximation of SVC anJ LPA to perform a tension free BCPS. It does not involve a suture line in the artium that may need future revisions. This can displace the pulmonmy arteries upwards and can make the completion by lateral tunnel Fontan difficult. However, most of these cases undergo subequent completion by extra cardiac Fontan for fear of pulmonary vein obstruction by the intracardiac baffle.Background: First direct vision ASD closure (first open heart) was done in 1952 under surface hypothermia and inflow occlusion by F John Lewis in USA. With introduction of CP Bypass the trend slowly shifted to close majority of ASDs on bypass. Hypothermia and inflow occlusion became historical. Due to its simplicity and low cost we started using this method and report here.Methods: 25 patients between age of 5-29 yrs over a period of 6 months (May-Oct '05 ) having isolated secundum ASD were selected for this technique. 2D Echo was done to confirm diagnosis and rule out SVC defect, Primum ASD and other cardiac defects. After anesthesia, patient was cooled using rubber blankets through which cold water was circulated. At 30° C midsternotomy was done and pericardium was opened. Tapes were passed around SVC and IVC. At 28° C circulation was stopped by snaring the tapes and RA was opened and ASD was inspected. If it was found suitable for direct closure, it was closed with 3'O or 4'O prolene in two layers. No suction was done in LA and lungs were ventilated before tying the suture line to remove air from LA. Rt atriotomy was controlled with a large clamp and circulation was restarted by opening the snares. Rt atriotomy was closed. CP Bypass was kept as stand by. Patient was rewarmed to normal level.Results: ASD could be closed directly in all patients. Conversion to CP Bypass was not required in any patient. There were no neurological complications. Patients were extubated after few hrs. Post operative drainage was less than 200ml. Repeat Echo after 7-10 days did not show residual shunt in any patient. There was marked reduction in cost of operation (60-70%).Conclusions: Closure of simple secundum ASD undcr hypothermia and inflow occlusion is a safe, simple and cost saving technique. It avoids side effects of CP Bypass. Minimal blood transfusion is required. This technique should be used more frequently and i...