Eur J Cardiothorac Surg 2003;23:246-247
© 2003 Elsevier Science NL
Closure of recurrent VSD due to dehiscence of calcified patch
Thomas Walthera*,
Victor T. Tsangb,
John E. Deanfieldb,
Marc R. de Levalb
a Klinik fur Herzchirurgie, Universitat Leipzig, Herzzentrum, Strumpellstrasse 39, 04289 Leipzig, Germany
b Great Ormond Street Hospital for Children NHS Trust, London, UK
Received 21 July 2002;
received in revised form 30 October 2002;
accepted 5 November 2002.
* Corresponding author. Tel.: +49-341-865-1424; fax: +49-341-865-1452
e-mail: walt{at}medizin.uni-leipzig.de
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Abstract
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Closure of residual ventricular septal defects may be extremely difficult in the presence of severe calcification of a previous patch. Removal of such calcification carries a risk of damaging the aortic and tricuspid valve as well as the conduction system. We describe a novel technique for closure of such a defect placing a new patch over and around the calcified one in an 18-year-old patient who had undergone initial surgery 12 years ago.
Key Words: Repeat ventricular septal defects closure • Calcified patch • Aortic and tricuspid valve
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1. Introduction
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We report a technique of repair for an unusual case of reopened ventricular septal defect (VSD) years after initial surgery due to dehiscence of a heavily calcified patch. Under such circumstances residual VSD closure is extremely difficult as additional stitches through a calcified patch are impossible without risk of damaging surrounding cardiac structures, especially the aortic and tricuspid valve as well as the conduction system. Due to these restraints we used a ‘patch on the patch’ technique by leaving the calcification in place and anchoring a second patch around it with good functional result.
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2. Methods and results
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An 18-year-old female patient who had undergone surgical repair of VSD and pulmonary atresia at the age of 6 years was admitted for management of reopened VSD and dilatation of the homograft between the right ventricle and the pulmonary artery. She had become short of breath on exertion and was in NYHA class II–III. Echocardiography revealed an enlarged and poorly contacting right ventricle. Blood pressure was at systemic level in the right ventricle and just sub-systemic in the pulmonary artery. There was a moderate gradient across the RVOT. The homograft was, however, heavily calcified and there was aneurysmal dilatation of the proximal part requiring repeat conduit replacement. In addition there was a residual VSD with left to right shunt that had been diagnosed 2 years before. Cardiac catheterisation confirmed the echocardiographic findings and showed a significant left to right shunt (Qp:Qs of 3:1) across two VSDs.
Repeat surgery was performed on femoro – femoral extracorporal circulation (ECC). The right ventricle was grossly dilated and adherent to the sternum. The heavily calcified homograft was excised. The original VSD patch (Gore-tex) was dehiscent at its upper and lower margins. Reattachment was impossible due to the heavy calcification that could not be penetrated even with the strongest needles. Thus, a second patch of Dacron (Sauvage) was used to cover the first one. It was anchored away from the previous suture line on the muscular margin of the defect and on the tricuspid valve posteriorly. RVOT continuity was reestablished with a 22 mm Hancock conduit. After rewarming, the heart took over in sinus rhythm and ECC was discontinued. Postoperative echocardiography revealed good biventricular function, no residual VSD and a blood flow of 2 m/s over the RVOT. Further postoperative recovery was uneventful, the patient was in sinus rhythm and was discharged 7 days after the operation.
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3. Discussion
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Dehiscence of a heavily calcified patch used to close a VSD is an unusual situation. The incidence of VSD patch dehiscence may be well below 5% but no definitive data are available at present [1]. In our patient reattachment of the original patch could not be performed due to the heavy calcification not allowing to penetrate the patch with any needle. Excision of the calcified patch would have been quite risky in terms of aortic and tricuspid valve damage or even heart block. Thus, the option of anchoring a second patch over the top and around the old one was chosen. This could be accomplished safely and securely without major difficulties. Patch on the patch VSD closure has not been described previously. It can be applied quite easily, with good access through the right ventricle and most importantly on the beating heart. This technique may be useful for the treatment of patients who require late re-intervention for VSD patch calcification and dehiscence.
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References
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- Sugita T., Ueda Y., Matsumoto M., Ogino H., Sakakibara Y., Matsuyama K. Repeated procedure after radical surgery for tetralogy of Fallot. Ann Thorac Surg 2000;70:1507-1510.[Abstract/Free Full Text]
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Abstract
1. Introduction
