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Table of Contents   
Year : 2010  |  Volume : 3  |  Issue : 2  |  Page : 199-201
Selected Summaries

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi 110 029, India

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Date of Web Publication16-Dec-2010

How to cite this article:
Talwar S, Choudhary SK, Airan B. Selected Summaries. Ann Pediatr Card 2010;3:199-201

How to cite this URL:
Talwar S, Choudhary SK, Airan B. Selected Summaries. Ann Pediatr Card [serial online] 2010 [cited 2019 Apr 23];3:199-201. Available from:

Treatment of isolated ventricular septal defects in children: Amplatzer versus surgical closure

Oses P, Hugues N, Dahdah N, Vobecky SJ, Miro J, Pellerin M, Poirier NC.

Ann Thorac Surg 2010;90:1593−8.

In this retrospective study from Canada, the hospital records of all patients undergoing surgical closure or percutaneous closure (PC) of hemodynamically significant isolated ventricular septal defects (VSD) were analyzed. Thirty-seven patients underwent PC closure using the Amplatzer VSD Occluder, and 34 had surgical closure. Patients undergoing PC were significantly older (age 108.8±61.4 months) compared to the surgical closure group (21.6±43.2 months, P<0.001). The mean VSD diameter on preclosure transthoracic echocardiography was 8.5±2.6 mm (range, 3.616 mm) with a mean VSD/body surface area ratio of 26.3±10.2 (range, 2.6−42.6) in the surgical group; this was significantly larger than in the PC group (P<0.02). Patients in the surgical group had more severe congestive heart failure. Surgical group had significantly lower VSD gradient (P<0.004). In 36 of 37 patients in the PC group, the defect was closed successfully. In two patients, the procedure was aborted; in one patient, it was impossible to obtain a stable position of the long sheath, but a second attempt was successful 6 months later; in the other, a 4-year-old girl, one device embolized into the left ventricle, requiring emergency surgical removal and VSD repair. No deaths occurred in either group. No patients received blood transfusion in the PC group, whereas 30 patients (88.2%) received red blood cells in the surgical group (P<0.001). The mean ventilation support time was 3.1±3.7 hours for the PC group and 15.0±24.3 h for the surgical group (P=0.016). The mean hospital stay was 1.4± 1.2 days for the PC group and 10.6± 7.2 days for the surgical group (P<0.001). Complications in the PC group included device mismatch requiring re-replacement (n=2), transient device thrombus (n=2), mild hemolysis (n=1), femoral artery thrombosis (n=1), transient clonic movements (n=1), permanent complete heart block requiring pacemaker (n=2), and device embolization requiring urgent surgical removal (n=1). Complications in the surgical closure group were pericardial effusion requiring drainage (n=2), bronchopneumonia (n=1), and permanent complete heart block requiring pacemaker (n=1). A periprosthetic residual shunt was present at discharge in four patients (11.1%) in the PC group and in eight patients (23.5%) in the surgical group (P=0.26). Preoperative aortic valve regurgitations (n=11, 30.5%) remained unchanged immediately after PC closure. After surgery, aortic valve regurgitations (n=6, 17.6%) were either unchanged or had decreased. Tricuspid valve regurgitations immediately after PC closure worsened in one patient (2.7%) and disappeared in five others (13.9%). Immediately after surgery, tricuspid valve regurgitations (n=8, 23.5%) were either unchanged or increased in five patients (14.7%).

Mean duration of follow-up for patients who underwent PC device and surgical closure was 42.1±25.9 and 42.8±28.5 months, respectively At follow-up, the PR interval was significantly longer in the device closure group (P=0.005). However, 27 children (82.4%) had incomplete right bundle branch block after surgery. There were no late pacemaker implantations in either group. All valvular regurgitations improved over time, except for three aortic regurgitations (5.4%) in the PC group that got worse. The authors concluded that although surgery remains the gold standard, it may be reasonably safe to perform transcatheter VSD closure using the Amplatzer device in selected older infants and children with small VSD.

Comparison of bovine jugular vein with pulmonary homograft conduits in children less than 2 years of age

Fiore AC, Ruzmetov M, Huynh D, Hanley S,

Rodefeld MD, Turrentine MW, Brown JW.

Eur J Cardiothorac Surg 2010;38:318−25.

The growing need for right ventricle to pulmonary artery conduits in small children has prompted the development and increased use of the bovine jugular vein conduit (BJV), Contegra (C), Medtronic, Inc., Minneapolis, MN, USA) as an alternative to the pulmonary homograft (PH). In this study from Riley Children's Hospital at Indiana University, Indianapolis, Indiana, USA and Cardinal Glennon Children's Hospital at St. Louis University, St. Louis, MO, USA, -52 pediatric patients, who had BJV implanted, were compared with 32 patients receiving PH. The choice of conduit was made preoperatively or in the operating room by the surgeon without randomization. There were no significant differences in age, sex, body surface area, or preoperative diagnoses. The mean conduit size was 13 mm for both cohorts, but a significantly greater number of patients received PHs in sizes 10 and 11 mm, while BJV patients were more likely to receive a 12-mm conduit (P<0.05). There were three early deaths in the BJV cohort (BJV, 3/52 6% versus PH, 0/32 0%; P=0.28). For PH, the mean follow-up was 5.9±3.3 years (median 7 years, range 3 months−10 years), while in the BJV group it was 4.4±3 years (median 4 years, range 2 months to 10 years). Graft dysfunction was considered to be present if the peak echo Doppler gradient was greater than 40 mmHg by two-dimensional echocardiography at any level within the right ventricular outflow tract and/or grade 2 or 3 conduit valve insufficiency.

Conduit failure was defined as the need for surgical repair, replacement and/or intervention with balloon dilatation or stent placement.

There were seven and four late deaths in BJV and PH group respectively (BJV, 7/52 13% versus PH, 4/32 12%; P=0.73). No death was attributed to structural failure of the conduit. The actuarial survival at 10 years was 80% in BJV group versus 88% in PH group (P=0.55). Among the 81 hospital survivors, 30 patients (BJV, 8/49 16%; PH, 22/32 69%; P=0.001) had evidence of significant conduit dysfunction at the most recent follow-up or before conduit replacement. Freedom from conduit dysfunction was significantly worse in the homograft cohort (71% and 24% at 5 and 10 years, respectively) as compared with BJV (90% and 85% at 5 and 10 years, respectively, P<0.001). In the PH group, five patients required a reoperation during the first 3 postoperative years, while 14 patients required re-operation 2-9 years postoperatively. The mean time to re-operation in the homograft cohort was 4.5±2.3 years (range: 8 months−9 years). In the BJV group, eight patients required a reoperation. The mean time to reoperation for was 4.4±3.4 years (range, 6 months-9 years) and was not significantly different from the PH cohort (P=0.68). Freedom from explanation was better in the BJV group as compared to the PH group (95% versus 85% at 10 years, P<0.0001). Among the 70 late survivors (BJV, 42/52, 81% versus PH, 28/32 82%, P=0.55), 47 patients retained their initial conduit (BJV, 35/52 67% versus PH, 12/32 37%; P=0.001). The authors concluded that the early performance of small BJV might be better than homografts. In addition to this, the advantages of the BJV are easy availability in all sizes, ease of insertion, and lack of antigenicity.

Palliative arterial switch for transposition of the great arteries, ventricular septal defect, and pulmonary vascular obstructive disease: Midterm outcomes

Lei B, Chen J, Cen J MD, Lui RC, Ding Y, Xu G, Zhuang J

J Thorac Cardiovasc Surg 2010;140:845−9.

In developing countries, it is not uncommon to encounter patients with transposition of the great arteries (TGA), ventricular septal defect (VSD), and severe pulmonary vascular obstructive disease. In this study from China, the authors studied the early and midterm outcomes of palliative arterial switch operation in which the VSD was not closed or repaired with a fenestrated patch in 21 such patients. Mean age was 3.7 years (range, 0.5-15). The mean preoperative pulmonary vascular resistance (PVR) was 18.3 ±11.6 U·m 2 (range, 7.8-45 U·m 2 ). The mean peak systolic pulmonary arterial pressure was 91 ±13 mm Hg (range, 68-115 mm Hg). The mean preoperative systolic pulmonary/systemic arterial pressure ratio was 0.99 ±0.10 (range, 0.79-1.20). The mean preoperative oxygen saturation and hematocrit value were 69% ±9.5% (range, 48%-86%) and 60% ±12% (28%-76%), respectively. In two cases in their early experience, the VSD was not closed, but in the remaining patients, the VSD was closed with a fenestrated patch. The diameter of the fenestration ranged from 4 to 10 mm. The sizes of fenestrations were determined according to one-half the expected aortic annulus size for each child. Oral sildenafil, inhaled nitric oxide, and continuous intravenous prostacyclin were selectively used postoperatively.

There were three early deaths, one each due to cardiac failure, pulmonary hypertensive crisis and pulmonary hemorrhage. The median postoperative length of stay for the early survivors was 17 days (range, 7−33 days). The mean follow-up for the 18 early survivors was 4.0 years with a maximum of 9.5 years. There was one late death that occurred 3 months after surgery due to sudden cardiac arrest. At last follow-up, the mean systemic arterial oxygen saturation increased from 69% preoperatively to 93% postoperatively (P<0.001), and the mean hematocrit value decreased from 60% preoperatively to 43% (P<0.001). Three patients with preoperative PVR of 20, 15, and 12 U·m 2 , respectively, underwent percutaneous closure using Amplatzer occluder devices of their VSD patch fenestrations when persistent left-to-right shunts at the ventricular level and normal-to-mild (<50 mmHg) estimated systolic pulmonary arterial pressures were documented on Doppler echocardiograms 7, 9, and 31 months after initial surgery. Four other patients who were documented to have left-to-right shunts at the ventricular level and mild-to-moderate (50-70 mmHg) estimated systolic pulmonary arterial pressures by Doppler echocardiograms were advised periodic follow-up. All together, eight patients' (44% of the early survivors) review showed a regression of pulmonary arterial pressure. The other nine patients (50% of the early survivors) displayed right-to-left or bidirectional shunt and persistent severe pulmonary hypertension. The authors concluded that the palliative arterial switch operation with closure of the VSD using a fenestrated patch may be a safe option and may improve the quality of life and possible life expectancy in patients with TGA, VSD and severe pulmonary vascular disease. If needed, the fenestration can safely be closed later in the cardiac catheterization laboratory.

More than 30 years' experience with surgical correction of atrioventricular septal defects

Hoohenkerk GJF, Bruggemans EF, Rijlaarsdam M, Schoof PH, Koolbergen DR, Hazekamp MG

Ann Thorac Surg 2010;90:1554−61.

This large series of patients with atrioventricular septal defects (AVSD) from Leiden, Netherlands covers more than three decades of experience with the surgical management of this condition. There is an elegant analysis of risk factors for mortality and reoperation. Between 1975 and 2006, 312 patients underwent surgery for complete AVSD (n=209; 67.0%), partial AVSD (n=76; 24.4%), or intermediate AVSD (n=27; 8.6%). Mean age was 2.4±3.9 years; 142 patients (45.5%) were younger than 6 months. The standard two-patch technique was used in patients with complete AVSD. One-patch technique was used in all partial AVSD patients. In patients with intermediate AVSD, a two-patch technique was used in 9 patients, and a one-patch technique was used in 18 patients. Cleft closure was performed to such an extent that regurgitation was managed optimally without creating valvular stenosis. Cleft closure was performed in 180 of 209 complete AVSD patients (86.1%), in 42 of 76 partial AVSD patients (55.3%), and in 19 of 27 intermediate AVSD patients (70.4%).

There were 26 (8.3%) in-hospital deaths. In-hospital mortality for complete AVSD patients was 22 of 209 (10.5%); for partial AVSD patients, it was 3 of 76 (3.9%); and for intermediate AVSD patients, it was 1 of 27 (3.7%). However, the mortality steadily decreased after 1996. Follow-up data were complete for 283 of 286 hospital survivors (99.0%). Eight patients (2.6%), seven with complete AVSD and one with partial AVSD required an early reoperation. The median follow-up period was 10.7 years (range, 0.4−29.3 years). For complete AVSD patients, median follow-up was 9.9 years (range, 0.4−28.9 years); for partial AVSD patients, it was 15.0 years (range, 1.9−29.3 years); and for intermediate AVSD patients, it was 6.2 years (range, 1.9−18.7 years). Late deaths occurred in 6 of 283 patients (2.1%), two with complete AVSD, one with partial AVSD, and three with intermediate AVSD, of which four were cardiac related. Forty three of the 278 hospital survivors (15.5%) required a late reoperation for left atrioventricular (AV) valve regurgitation, the median interval being 2.2 years (range, 2 months−21.1 years) after the primary repair. Estimated freedom from late reoperation for all hospital survivors without an early reoperation was 96.4% at 1 year, 89.3% at 5 years, and 81.8% at 15 years, and it did not differ in any of the three groups. Estimated overall survival for all AVSD patients was 91.3% at 1 year, 90.6% at 5 years, and 88.6% at 15 years. For complete AVSD patients, it 88.3% at 5 years and 15 years, for partial AVSD patients was 96.1% at 5 years, and 94.5% at 15 years, for patients with intermediate AVSD, it was 92.4% at 5 years. In the multivariable logistic regression analysis, surgical era (P<0.001), age (P=0.004) and preoperative AV valve insufficiency (P=0.032) were found to be independent risk factors for in-hospital mortality. The authors concluded that early surgical era, associated cardiovascular anomalies, left AV valve dysplasia, and absence of cleft closure negatively influence survival and risk of reoperation.

Correspondence Address:
Sachin Talwar
Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi 110 029
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Source of Support: None, Conflict of Interest: None

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