Unidirectional valved patch closure of ventricular septal defects with severe pulmonary arterial hypertension

Abstract

Delayed presentation of ventricular septal defect (VSD) is common in developing countries. Such patients often have severe pulmonary arterial hypertension (PAH), which increases post-operative morbidity and mortality. To address these problems, we used our technique of unidirectional valved patch (UVP) for closure of VSD. Between January 2006 and December 2010, 17 patients (age 2-23 years, median 9 years) with a large VSD and severe PAH underwent VSD closure with UVP. Pre-operative mean indexed pulmonary vascular resistance (PVRI) was 10.9 ± 2.2 Wood units and mean pre-operative systemic saturation was 93.4 ± 2.6%. Shunt was bidirectional in 15 patients and predominantly right to left in two. After VSD closure, intra-operative transoesophageal echocardiography revealed a right to left shunt across the patch in three patients 2, 7 and 9 years of age who had pre-operative PVRI of 9.5, 9.8 and 11.1 Wood units, respectively. There were no in-hospital deaths and all patients had uneventful recovery. Mean follow-up was 30 ± 14.7 months and all patients are well without cyanosis. Echocardiography showed no shunt across the patch and all have systemic saturation >95%. We conclude that UVP is a promising technique in patients with large VSD and severe PAH.

Figure 1:

The technique of a unidirectional valved patch: (A) an appropriate size Dacron patch is selected and a fenestrated (B) patch is folded upon itself at the dotted line; (C) the patch is sutured (outer dots) to close the defect (D) mechanism of a right to left shunting through the patch in situ (arrow). The suture line has been removed for clarity. RV: right ventricle; LV: left ventricle. Reproduced with permission from: Talwar S, et al. Unidirectional valved patch for closure of septal defects in patients with severe pulmonary hypertension. Ann Pediatr Cardiol 2008;1:114–9. Copyright Medknow Publications.