This describes surgical and interventional management of VSD

1. Surgical
Management of
VSD
Presenter – Dr. Prateek Vaswani
Moderator – Dr. Milind P Hote
Discussant – Dr. Sachin Talwar

2. Outline
• Natural History
• Evaluation
• Indications for surgical intervention
• Various surgical approaches and techniques
• Complications
• Results
• Outcomes

3. Natural History of VSD (Recap)
1. Spontaneous closure
2. Premature death
3. Pulmonary vascular disease
4. Development of aortic incompetence
5. Bacterial endocarditis
6. Development of Infundibular PS

5. 5
EVALUATION

6. CXR

8. ECG findings
Vary according to size of VSD
• Small : Normal
• Moderate : LVH
• Large : 3 stages
– LVH
– BVH
– RVH – Eisenmenger Syndrome

11. Echocardiography
A. General
B. VSD
C. Valves
D. Chambers
E. Associated anomalies

12. Echocardiography
A. General
1. Situs
2. AV connection
3. VA connection
4. Systemic venous drainage
5. Pulmonary venous drainage

13. Echocardiography
B. VSD
1. Number
2. Location
3. Size
4. Margins
5. Direction of flow
6. Gradients/Jet velocity
7. RV Pressure
PRV = TR gradients + PRA
8. QP – QS

14. Echocardiography
C. Valves
1.TV : Morphology, Size, Straddling, Override, TR
2. MV : Morphology ( Cleft, parachute), Size, MS,
MR, Supra-mitral membrane
Aorto-mitral continuity
3. AoV: BAV (AS), AR due to cusp prolapse
4. PV : Morphology, PS, RVOTO

15. Echocardiography
D. Chambers
LA/RA/RV/LV : Size (Dilatation / Hypertrophy)
Function

16. Echocardiography
E. Associated anomalies
1. MV associated
2. AS, AR
3. PS
4. Arch Hypoplasia, Coarctation
5. PDA

17. Cardiac catheterization
• Indication : Doubtful operability(Pulmonary
vascular disease)
• For Assessment of PVRI
PVR :(Mean PA pressure-Mean LA pressure)/Qp
PVRI: PVR x BSA
Unit of PVRI: unit . m2
PVRI > 8 – Doubtful Closure
PVRI < 7 after administering O2 – Indicates
Operability

18. INDICATIONS FOR
SURGICAL INTERVENTION

19. Saxena A, Relan J, Agarwal R, Awasthy N, Azad S, Chakrabarty M, et
al. Indian guidelines for indications and timing of intervention for
common congenital heart diseases: Revised and updated consensus
statement of the Working group on management of congenital heart
diseases.
Ann Pediatr Card 2019;12:254‐86.

20. Classification of VSD : Size
Large Moderate Small
Size in relation to
aortic annulus
75% or more 33%-75% < 33%
Flow Velocity < 1m/s 1-4 m/s >4m/s
VSD Resistance Index < 20 units . m2 >20 units . m2 >> 20 units . m2
RV/ LV Systolic
Pressure
2/3 - 1 1/3 - 2/3 < 1/3
Op / Qs Very high. Depends
upon PVRI
> 2 < 1.7

21. 22
Size of VSD Recommendation
Small VSD –
1. Asymptomatic
2. Normal PA pressure
3. Normal left heart chambers
4. No cusp prolapse
However, if –
• Endocarditis episode
• Development of AR
• Development of RVOTO
Annual Follow up till 10 years and
then every 2-3 years
Prompt Closure
Moderate VSD:
Asymptomatic
Symptomatic (Controlled with medications)
Closure of VSD by 2–5 years of age
Closure by 1–2 years of age
Large VSD:
a. Poor growth/congestive heart failure (NOT
controlled with medications (Diuretics and Digoxin)
b. Controlled heart failure
Closure as soon as possible
Closure by 6 months of age

22. APPROACHES AND
SURGICAL TECHNIQUES

23. History
Lillehei, Varco(1954):
Repaired using controlled cross circulation
DuShane et al in Mayo Clinic(1955-1956):
Intracardiac repair with pump oxygenator
Lillehei(1957):
Atrial approach to VSD closure
Eisenmenger : Autopsy finding in 1897

24. 25
APPROACH ADVANTAGES DISADVANTAGES SUITABLE FOR TYPE OF VSD
TRANS RA
MOST
COMMON
1. AVOIDANCE OF
VENTRICULOTOMY SCAR-
• DECREASED RISK OF POST OP
RV DYSFUNCTION
• DECREASED RISK OF LATE
POSTOP VENTRICULAR
ARRYTHMIAS
2. DECREASED RISK OF INJURY
TO BUNDLE -> RBBB
1. DIFFICULT TO CLOSE -
• OUTLET EXTENSION /
OUTLET VSD
• APICAL VSD
2. DAMAGE TO TRICUSPID
VALVE(CHORDAE/LEAFLETS)-
>TR
• PM VSD
• INLET VSD
• UPPER MUSCULAR
(TRABECULAR) VSD
TRANS RV 1. ACCURATE
VISUALISATION OF AREA OF
BUNDLE AND RIGHT
TRIGONE
2.EASE OF CLOSURE
RV SCAR -> DYSFUNCTION
RBBB
VENTRICULAR ARRHYTHMIAS
HIGH TRANS RV
• OUTLET VSD
LOW TRANS RV
• APICAL VSD

25. APPROACH ADVANTAGES DISADVANTAGES SUITABLE FOR
TYPE OF VSD
TRANS PA SUBPULMONARY
VSD
TRANS AORTIC S/A VSD OR PM
VSD WITH AR
TRANS LV 1.VENTRICULAR
DYSFUNCTION
2.LATE VENTRICULAR
ARRYTHMIAS
1.SWISS CHEESE
SEPTUM
2.POST MI VSD
(ADULTS)
COMBINED TRANS RA-
RV/PA
PM VSD WITH OUTLET
EXTENSION
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26. Patch material
Choice between three materials
Knitted Dacron
Used for the majority of VSDs
Reasonably flexible
Fibrous reaction
Autologous pericardium ±
treated with glutaraldehyde
Where fibrosis is not desirable
PTFE

27. AVOIDANCE OF CONDUCTION
BUNDLE
28

29. PM VSD

30. PM VSD WITH INLET EXTENSION

31. MUSCULAR INLET VSD

32. PM VSD AND INLET VSD

43. Right Ventricular
approach
INDICATIONS:
• Inaccessibility from the
right atrium or pulmonary
trunk
• Defect opening directly
into the infundibular area
• Obstructive infundibular
muscle bundles
• Difficulty exposing the
inferior margin of an outlet
defect

44. Trans Aortic
Approach

45. Trans pulmonary
arterial approach

46. Left ventricular
approach

47. 48
IDENTIFYING ADDL VSD -
• Using blunt right angled forceps through the VSD explore on the LV side of
septum(smooth LV septum, single opening) -> tip engages the VSD easily.
• Switch off vent
• Light test - via IAS place a paediatric bronchoscope into LV-> Illuminate LV->
see the site on IVS from where light is coming.
• RV Incision- > Few trabeculations at apex are cut

48. MANAGEMENT OF MULTIPLE VSDS
• Fibrin glue
Leca F, Karam J, Vouhe PR et al. Surgical treatment of
multiple ventricular septal defects using a biologic glue.
J Thorac Cardiovasc Surg 1994; 107:96–102
• Intraoperative use of double umbrella devices
Murzi B, Bonanomi GL, Giusti S et al. Surgical closure of
muscular ventricular septal defects using double
umbrella devices (intraoperative VSD device closure).
Eur J Cardiothorac Surg 1997; 12:450–454.

49. Closure of Trabecular VSD
Sandwich Technique

50. Complications
Intra-operatively
1. Damage to Structures
a) Bundle : CHB, RBB
b) Aortic valve
c) Tricuspid valve
2. Residual VSD
3. Imperfect myocardial preservation
4. Air embolism

51. Immediate Post-op Complications
Related to VSD:
1. Continuation of Intra-op problems: CHB, AR, TR,
RBBB
2. Acute myocardial dysfunction
3. Pulmonary hypertensive crisis
4. Ventricular arrhythmias
5. Patch dehiscence
Related to open heart : Bleeding

52. Late complications after VSD closure
1. Progression of PAH
2. Patch endocarditis
3. Sudden cardiac death (in patients with
transient CHB in post op period)

53. Surgical Cure
• Surviving the early postoperative period and
being alive late postoperatively with
essentially normal PPA
• Survival with mean PA pressure less than 25
mm Hg after 5 years
• Depends upon age and PVRI at surgery

54. Dushane and Kirklin 1973

55. Dushane and Kirklin 1973

56. Dushane and Kirklin 1973

57. 58
VSD WITH AR
• Lack of support to aortic annulus : Diastolic prolapse of
unsupported cusp.
• Venturi effect : Cusp is sucked during systole

58. TRUSLER’S REPAIR

59. YACOUB’S REPAIR

61. 62
• Palliative
• Consider in -
a. Multiple VSDs (Swiss cheese VSDs), inaccessible VSDs
(Class I)
b. Rarely in patients with contraindications for
cardiopulmonary bypass, e.g., sepsis, severe
malnutrition where used as inter-rim measure (Class
IIa).
PA Banding

62. Pulmonary Artery Banding
• Fixed PA Band (CPAB)
– Problems of band tightening in sedated, ventilated patient
– Sudden increase in afterload
– Acute adverse events
– Multiple re-operations
– High morbidity & mortality
• Adjustable PA Band (APAB)
– Adjustments in extubated, breathing patient on room air
– Gradual tightening
– Better tolerated by sicker patients

64. APAB: Band tightening
• Pule oxymetry, Echo guidance
• By placing additional clips
• Room Air
• Add no more than 20 mm gradient at one sitting
• 2 Ventricle: Gradient 50% of systemic pressure
(max 50), Sat > 85%
• 1 Ventricle: As much tight as possible, Sat > 75%

65. Trusler’s formula for Band
• Two ventricle: 20 +Weight in Kg mm
• Complex Cyanotic: 24 +Weight in Kg mm

66. Special Situation & Controversies
1. VSD and PDA
– Large PDA, 6-8 weeks of life with moderate or less VSD – PDA closure is done
– VSD + PDA in case of Large VSD
2. VSD and CoA
– Severe CoA with Large VSD ->CoA + VSD closure
– Severe CoA with Swiss Cheese septum -> CoA + PA Banding
– Severe CoA with moderate or less VSD -> CoA only
3. Surgical options for patients with borderline operability
– Fenestrated VSD patch closure
– fenestrated flap valve VSD patch closure
– Leaving (or creating) a 5 mm ASD(PFO)
*In addition to Pulmonary vasodilators

67. AIIMS Technique of Flap valve VSD
68

68. Eligibility criteria:
• a. Weight >8 kg (5 kg for muscular
VSD)
• b. Left‐to‐right shunt > 1.5:1.
Indications:
• Midmuscular VSD,
• Anterior muscular VSD
• Postoperative residual VSD
69
Device Closure
Contraindications -
a. Irreversible PVD
b. Preexisting LBBB or
conduction abnormalities
c. Associated AR
d. Associated lesions requiring
surgery
e. Inlet and Sub-pulmonic VSD
Device should not be deployed if any of the following findings
develop at the time of procedure -
a. Any degree of AR
b. Conduction defect: CHB / LBBB
c. MR or TR

71. Follow up For Device Closure
• Antiplatelet agents: Aspirin (3–5 mg/kg/day) is
given a day before or immediately after
procedure and continued for total duration of
6 months.
• Follow‐up visits: At 1 month, 6 months, 1 year,
then annually till 5 years, and then every 3–5
years.
– Echocardiogram
– ECG
• IE prophylaxis is recommended for 6 months
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72. THANK YOU
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