Neonatal Closure of Apical Ventricular Septal Defect
Discussion about the best approach was held. Pulmonary artery banding
is always a straightforward palliative option. Neither peripheral nor
perventricular hybrid VSD closure sounded appropriate. Surgical VSD
closure was regarded as the best choice to fix the defect.
Lower
ministernotomy was carried out and bypass was established with aortic
and bicaval cannulation.The inferior vena cava cannula was inserted by a
separate stab wound, which later became the drain exit. Cardioplegic
arrest was achieved, the right atrium opened, and a vent sucker slid
through the ASD. Both tricuspid and mitral valves looked normal.
Attention was then turned to the apex, lifted with two tackle stitches.
Interestingly, the anterior descending coronary artery was absent in its
distal portion (a common finding in apical VSD). The apex was incised
towards the boundaries of the VSD. A previously harvested
glutaraldehide-treated autologous pericardial patch was parachuted to
the muscular crescent with a running suture. On reaching both hinge
points, the patch was further trimmed to size and sandwiched between the
ventriculotomy edges. The ASD was partially closed, leaving a 3-4 mm
residual pop-off and the atriotomy was closed. De-airing maneuvers and
weaning off bypass on moderate inotropic support were performed as
usual. Intraoperative echo showed good result.
The
patient was extubated two days later, with an uneventful postoperative
recovery. Discharge two weeks later was agreed by the parents because of
poor oral feeding and long distance to nearest hospital facilities.
After six months of follow-up, the child was thriving properly.
Conclusions
- Truly apical VSD can be succcessfully closed, even in neonates.
- A sandwich technique to fix the defect proved safe and simple.
- Minimally invasive incisions can be considered, provided that the cardiac chambers involved (right atrium and apex) are easily approached, as displayed in this case report.
