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Object To compare the clinical data of sternotomy and left intercostals incision, combined with the literature, to provide the best surgical incision for committed subarterial ventricular septal defect (DCS-VSD). Methods From July 2016 to July 2020, a total of 117 cases of occlusion surgeries for DCSVSD, which guided by transoesophagel echocardiography (TEE) were completed, including 34 cases with sternotomy incision and 83 cases with left intercostal incision. Statistics and analysis of the operation and follow-up. Results A total of 115 cases successfully occluded, the successful rate was 98.29%, and 1 case failed in each group. Pericardial effusion occurred in five children after the drainage device was removed, and the pericardial effusion disappeared after diuretic treatment. There was no statistical difference between the two groups in operation time, occlusion time, thoracotomy time and postoperative hospital stay. All the children recovered and were discharged from the hospital, and were followed-up for 2-30 months after operation. Conclusion TEE-guided intercostal DCS-VSD occlusion is safe and effective. There is no statistical difference between two approach with the operation time, chest opening and closing time, occluder placing time, and postoperative hospital staying. At the same time, the surgical incision by intercostal incisionis smaller and the operation invasion is less, it is a surgical approach which worth to develop.

Background:The research was to introduce the experience of doubly committed subarterial ventricular septal defect (DCVSD) repaired through tricuspid approach.Methods:From January, 2015 to September, 2019, 86 consecutive DCVSD paediatrics underwent repair via right subaxillary vertical incision (RAVI) through tricuspid approach. Perioperative and follow-up data were collected.Results:The age and weight at operation were 28.1 ± 18.5 (range: 7–101) months and 12.2 ± 4.2 (6–26.5) kg. There were two patients combined with discrete subaortic membrane, two patients with patent ductus arteriosus, one patient with atrial septal defect, and two patients with abnormal muscle bundle in right ventricular outflow tract. The mean size of ventricular septal defect was 7.0 ± 2.4 (3–13) mm. The defect was repaired with a piece of Dacron patch in 68 patients or directly with 1–2 pledgetted polypropylene sutures in 18 patients. The cardiopulmonary bypass time and aortic cross-clamp time were 46.2 ± 13.3 (23–101) minutes and 29.2 ± 11.5 (12–84) minutes. After 3.1 ± 2.4 (0–14) hours’ ventilator assist and 23.2 ± 32.1 (0–264) hours’ ICU stay, all patients were discharged safely. At the latest follow-up (27.9 ± 14.6 months), echocardiography showed trivial residual shunt in two patients. There was no malignant arrhythmia occurred and there was no chest deformity or asymmetrical development of the breast was found.Conclusions:DCVSD repaired via right subaxillary vertical incision through tricuspid approach was safe and feasible, providing a feasible alternative to median sternotomy, and it can be performed with favourable cosmetic results.

We determined the occurrence of aortic regurgitation (AR), AR progression and risk factors in patients followed up for up to three decades after closure of subarterial VSD. We reviewed the outcomes of 86 patients categorized into three groups: group I comprised 37 patients without AR and had VSD closure alone, group II comprised 40 patients with AR and had VSD closure without aortic valvoplasty, and group III comprised 9 patients with AR and required both VSD closure and aortic valvoplasty. Patients were followed up for 18.9 ± 7.3 years (median 19.5 years, range 3.5–36.6). At latest follow up, 54.7% (47/86) of patients had AR. The prevalence of progression of AR from any one grade to the next one higher was 37.2% (32/86). Freedom from AR progression was 75.6%, 52.1%, and 22.2% at 20 years of follow-up for groups I, II and III, respectively (p

Background The traditional treatment of subarterial ventricular septal defect (VSD) is open heart surgery. This study aimed to evaluate the feasibility, safety and outcome of transcatheter closure with the Amplatzer duct occluder (ADO). Methods Between March 2012 and June 2015, a total of 16 patients (8 male and 8 female) with subarterial VSD who underwent transcatheter closure with the ADO were enrolled retrospectively. Their age ranged from 3.0 to 65.6 years, with the median of 35.6 years; their body weights ranged from 14 to 92 kg with the median of 60 kg. All patients had prolapse of the right coronary cusp without subaortic rim. Mild aortic regurgitation was noted in 11 (69%) patients. Results Left ventriculogram showed VSD size ranged from 1.3 to 9.3 mm with the median of 3.5 mm. The device was successfully implanted in 88% (14/16) of the patients. Although one patient had mild skin allergy to contrast medium, no other complication was noted. Complete closure rate was 64%, 86%, 86% and 86% at 1-day, 1-month, 6-month and 12-month follow-up, respectively. Two patients developed new or worsening aortic regurgitation during follow-up. Conclusion Transcatheter closure of subarterial VSD with ADO is technically feasible and safe in patients older than 7 years of age. However, development or worsening of aortic regurgitation requires long-term follow-up.

Highlights • Minimally invasive cardiac surgery for closure of subarterial ventricular septal defect. • The approach using left parasternal thoracotomy via third intercostal space. • Excellent exposure of subarterial ventricular septal defect without special instruments., Introduction Minimally invasive cardiac surgery has been applied for the treatment of ventricular septal defect (VSD) with various approaches. However, closure of subarterial VSD with minimally invasive technique via left parasternal thoracotomy is rarely reported. Case presentation A 22-year-old man, weighing 65 kg, with a diagnosis of subarterial VSD underwent successful repair with minimally invasive technique via left parasternal thoracotomy through third intercostal space. The peripheral perfusion was performed with femoral arterial and venous cannulation. Myocardium was protected by warm blood cardioplegia injected directly into aortic root by a long needle and aortic clamp introduced through the thoracotomy incision. Discussion The left parasternal thoracotomy through third intercostal space (ICS) allows to expose both the subarterial VSD and ascending aorta. Myocardial protection and repair of this defect can be performed merely without requirements of video assistance or unique instruments. The patient recovered rapidly and was satisfied with the cosmetic result. The primary concern of this technique is mammary tissue which can be injured by a transverse incision in female patients. In this case, we can transform into the longitudinal incision. Conclusion This minimally invasive technique is feasible for the surgical treatment of subarterial VSD. Long-term follow-up and additional cases will be needed for validation of the safety and efficacy of this approach.

In patients with subarterial ventricular septal defect (VSD), the progression of aortic regurgitation (AR) still remains unclear. This review is to identify the incidence of AR progression after VSD repair and to determine the optimal operation timing for subarterial VSD repair with or without aortic valve prolapse or AR. From January 2002 to December 2015, 103 patients who underwent subarterial VSD repair alone at our hospital were reviewed. All patients routinely underwent echocardiography (echo) performed by our pediatric cardiologists. The operative approach was through the pulmonary artery in all patients. The median age of patients at operation was 10 months (range 3 to 16.5 months). Eighty-nine patients (86.4%) underwent subarterial VSD closure before the age of 4 years. In the preoperative evaluation, 27.2% (28 patients) of the patients showed more than faint degree AR. The mean follow-up duration after VSD repair was 6.6 ± 4.0 years. In the latest follow-up echo after VSD repair, four patients had more than mild degree AR owing to aortic valve abnormalities or delayed operation period. Among them, AR progression occurred in only one patient (0.98%). Early and accurate assessment of the anatomical morphology of the aortic valve and optimal operation timing may be important to achieve better outcomes after repair and to prevent the development of aortic valve complications.

Background The report of transcatheter doubly committed subarterial ventricular septal defect closure is limited. The objective was to evaluate the efficacy and outcome of transcatheter closure of doubly committed subarterial ventricular septal defect. Methods Clinical records, procedural and early to one-year follow-up data of doubly committed subarterial ventricular septal defect patient who underwent transcatheter closure between 2013 and 2018 in Hasan Sadikin Hospital Bandung Indonesia were retrosprectively reviewed. Results There were 40 patients of doubly committed subarterial ventricular septal defect who underwent transcatheter closure, consisted of 18 female and 22 male. The median of age was 8.8 (range 2.7–48) years, weight 24 (range 10.3–70) kg, and defect size 3.1 (1.24–7.4) mm. Mean pulmonary arterial pressure 23.4 SD 5.4 mmHg and flow ratio 1.65 SD 0.28. Median of latest follow-up was 14 months. No serious complications or death. The median length-of-stay period was 3 days, without intensive care admission. Failure to attempt in 3 cases, resulted 92.5% of acute procedural success rate. The acute efficacy was 37.5%, and increased up to 92% on latest follow-up. Of 7 patients with pre-existing aortic regurgitation, three was improved, two persisted, and one progressed to moderate regurgitation. New onset mild aortic regurgitation occurred in 1 patient, which persisted in the same degree during follow-up. Conclusion Transcatheter closure of doubly committed subarterial ventricular septal defect is feasible, safe and effective as an alternative treatment to surgical closure in selected patient. The competence of the aortic valve remain the main concern and required further follow-up.

Background This study sought to investigate the feasibility of transthoracic occlusion of a subarterial ventricular septal defect using a minimally invasive incision. Methods Between January 2009 and June 2014, we performed transthoracic subarterial ventricular septal defect occlusion for 81 patients via a minimally invasive incision. A special delivery sheath was used during surgery, and an eccentric occluder was implanted in the ventricular septal defect. Results Successful defect closure was achieved in 74 cases, perioperative arrhythmia occurred in five cases, and a large pericardial effusion was observed in two cases. Open heart surgery was performed for two patients to repair postoperative dislocation of the occluder. Intraoperative conversion to surgical repair was required in seven cases. During one to five years of follow-up, there was no late occluder dislocation, residual leakage, or thrombus-related complications. Conclusions Transthoracic subarterial ventricular septal defect occlusion using a minimally invasive incision may be an alternative to open surgical repair in selected patients. doi: 10.1111/jocs.12754 (J Card Surg 2016;31:398-402).

Transfemoral device occlusion and minimally invasive surgical repair are performed for doubly committed subarterial ventricular septal defect (dcVSD) to reduce the invasiveness of the conventional surgical repair through a median sternotomy. However, few studies have compared them in terms of effectiveness and cost. Inpatients with isolated dcVSD who had undergone transfemoral device occlusion or minimally invasive surgical repair from January 2011 to June 2014 were reviewed for a comparative investigation between the two procedures. Procedure success was achieved in 36 transfemoral (75 %) and in 36 surgical (100 %) procedures (p = 0.001). Transfemoral patients were older, with a VSD size similar to that of surgical patients (14.5 ± 11.7 vs 4.4 ± 2.9 years, p

Transfemoral and perventricular device occlusions are performed for doubly committed subarterial ventricular septal defect (dcVSD) to reduce the invasiveness of the conventional surgical repair through a median sternotomy. Few comparative studies have been conducted of these three procedures.Inpatients with isolated dcVSD who had undergone transfemoral and perventricular device occlusions or conventional surgical repair from January 2009 to June 2013 were reviewed to compare the three procedures.Procedure success was achieved in 33 transfemoral (66%), in 74 perventricular (94.9%), and in 205 repair (97.6%) procedures. The transfemoral group had the lowest success rate (p0.001), whereas the perventricular and repair groups had similar success rates (p = 0.418). Transfemoral patients were the oldest (p0.001) and had a dcVSD size similar to that of patients in other two groups (p = 0.518). The repair group required the longest hospitalization and longest stays in the intensive care unit (p0.001), required the longest operating room and mechanical ventilation times (p0.001), and had the highest rate of transfusion (p0.001). Major adverse events occurred in one transfemoral (3%), in two perventricular (2.7%), and in three repair (1.4%) procedures. Minor adverse events were absent in transfemoral (0%) and occurred in three perventricular (4%) and 14 repair (6.7%) procedures. No significant difference was noted in the rates of adverse events the three groups (p = 0.569). No grade 3 valvular regurgitation or complete atrioventricular block was observed in the studied patients.Device occlusion may be an alternative to surgical repair in selected patients with dcVSD. Perventricular occlusion was the preferred approach because it showed a higher success rate than transfemoral occlusion.

Background: Tetralogy of Fallot (TOF) with subarterial ventricular septal defect (VSD) is more common among Asians than Caucasians. Compared with the regular subaortic VSD postoperative right ventricular outflow obstruction is more common because of the sub-pulmonary extension of the defect. The objective of this study is to analyze the surgical implications and outcomes of patients with TOF - subarterial VSD in the current era. Patients and Methods: In all, 539 consecutive operated patients with TOF from May 2005 to September 2012 were retrospectively reviewed. Eighty-five patients had subarterial VSD. Seventy-nine of these underwent intracardiac repair. Preoperative clinical, echocardiographic features, operative and postoperative variables were assessed. Results: The median age at surgery was 6 years and the median weight was 14 kilograms. The male to female ratio was 1.7:1. TOF with subarterial VSD was associated with frequent use of transannular patch (74.6%). The early mortality was 2.5%. Follow up was 92% complete with a mean duration of 20 months with actuarial survival of 97.3% at 5 years. Two patients required reoperation for significant right ventricular outflow tract obstruction (RVOTO) at one year and three years, respectively. Conclusions: Intra cardiac repair for TOF with subarterial VSD has low perioperative mortality and morbidity. Transannular patch augmentation of the right ventricular outflow tract (RVOT) is required in a significant proportion of these patients. Precise suturing of the VSD patch, adequate infundibular resection and lower threshold for a transannular patch placement ensures a smooth early postoperative recovery.

Objective: To review the surgical outcome of doubly committed subarterial (DCSA) ventricular septal defect repair. Method: Data of 51 patients of doubly committed sub arterial Ventricular septal defect from January 2012 to June 2017 that were referred to Chaudhary Pervaiz Elahi institute of Cardiology Multan was retrospectively reviewed using electronic database. All patients were operated by first author. In our study, we segregated patients into four main groups depending on presence or absence of aortic structural defect and degree of aortic valve regurgitation. Group-A comprised of nineteen (37%) patients who neither had aortic structural nor functional abnormality while Group-B had six (11.7%) patients, having aortic valve cusp prolapse without aortic regurgitation. Group-C and Group-D consists of seventeen (33.3%) and nine (17.6%) patients respectively depending upon degree of aortic regurgitation. Furthermore, six (11.7%) patients among these 51 had associated defects as well. Results: Group-A patients had no aortic valve regurgitation post operatively and at follow up of 22.6 months (1.8 years) as well. In Group-B, aortic valve was not addressed and aortic regurgitation was also not present post operatively or on follow up of 33.6 months (2.8 years). Similarly, in Group-C aortic valve was not addressed, these patients also did not show progression of disease on regular follow up of 18 months (1.5 year). While, in Group-D, eight patients underwent aortic valve repair and one patient had aortic valve replacement. Aortic regurgitation improved significantly in all patients of this group and remained unchanged on follow up of 22.7 months (1.8 years). Conclusion: Early closure of doubly committed subarterial ventricular septal defect with appropriate management of aortic valve disease can halt the process of disease progression.

Background The past decade has witnessed considerable improvement in implantation techniques for percutaneous closure of ruptured sinus of Valsalva aneurysm. This study was undertaken to compare the immediate results and mid-term follow-up of traditional surgery and percutaneous closure of ruptured sinus of Valsalva aneurysm in China. Methods Between January 1993 and January 2013, a total of 35 patients with ruptured sinus of Valsalva aneurysm were enrolled for attempted closure in our institution. Twenty patients (57.1%) underwent surgical repair and the other 15 patients (42.9%) underwent percutaneous closure. Results Nineteen patients (95.0%) in the surgical group had complete closure and 14 patients (93.3%) in the percutaneous closure group were treated successfully (p = 0.681). Twelve patients with ruptured sinus of Valsalva aneurysm combined with subarterial ventricular septal defect (VSD) underwent surgical repair concomitantly. Two patients in the percutaneous closure group were treated for ruptured sinus of Valsalva aneurysm and perimembranous VSD using occluders concomitantly. One case of severe hemolysis developed 8 h after the procedure in the percutaneous closure group. One death and one case of patch leak occurred in the surgical group during hospitalization. The time of hospital stay in the percutaneous closure group was shorter than that in the surgical group (p = 0.004). The total medical cost of isolated ruptured sinus of Valsalva aneurysm in the percutaneous closure group was lower compared with that in the surgical group (p = 0.046). During a median follow-up of 15 months (2–240 months), there were no deaths, infective endocarditis, device embolization, or malposition. Conclusions Percutaneous closure is an attractive alternative to surgery in selected patients with ruptured sinus of Valsalva aneurysm for the better clinical advantages and economic benefits.

Double-chambered right ventricle (DCRV) is a rare congenital heart disease in which the right ventricle (RV) is divided into two chambers by anomalous muscle bundles. Here, we report a case of DCRV associated with subarterial ventricular septal defect (VSD) and rupture of right coronary sinus aneurysm (RCSA); the patient was diagnosed by echocardiography and later confirmed by surgical operation.

Background Doubly committed Subarterial ventricular septal defect (VSD) is a specific anatomic type of VSD located just beneath the aortic valve. The purpose of this study was to evaluate the safety and feasibility of using minimal invasive perventricular device closure in managing this type of VSD. Methods During Dec 2008 and Aug 2010, 34 Pediatric patients with doubly committed subarterial VSD who met the inclusion criteria for device closure were enrolled in this study. Perventricular closure was attempted using a unique design eccentric device under the guidance of real-time transesophageal echocardiography. Complications such as residual shunt, valve regurgitation, arrhythmias were all recorded in postoperative period and during follow-up. Result Perventricular device closure was successfully done in 28 patients (82%). 6 patients converted to open surgical repair due to residual shunt >3mm (1 patient), more than mild degree aortic regurgitation (3 patients) and device mal-position (2 patients). Complete closure rate was achieved in 93% at discharge and 100% during 20 months follow-up. No severe complications such as device embolism, significant arrhythmias and noticeable valve regurgitation were noted during follow-up. Procedure induced trivial grade aortic valve regurgitation was noted in five (18%) patients after procedure while only one (4%) persisted during midterm follow-up. Conclusion Perventricular closure of doubly committed subarterial VSDs appears to be a safe and effective minimally invasive technique with good mid-term outcomes. © 2013 Wiley Periodicals, Inc.

A doubly committed subarterial ventricular septal defect (VSD) used to be a contraindication for device closure. Perventricular device closure has been widely applied in China in the past years, but not in a doubly committed subarterial VSD. Chinese surgeons are now beginning to try this procedure also in a doubly committed subarterial VSD in selected patients. The technique of closure of the perimembranous defect has been described previously in this journal, but we hereby present some additional information on this procedure performed in a doubly committed subarterial VSD.

Rupture of a sinus of Valsalva aneurysm (SVA) is a rare, but life-threatening, event and requires immediate recognition and intervention. We present two previously healthy and physically active patients who were 12 and 33 years of age when rupture of a right coronary SVA into the right ventricle occurred. A subarterial ventricular septal defect (VSD) was detectable in both patients. Cardiac surgery involved VSD closure as well as reconstruction of the aortic valve. Considering complications of subarterial VSD, such as aortic cusp prolapse, aortic insufficiency or SVA, we suggest close follow-up and surgical closure of the VSD in case of any aortic valve deformity.

Previous reports on the long-term outcome of surgical closure of subarterial ventricular septal defect were based on a relatively small number of patients.We reviewed the long-term outcome of 135 patients who underwent closure of their defect and, in light of the findings, assessed the impact of preoperative aortic cusp prolapse and surgical interventions on occurrence of aortic regurgitation (AR) in the long-term. The patients were categorized into three groups for comparison: group I consisted of 79 patients with no aortic cusp prolapse and underwent simple closure of ventricular septal defect, group II comprised 39 patients with mild to moderate cusp prolapse who similarly had only closure of the defect performed, whereas group III comprised 17 patients who had additional aortic valvoplasty for greater than moderate to severe cusp prolapse.Group I patients had significantly higher pulmonary arterial pressure (p0.001) and ratio of pulmonary blood flow to systemic blood flow (p0.001). None of these patients had AR before their operation, and none experienced AR afterward at a median follow-up of 6.1 years. Of the 39 group II patients, 30 (77%) had trivial or mild AR preoperatively. The AR improved in 15 patients, remained trivial or mild in 14 and absent in 7, but progressed to trivial or mild in 3 at a median follow-up of 3.1 years. None required further interventions. In contrast, 14 (82%) of the 17 group III patients had moderate to severe AR before operation. The regurgitation improved in 10, but remained moderate or severe in 4 and worsened further in 3 at a median follow-up of 4.6 years. The freedom from failure of aortic valvoplasty was (mean +/- standard error of the mean) 71%+/-11%, 64%+/-12%, and 43%+/-19% at 1, 5, and 10 years, respectively. An older age at latest follow-up was the only identifiable significant risk factor (p = 0.03).Our data do not support the need of aortic valvoplasty for mild to moderate aortic cusp prolapse. Close follow-up is warranted in those with greater than moderate to severe cusp prolapse despite valvoplasty as there is continued failure on follow-up. Nothing, however, is better than early closure of defects before development of aortic valve complications.

Doubly committed subarterial ventricular septal defects should be closed surgically once aortic valve deformity is present before the onset of aortic regurgitation.

Background . Many surgeons recommend early repair of doubly committed subarterial ventricular septal defect regardless of the clinical symptoms. We reviewed our patients of this anomaly with aortic cusp prolapse to justify this strategy. Methods . We reviewed the preoperative and postoperative records of 27 patients with doubly committed subarterial ventricular septal defect and aortic cusp prolapse. The patients' ages ranged from 2 months to 11 years (median, 4.6 years). Results . During the preoperative observation period, aortic regurgitation (AR) developed in 65% of the patients. In the 8 patients without AR before the operation, AR did not develop after the operation, whereas AR persisted in 12 (63%) of the 19 patients with preoperative AR. To identify the risk factors for persistent AR after the operation we analyzed the data for the patients with preoperative AR in the persistent AR group (n = 12) and eliminated AR group (n = 7) and found a longer period from the onset of AR to the operation in the persistent AR group (32.1 ± 10.1 versus 5.6 ± 1.9 months; p = 0.014). During the follow-up period 10 of the 17 patients with mild AR before the operation showed persistent AR in the postoperative period, but it did not progress. Conclusions . We conclude that early surgical repair with a minimum observation period is essential for prevention of residual AR. Even if a tiny AR is detected preoperatively, the patient should be surgically treated immediately.

Background Certain conditions, including discrete subaortic stenosis and right ventricular outflow tract obstruction are well-known associations with ventricular septal defect. However, the association of discrete type subpulmonary and subaortic stenosis with ventricular septal defect has not been described to date. Patients In this report we present our experience in nine patients with doubly committed subarterial ventricular septal defect in whom associated discrete subpulmonary and subaortic stenosis were diagnosed by two-dimensional echocardiography. The mean age of the patients was 5·7 years, and eight of them were male. Two patients had additional hypertrophied anomalous muscle bundles with pressure gradients across the right ventricular outflow tract. Aortic valve prolapse was detected in two patients with one of them having mild aortic regurgitation. Intervention Cardiac catheterization was performed in four patients, and three underwent surgery. Doubly committed subarterial ventricular septal defect was closed, and subpulmonary and subaortic ridges were resected in each patient. Histological findings were similar for both ridges, which were composed of thin, short and irregularly arranged elastic fibres covered by endothelial cells. Results The finding of fibrous ridge on both sides of the doubly committed ventricular septal defect, where the turbulence is likely to be maximum, and the histopathological similarities of subpulmonary and subaortic ridges, may suggest a common mechanism for the development of fibrous ridges. Conclusion Serial echocardiographic assessment of patients with doubly committed ventricular septal defect is recommended.

To detect in children with tetralogy of Fallot (ToF) the prevalence of associated cardiac anomalies in syndromic and isolated cases, the additional cardiac defects of 150 consecutive patients with ToF (102 isolated and 48 syndromic cases) were evaluated by review of echocardiographic, angiocardiographic, and surgical reports. Syndromic patients were classified into groups with branchial arch defects, Down syndrome, and other genetic conditions. ToF is significantly associated with additional cardiac malformations in patients with branchial arch (11 of 21, p

We report a case of Tetralogy of Fallot with severe cyanosis who underwent a successful right ventricular outflow tract stenting. Follow-up echocardiography revealed moderate aortic regurgitation due to the impingement of the stent on the aortic valve. The patient underwent successful surgical correction at which time the stent was removed completely with a resolution of the aortic regurgitation.

We report a 10-day-old newborn, weighing 2.9 kg with an interrupted left aortic arch type B, a large subarterial ventricular septal defect and a right ductus connecting the right pulmonary artery to an isolated right subclavian artery. The patient underwent successful total surgical repair and the isolated right subclavian artery was ligated. He was discharged from hospital without complication and maintains excellent perfusion to the right arm via collaterals.

Subaortic stenosis usually occurs without a previous heart operation, however, it can occur after heart surgery as well, with a condition known as a secondary subaortic stenosis (SSS). SSS has been reported after surgical repair of several congenital heart defects. There are only a few recorded cases of SSS after repair of ventricular septal defect (VSD). Here we report a rare case of SSS that occurred 3 years after surgical repair of subarterial VSD. A follow-up echocardiogram is essential for detecting SSS caused by the newly developed subaortic membrane in patients who had cardiac surgery.

Background The purpose of this study was to evaluate the safety and feasibility of intraoperative device closure of the doubly committed subarterial ventricular septal defect (VSD). Methods From January 2009 to January 2010, we enrolled 15 patients with doubly committed subarterial VSD who underwent intraoperative device closure in our institution. Our method involved a minimal inferior median incision that was performed after full evaluation of the doubly committed subarterial VSD by real-time transesophageal echocardiographic guidance, and the insertion of the device through the delivery sheath to occlude the VSD. The proper size of the device was determined by means of transesophageal echocardiographic analysis. An asymmetric, domestically made device was chosen for closure (Shanghai Xingzhuangjiyi Alloy Material Co, Ltd). Results Implantation was ultimately successful in 13 patients (86.7%). The complete closure rates at 24 hours and 3 months were 69.2% and 100%, respectively. In 5 of 13 patients, minor complications occurred: transient arrhythmia (n = 5) and blood transfusion (n = 3). In a follow-up period of 1 to 12 months there was no residual shunt, noticeable aortic regurgitation, significant arrhythmias, thrombosis, or device failure. Conclusions Minimally invasive transthoracic device closure of the doubly committed subarterial VSD with an asymmetric domestically made device without cardiopulmonary bypass is safe and feasible under transesophageal echocardiographic guidance. However, it is necessary to evaluate the long-term results.

Background . We performed direct closure of doubly committed subarterial ventricular septal defects with aortic cusp prolapse. Postoperative echocardiographic studies showed that this method improved coaptation of the prolapsing aortic cusp, especially in patients with mild aortic regurgitation (AR). Methods . Twenty-one patients (mean age, 7.8 ± 4.3 years; range, 2 to 18 years) with doubly committed subarterial ventricular septal defect underwent direct closure alone. Aortic valve prolapse was observed in all 21 patients, with mild AR found in 13 patients but not in the remaining 8. The site of the prolapsed aortic valve was in the right coronary cusp in all patients. We inserted an interrupted 4-0 or 5-0 polypropylene suture with a pledget from the lower margin of the ventricular septal defect to the pulmonary ring to increase protrusion of the prolapsed cusp by pushing it back and to improve coaptation of the aortic cusp. Results . The interval between surgical treatment and the last postoperative evaluation ranged from 3 to 24 months (median, 11 months). No residual ventricular septal defect was detected in any patient. In the 8 patients who had aortic valve prolapse without AR preoperatively, no AR was found at follow-up. Of the 13 patients who had mild AR associated with aortic valve prolapse preoperatively, AR diminished in 7 and did not progress in the remaining 6. Furthermore, no anatomic changes in either the aortic or pulmonary annulus were found on follow-up echocardiography. In the group of 13 patients with mild preoperative AR, AR significantly persisted in patients who were more than 10 years old at operation (p Conclusions . Our findings suggest that direct closure for this type of ventricular septal defect is safe and reliable in improving mild AR and that direct closure is more effective for younger patients in whom the prolapsing aortic cusp is mobile enough to be protruded. However, further long-term follow-up studies will be needed to ascertain the adequacy and usefulness of the method.

sus, truncus arteriosus communis, common aorticopulmonary trunk) is a congenital cardiac malformation that involves the ventriculoarterial connection in which a single outlet is present. It is characterized by the presence of a single semilunar valve annulus as the only exit from the heart, a subarterial ventricular septal defect, and the absence or severe deficiency of the aortopulmonary septum. Two related but different malformations are aortopulmonary window and subarterial ventricular septal defect.

A 52-year-old female, with aortic insufficiency due to doubly committed subarterial ventricular septal defect (VSD) underwent a successful surgical repair by the Ross procedure. Preoperatively, she developed congestive heart failure because of less compliance to oral medication, raising concerns regarding life-threatening thromboembolism if she undergoes mechanical valve replacement. Despite the pulmonary autograft being defective, there were no difficulties in completing the surgery. The defect of pulmonary autograft and the VSD was closed by an expanded polytetrafluoroethylene patch. She tolerated the procedure well and now enjoys improved quality of life. We present a discussion of the indication of Ross procedure in the rare presentation of congenital heart disease, as well as several issues raised in this case.

Fifty specimens of double outlet right ventricle were studied. The insertion of the outlet (infundibular) septum determines two types of infundibular interrelationships. In the first type, with anterior and posterior infundibulums, the outlet septum is inserted to the anterior limb of the septomarginal trabeculation; the posterior infundibulum is related with the atrioventricular orifices and the interventricular septum forms exclusively one of the walls of the posterior infundibulum. Therefore, the artery connected with the posterior infundibulum may be related with a subarterial ventricular septal defect. Of our material, 35 cases (70% of 50) had anterior and posterior infundibulums and, in 32, the aorta was connected with the posterior infundibulum (91.4% of 35). The ventricular septal defect was subaortic in 26 cases (81.2% of 32). In the second type, with side-by-side infundibulums, the outlet septum is inserted in to the ventriculo-infundibular fold in the proximity of the posterior limb of the septomarginal trabeculation. Both infundibulums are related with the atrioventricular orifices and the interventricular septum forms exclusively one of the walls of the medial infundibulum. Therefore, the artery connected with the medial infundibulum has the possibility of being related with a subarterial ventricular septal defect. Of our material, 13 cases (26% of 50) had side-by-side infundibulums. In all of these (100% of 13), the pulmonary trunk was connected with the medial infundibulum and the ventricular septal defect was subpulmonary in 12 cases (92.3% of 13). There were two cases (4% of 50) with a doubly committed ventricular septal defect. The insertion of the outlet septum permits one to determine the infundibular interrelationships, information which cannot be attained by taking into account the relationship of the great arteries with each other. Once the infundibular interrelationship is established, one must determine if the aorta is connected with the posterior or with the medial infundibulum, since, depending on the anatomical constitution of these infundibulums, there is the possibility of a ventricular septal defect being related with this artery. This information is indispensable before attempting the surgical correction of the double outlet right ventricle and it may be obtained by echocardiography or by angiocardiography.

The incidence of infective endocarditis in children is 1.3 cases per 1,000 children who had been admitted. Recognizing infective endocarditis is very important because regardless of prolonged antibiotic treatment, it can entail serious complications, resulting in high morbidity and mortality. One of the important complications is the rupture of Valsalva sinus. We report a case of delayed rupture of the sinus of Valsalva in a 15-year-old boy with subarterial ventricular septal defect complicated with infective endocarditis. Physician must consider the possibility of delayed rupture of the sinus of Valsalva after infective endocarditis although initial evaluations revealed no evidence of periannular extension of infection and of perforation or rupture.

A term infant with antenatal diagnosis of trisomy 21 and double-outlet right ventricle (tetralogy of Fallot type) developed progressive biventricular dysfunction. Echocardiogram showed an overriding aorta with aortic-to-mitral valve discontinuity but good ventricular function. The ventricular septal defect (VSD) showed a doubly committed subarterial position. Subsequent echocardiogram revealed depressed biventricular function with a …

A 2 month old was referred for ventricular septal defect closure. Echocardiography demonstrated malposed (crossed) pulmonary arteries and a large subarterial ventricular septal defect. Magnetic resonance imaging confirmed the …

Five patients with clinical features of tetralogy of Fallot had subarterial doubly committed ventricular septal defect (VSD) with absence or deficiency of the infundibular septum. Two-dimensional (2-D) echocardiography differentiated this special group from those with the usual Fallot's anatomy. In addition to the long-axis view of the left ventricle which showed the subaortic VSD and the aortic and mitral fibrous continuity, the short-axis view at the cardiac base clearly demonstrated the subpulmonary extension of the VSD in the atypical group. Two-dimensional echocardiography was found superior to biplane angiography, which in 3 patients suggested the erroneous diagnosis of double-outlet right ventricle with pulmonic valve stenosis. This variant form of Fallot's tetralogy poses special surgical problems.

To gain a better understanding of the anatomy of doubly committed subarterial defects and its relation to findings at cross sectional echocardiography and angiocardiography, eight necropsy specimens from patients with this condition were examined, and preoperative echocardiograms and angiocardiograms from 313 patients with surgically or necropsy confirmed outlet defect were reviewed. Of these, 48 had doubly committed subarterial defects. Morphological review showed that doubly committed defects are roofed by the arterial valves in fibrous continuity because of lack of both the outlet septum and the "septal" aspect of the subpulmonary infundibulum. Angiocardiography had a lower sensitivity (50%) than echocardiography (95%) for diagnosis of doubly committed defects, but each was highly specific. In five (14%) of 35 available echocardiograms the arterial valves were normally offset, but in the remainder they were at the same level. The ventriculoarterial connection was concordant in 37/48 (77%), discordant in five (10%) of 48, and double outlet right ventricle in six (13%) of 48. Displacement of the fibrous raphe between the arterial valves in relation to the ventricular septum below was associated with outflow obstruction in 14 patients (pulmonary in nine and aortic in five). These features were readily identified by echocardiography. Thus echocardiography is not only a more accurate method than angiocardiography of recognising these defects, but also shows that the arterial pole of the heart is architecturally abnormal.

Doubly committed subarterial (supracristal, subpulmonary) ventricular septal defects are often complicated by aortic regurgitation resulting from aortic valve herniation into the defect. The clinical, echocardiographic and catheterization findings in 48 patients aged 0.3 to 46.4 years (median 9.5) with a doubly committed subarterial ventricular septal defect were reviewed. Aortic valve herniation was present in 38 (79%) and 55% of these had aortic regurgitation. The prevalence of both findings increased gradually with advancing age. The defect was closed surgically in 41 patients. Surgery during the first 2 years of life (median 0.4 year) was performed in 13 patients (group I), mainly because of a large shunt with a pulmonary to systemic flow ratio (Qp/Qs) 3.8 +/- 1.4 (mean +/- SD). Aortic regurgitation was present preoperatively in two patients (15%), persisted postoperatively in one patient and did not develop in any after repair (median duration of follow-up 2.3 years, range 0.1 to 7.4). In the other 28 patients (group II) surgery was performed between 4.8 and 46.4 years of age (median 11.5). These patients were generally less symptomatic and had a smaller shunt (Qp/Qs 1.5 +/- 0.5, p less than 0.001). Preoperative aortic regurgitation was present in 18 (64%). It persisted in 15 postoperatively, but in 13 of these it had diminished. Two-dimensional echocardiography in multiple views identified the site of the ventricular septal defect in all patients. Serial echocardiographic examinations demonstrated the progressive nature of aortic valve herniation, the partial occlusion of the defect by the herniated sinus and the development of aortic regurgitation. These findings suggest that timely surgical closure of these defects may prevent aortic regurgitation.

A stillborn baby girl was found to have an anomalous muscle bundle of the right ventricle, associated with a doubly committed subarterial ventricular septal defect. The latter was separated from the area of the atrioventricular conduction bundle by muscle. Serial histologic sectioning of the specialized atrioventricular junctional area revealed that the final bifurcation of the branching bundle came astride the septum in the inferior angle of the defect. The right bundle branch bifurcated and one of its branches continued along the anomalous muscle bundle in subendocardial position. This anatomy supports the concept that the bundle, in this heart, represented an early takeoff of the moderator band. The surgical anatomy suggests that resection of the anomalous muscle bundle and closure of the ventricular septal defect might well have produced heart block. The generally accepted rule that resection of anomalous muscle bundles in the right ventricle is surgically safe should be reconsidered.