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The patient was a 2-month-old, 4.5 kg infant with heart failure symptoms and severe pulmonary hypertension who was diagnosed with multiple apical ventricular septal defects (VSDs). He was placed on home oxygen and Sildenafil in an attempt to lower his pulmonary artery pressure. After a thorough evaluation, cardiac catheterization showed improvement in his pulmonary vascular resistance (PVR) and reactivity in his pulmonary vascular bed, with a good response to nitric oxide. At that time, it was felt that he was a better surgical candidate.
The procedure was performed through a median sternotomy with mild hypothermic cardiopulmonary bypass via aortic and bicaval cannulation. After achieving cardioplegic arrest, the intra-cardiac anatomy was evaluated. However, due to the complexity and multiplicity of his apical VSDs, it was concluded that the left ventriculotomy approach would be more effective.
A left ventricular apical exclusion with a 0.4 mm Gore-Tex patch was performed, effectively eliminating all significant shunts. A 4 mm atrial level fenestration was left in place. The postoperative course was overall uneventful, and he was discharged on the sixth postoperative day. He did not need oxygen when he was discharged home.
The initial postoperative echocardiogram showed left ventricular systolic dysfunction with new mitral valve regurgitation, which was attributed to the left ventricular apical incision. However, this condition completely resolved by the time of hospital discharge. The authors believe that this is a valuable approach to consider in cases with such complex anatomy.
References
- Singh AK, del Leval MR, Stark J. Left ventriculotomy for closure of muscular ventricular septal defects. Treatment of choice. Ann Surg 1977 Nov;186(5):577-580
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