Neonatal Closure of Apical Ventricular Septal Defect

A 2-week-old, 3.5 kg child was transferred from a distant hospital (300 miles away) on congestive heart failure. Suspected diagnosis was ventricular septal defect (VSD), atrial septal defect (ASD), and pulmonary hypertension (PHT). On arrival at the authors’ NICU, the patient was stabilized with diuretics and vasodilators and eventually intubated. Echo showed an apical VSD and ASD. Cath lab exploration confirmed the diagnosis, ruling out PHT and mitral pathology.

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

1. Truly apical VSD can be succcessfully closed, even in neonates.
2. A sandwich technique to fix the defect proved safe and simple.
3. 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.

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