Spontaneous closure of small residual ventricular septal defects after surgical repair.
BACKGROUND
Residual shunts may be detected by intraoperative or postoperative echocardiography after surgical closure of a ventricular septal defect (VSD). The hemodynamic relevance and rate of late closure are unknown.


METHODS
Between 1994 and 2005, 198 consecutive patients underwent surgical correction of an isolated VSD (n = 100), tetralogy of Fallot (n = 52) or atrioventricular septal defect (n = 46). Intraoperative transesophageal echocardiography (TEE) was routine, and postoperative transthoracic echocardiography was performed in the intensive care unit, at hospital discharge, and during follow-up. Residual defects were graded as absent, between 1 and 2 mm, or greater than 2 mm.


RESULTS
Shunt-related discrepancy was observed between intraoperative TEE and intensive care unit transthoracic echocardiographic findings; significantly so after Fallot repair (p < 0.0001). After discharge, 83% of all residual defects less than 2 mm closed. Of nine residual defects greater than 2 mm, only three closed after a median follow-up of 3.1 years. In patients with residual shunts, they were hemodynamically insignificant, required no medication, and no endocarditis was noted. At last follow-up, there was no significant difference between the percentage of residual shunts among the three groups (p = 0.135).


CONCLUSIONS
Postsurgical residual VSDs less than 2 mm closed spontaneously in the majority within a year. Defects greater than 2 mm are unlikely to close spontaneously. Residual shunts after atrioventricular septal defect repair almost always close, whereas one third will remain open after Fallot or isolated VSD repair. At midterm follow-up, residual shunts remained hemodynamically and clinically irrelevant. Revision of a residual defect greater than 2 mm on cardiopulmonary bypass at initial repair, guided by TEE, may spare late redo surgery and lifelong antibiotic prophylaxis.
Dodge-Khatami
Ali
A
Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zürich, Switzerland. ali.dodge-khatami@kispi.unizh.ch
Knirsch
Walter
W
Tomaske
Maren
M
Prêtre
René
R
Bettex
Dominique
D
Rousson
Valentin
V
Bauersfeld
Urs
U
D006348:Cardiac Surgical Procedures; D002648:Child; D002675:Child, Preschool; D004452:Echocardiography; D017548:Echocardiography, Transesophageal; D005500:Follow-Up Studies; D006344:Heart Septal Defects, Atrial / Q000150:complications / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery; D006345:Heart Septal Defects, Ventricular / Q000150:complications / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery*; D006801:Humans; D007223:Infant; D007362:Intensive Care Units; D007432:Intraoperative Period; D011184:Postoperative Period; D012075:Remission, Spontaneous; D012189:Retrospective Studies; D013771:Tetralogy of Fallot / Q000150:complications / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery; D013997:Time Factors