title: Intramural Ventricular Septal Defect Is a Distinct Clinical Entity Associated With Postoperative Morbidity in Children After Repair of Conotruncal Anomalies.
abstract: BACKGROUND
  Intramural ventricular septal defects (VSDs) are interventricular communications through right ventricular free wall trabeculations that can occur after repair of conotruncal anomalies. We assessed the prevalence of residual intramural VSDs and their effect on postoperative course.
  
  
  RESULTS
  Children who underwent biventricular repair of a conotruncal anomaly from January 1, 2006, to June 30, 2013, and had a postoperative transthoracic echocardiogram were included. Images were reviewed for residual intramural or nonintramural VSDs. The primary outcome was a composite of mortality, extracorporeal membrane oxygenation use, and need for subsequent catheter or surgical VSD closure. The secondary outcome was postoperative hospital length of stay. A residual VSD was present in 256 of the 442 subjects (58%), of which 231 (90%) were <2 mm in size. Forty-nine patients (11%) had intramural VSDs, and 207 (47%) had nonintramural VSDs. Patients with intramural VSDs were more likely to reach the primary composite outcome compared with those with nonintramural VSDs or no residual VSD (14 of 49 [29%] versus 15 of 207 [7%] versus 6 of 186 [3%]; P<0.0001). In addition, those with intramural VSDs had longer postoperative hospital length of stay compared with those with nonintramural VSDs or no residual VSD (20 days [interquartile range, 11-42 days] versus 7 days [interquartile range, 5-14 days] versus 6 days [interquartile range, 4-11 days]; P=0.0001). These associations remained significant after adjustment for known risk factors for poor outcomes, including residual VSD size and operative complexity.
  
  
  CONCLUSIONS
  Among residual VSDs after repair of conotruncal anomalies, intramural VSDs are uniquely associated with postoperative morbidity, mortality, and longer postoperative hospital length of stay. It is important to recognize intramural VSDs in the postoperative period.
authors.affiliation: From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA. cohenm@email.chop.edu.
authors.forename: Jyoti K
authors.initials: JK
authors.lastname: Patel
authors.affiliation: From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Glatz
authors.affiliation: From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Reena M
authors.initials: RM
authors.lastname: Ghosh
authors.affiliation: From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Shannon M
authors.initials: SM
authors.lastname: Jones
authors.affiliation: From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Shobha
authors.initials: S
authors.lastname: Natarajan
authors.affiliation: From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Chitra
authors.initials: C
authors.lastname: Ravishankar
authors.affiliation: From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Christopher E
authors.initials: CE
authors.lastname: Mascio
authors.affiliation: From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Spray
authors.affiliation: From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Meryl S
authors.initials: MS
authors.lastname: Cohen
mesh_terms: D006328:Cardiac Catheterization / Q000706:statistics & numerical data; D015199:Extracorporeal Membrane Oxygenation / Q000706:statistics & numerical data; D005260:Female; D006330:Heart Defects, Congenital / Q000601:surgery*; D006345:Heart Septal Defects, Ventricular / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology* / Q000601:surgery; D006346:Heart Septum / Q000000981:diagnostic imaging; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007234:Infant, Premature; D007235:Infant, Premature, Diseases / Q000453:epidemiology / Q000601:surgery; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology* / Q000601:surgery; D015995:Prevalence; D012086:Reoperation / Q000706:statistics & numerical data; D012307:Risk Factors; D016896:Treatment Outcome; D014338:Truncus Arteriosus / Q000002:abnormalities* / Q000601:surgery; D014463:Ultrasonography
keywords: cardiac surgical procedures; congenital; heart defects; heart septal defects; pediatrics; ventricular