Apical ventricular septal defects: follow-up concerning anatomic and surgical considerations Stella Van Praagh, MD, John E Mayer, MD, Norman B Berman,

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Ventricular septal defects

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Presentation transcript:

Apical ventricular septal defects: follow-up concerning anatomic and surgical considerations Stella Van Praagh, MD, John E Mayer, MD, Norman B Berman, MD, Michael F Flanagan, MD, Tal Geva, MD, Richard Van Praagh, MD The Annals of Thoracic Surgery Volume 73, Issue 1, Pages 48-56 (January 2002) DOI: 10.1016/S0003-4975(01)03249-0

Fig 1 (A) Opened normal right ventricle (RV). The apex of the infundibular recess is anterior and to the left of the moderator band (MB). The apex of the RV inflow is inferior and to the right of the infundibular apex. The two apices are separated by a muscular ridge, which in some cases may exhibit some intertrabecular spaces. (Reproduced and modified with permission from Van Praagh R, Plett JA, Van Praagh S. Single ventricle: pathology, embryology, terminology, and classification. Herz 1979;4:113–50 [Copyright Urban & Vogel].) (B) A normal RV showing the relative positions of the RV sinus apex and of the infundibular apical recess. A muscular ridge, the infundibulosinus partition, separates those two areas in the normal RV. (PB = parietal band; PV = pulmonary valve; SB = septal band; TV = tricuspid valve.) The Annals of Thoracic Surgery 2002 73, 48-56DOI: (10.1016/S0003-4975(01)03249-0)

Fig 2 The heart of a 2.5-month-old girl with apical ventricular septal defect (VSD), coarctation of the aorta, and patent ductus arteriosus (case 5, Table 1). (A) Opened right ventricle (RV). The apical VSD is located in the area of the ventricular septum, which lies between the left ventricle (LV) and the apical infundibular (Inf) recess. A muscular partition separates the apical Inf recess from the RV apex. In the exit of the Inf recess there is a small remnant of the patch, which was placed transatrially. (B) Opened LV showing the large apical VSD (25% of the left ventricular septal length, Table 1). (C) Angiocardiogram of same case at 17 days of age. Left anterior oblique view of an LV injection after coarctation repair, patent ductus arteriosus ligation, and main pulmonary artery banding. Note how the dye enters the Inf apical recess adjacent to the apical VSD (white arrows), which has a nonrestrictive exit (gray arrows). (Ao = aorta.) The Annals of Thoracic Surgery 2002 73, 48-56DOI: (10.1016/S0003-4975(01)03249-0)

Fig 3 Diagrammatic presentation of apical infundibulotomy. The incision (dotted line) is parallel to and to the right of the distal part of the anterior descending coronary artery (LAD). The length of this incision, which extended close to the apex of the heart, varied from 1.5 to 2.5 cm. Inset shows the exposed apical ventricular septal defect (VSD). In this diagram and in some cases of this report the defect extends above and below the moderator band (MB). (Ao = aorta; LV = left ventricle; MPA = main pulmonary artery; RV = right ventricle; SB = septal band.) Reproduced with permission from The Society of Thoracic Surgeons (Stellin G, Padalino M, Milanesi O, et al. Surgical closure of apical ventricular septal defects through a right ventricular apical infundibulotomy. Ann Thorac Surg 2000;69:597–601.) The Annals of Thoracic Surgery 2002 73, 48-56DOI: (10.1016/S0003-4975(01)03249-0)

Fig 4 The explanted heart of a 2.5-year-old boy with a large apical ventricular septal defect (VSD), abnormal tricuspid valve (TV), and biventricular dysplasia (case 1, Table 1). (A) Opened right ventricle (RV). The abnormal TV was both stenotic and regurgitant. The pulmonary valve (PV) was stenotic. The RV free wall shows extensive endocardial fibroelastosis. (B) The extremely large apical VSD (white arrows) occupies 60% of the left ventricular (LV) septal length. The mitral valve (MV) is seen through the VSD. Patchy endocardial sclerosis is seen in the LV free wall. The Annals of Thoracic Surgery 2002 73, 48-56DOI: (10.1016/S0003-4975(01)03249-0)

Fig 5 The angiocardiogram of a 5-year-old boy with an apical ventricular septal defect (VSD) and restrictive exit from the apical infundibular (Inf) recess (case 10, Table 2). (A) Left anterior oblique projection of a left ventricular (LV) injection. The dye entered the apical Inf recess through the apical VSD (white arrowheads). The exit of the Inf recess (white arrowheads) was restrictive, minimizing the left-to-right shunt and preventing right ventricular hypertension. (B) Lateral projection of the angiocardiogram of the same patient with an injection into the Inf recess where the pressure was similar to that of the LV. The dye flowed into the LV through the apical VSD (white arrowheads) and a small amount escaped around the catheter, which almost occluded the exit of the Inf recess. The Annals of Thoracic Surgery 2002 73, 48-56DOI: (10.1016/S0003-4975(01)03249-0)

Fig 6 Two-dimensional echocardiogram in case 3 (Table 2). (A) Preoperative examination at 3 months of age. Diastolic frame from the apical four-chamber view showing a large muscular defect between the left ventricular (LV) apex and the infundibular (Inf) recess. The ventricular septal defect (VSD) extends from inferior to the moderator band (MB) to the cardiac apex (arrows). (B) Postoperative scan at 7 months of age from the subxiphoid short-axis view. The patch extends across the junction between the Inf recess and the right ventricular outflow tract (RVOT), leaving the Inf recess incorporated with the LV through the VSD (arrows). (LA = left atrium; RA = right atrium; RV = right ventricle.) The Annals of Thoracic Surgery 2002 73, 48-56DOI: (10.1016/S0003-4975(01)03249-0)

Fig 7 Angiocardiogram of a 3-month-old boy with a single apical ventricular septal defect (VSD; case 3, Table 2). At the time of this cardiac catheterization he had severe left ventricular (LV) dysfunction and his LV free wall showed an increased stratum spongiosum and a diminished stratum compactum. (A) Left anterior oblique projection with cranial angulation of an LV injection. The dye is beginning to cross the apical VSD. (B) The infundibular (Inf) apical recess next to the apical VSD is now visualized and the dye escapes through its unobstructed exit into the right ventricle. Note a tiny jet of dye (white arrow), which shows a narrow intertrabecular space in the muscular partition between the Inf recess and the right ventricular sinus. The Annals of Thoracic Surgery 2002 73, 48-56DOI: (10.1016/S0003-4975(01)03249-0)