Surgical closure of ventricular septal defects in small children in 2021: is it still the preferred therapeutical option?

Closure of a ventricular septal defect (VSD) is one of the most common operative procedures performed in congenital cardiac surgery, both in the starting days and currently. It is often used as a benchmark operation with mortality rates around 0.5% and minimal morbidity (short stay on intensive care unit, low incidence of heart block and no to trace tricuspid regurgitation) [1].

One should always consider that there are several anatomical descriptions of different kind of VSDs: perimembranous (paramembranous, subaortic, infracristal) VSD, conoventricular (subaortic, infracristal) VSD, subpulmonary (supracristal) VSD, inlet (atrioventricular canal type) VSD and muscular VSD. Most common is the perimembranous defect; however, e.g. the subpulmonary VSD is much more common in oriental populations [2].

The quintessence of every surgical procedure is exposure. The better the exposure the easier the access and the better the results. However, another important part of medicine is the Hippocratic oath which says: ‘primum non nocere’ (do no harm). If we take both those principles into consideration one could say that exposing a VSD by detaching a good functioning tricuspid valve is a way to get better exposure and thereby a better operative result for the closure of a VSD. On the other side, why sacrifice a good functioning tricuspid valve with the risk of damaging the valvar tissue, if the same result can be achieved without detaching the valve. With gentle traction, the same exposition can be accomplished, and the same surgical results can be met. In the past several methods have been described to close VSDs. The old surgical school started through the right ventricle. Transaortic, transpulmonary approaches have been described depending on the kind of VSD. Nowadays, the most used and accepted repair is the trans-atrial approach [3].

The high incidence of tricuspid valve detachment in this series gives the impression that this technique has to be used regularly. Although this technique should certainly be in the armamentarium of every congenital cardiac surgeon, it is not a technique that should be used routinely. We live in an era of outer aesthetics. There is a contest to achieve smaller and cosmetically more acceptable and almost ‘invisible’ incisions to be able to compete with the paediatric cardiologists, who also have advanced their interventional procedures to close VSDs. Especially with the smaller incisions and the angle the VSD is visualized through this approach the tricuspid valve detachment can be very helpful [4].

Taking care of delicate structures can be a challenge for both surgical and interventional strategies. However, while the surgeon is able to actively see and take care of these delicate structures, the interventionalist has to trust his device in causing no harm. Kozlik-Feldmann and co-workers [5] describe in a recent publication looking at 85 patients, which received a current device, a serious adverse event rate of 3.5% and a major adverse event rate of 5.9% during a 5-year follow-up period.

There are limitations for the interventional closure at the moment and most centres would start with patients from 10 kg and onwards, due to arterial and venous access. This might, however, change in the near future and this could be a competing partner for the simple VSD. So, taking this interventional closure into consideration is not applicable at the moment since the patients described in the article are also around 5 kg, but it might be something for the near future.

In the current issue of the European Journal of Cardio-Thoracic Surgery, Lee and co-workers [6] describe their surgical experience treating 462 infants <5 kg with VSD in a 16-year time period from 2004 to 2020. They assessed long-term postoperative clinical outcome and in particular the risk of regression of tricuspid valve regurgitation depending on whether the tricuspid valve was detached and reattached during surgery or not. Although there was no statistically significant difference regarding the grade of postoperative tricuspid regurgitation (freedom from significant tricuspid regurgitation was 94.4% in both groups at 5 and 10 years), there was a statistically significant difference regarding the progression of tricuspid regurgitation (P = 0.019).

In summary, the authors describe and compare 2 well-known techniques. Their question is: should we be hesitant to detach the tricuspid valve. In the end, whichever technique is used, one should thrive for optimal results according to lowest incidence of postoperative residual defects, lowest incidence of junctional ectopic tachycardia or complete heart block, minimal to no tricuspid regurgitation and in principle do not harm. So, my answer to the question should we be hesitant to detach the tricuspid valve is affirmative, however, it should be a technique that one should have knowledge of.

REFERENCES