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Last Post:
Nov 14, 2009 9:09 AM
by: Oleksandr Golov...
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Posts:
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Registered:
9/27/08
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VSD, SEVERE PHTN
Posted:
Apr 18, 2009 3:53 PM
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16 Y, F, big perimembranous VSD, SEVERE PHTN, bidirectional shunt but mainly LT TO RT, no cyanosis, no clubbing, no ploythiasemi.
almost asymptomatic
to operate or nor?
plz, i need urgent response.
thanks
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Posts:
26
Registered:
9/23/08
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Re: VSD, SEVERE PHTN
Posted:
Apr 20, 2009 2:40 PM
in response to: Ahmed El-Eshmawi
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Dear Ahmed i do find that surgical closure of the defect is the trt of choice cause as far as the shunt is left to right the patient will recover by means of closure...and if you encounter a right side failure once u go off all what u have to do is either u open the foramen ovale or u fenestrate the VSD patch,in order to get a RV relief and maintain a cardiac output despite the high PA....try to do it as soonly as possible ...good luck...beside i remember about the case i posted about MVD and PHT, actually i did one case one mounth ago it was a longstanding mitral stenosis with also high PA, unfortunately the patient maintained a fixed PA pressure of around 65mmHg in the post op resistant to all kind of therapy and she passed away the last week..
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Posts:
10
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9/27/08
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Re: VSD, SEVERE PHTN
Posted:
Apr 22, 2009 2:23 PM
in response to: Sarkis Ejbeh
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dear dr Sarkis;
thanks for your comment, i did this case today with fenestrated patch, the VSD was terribly large, we opened the TV septal leaflet radially so i can reach the upper bprder of the VSD, i closed it with running suture technique to save the CPB time.
i could come off the CPB with excellent hemodynamics on MILIRINON, the TEE shoed that the patch dosnt shunt right to left which was a very good sign.
the patient wxtubated few hours later.
i wonder how this big VSD didt induce Eisenmenger syndrome in this young lady?
thanks any way and good luck
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Posts:
7
Registered:
9/23/08
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Re: VSD, SEVERE PHTN
Posted:
Nov 4, 2009 6:14 PM
in response to: Ahmed El-Eshmawi
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Congratulations,
In our clinic we perform catheterization for these patients to measure Qp/Qs, Wood Units before and after pulmonary vasodilatation test. Sometimes we are using fenestrated patch with the valve for VSD closure.
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Posts:
20
Registered:
9/23/08
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Re: VSD, SEVERE PHTN
Posted:
Nov 13, 2009 7:25 AM
in response to: Ahmed El-Eshmawi
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Hi, did you use Sildenafil? I don´t use fenestrated patch because i wonder if you maintain the risk of endocarditis associated to VSD. I´d prefer open the atrial septum if necessary.
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Posts:
7
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9/23/08
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Re: VSD, SEVERE PHTN
Posted:
Nov 14, 2009 9:03 AM
in response to: Marco Travessa
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We have now 28 patients with fenestrated double patch repair for the last 12 years. We have no infective endocarditis in follow up. This fenestration with valve is not working after long period. In follow up we have only 1 patient with working valve (Eisenmenger complex after 9 years after operation). We have started usage of sildenafil from 2006 for patients with High PVR and High PH not only in postoperative period, but also in preoperative period to decrease PVR. After we start Sildenafil therapy and Inhaled Iloprost in some cases - we didn't use fenestrated patch with the valve. We close VSD and nothing more. I see 2 ways to use this technique
1. For patients with a high risk of postoperative pulmonary hypertension crisis (from 6 months to 1,5 years) if you think that there are will be some problems with a postoperative management of this patient in YOUR ICU !
2. Older patients with defects and High PVR. It's very difficult to prognose result. Indications for VSD closure is very rare using only CATH LAB data with vasodilator tests. Lung Biopsy is not full informative. That's why sometimes indications to close VSD maybe overvalued. In cases of irreversible PH it's better when you have this fenestration on the ventricle level.
P.S.:
You can read our results as a part of international experience in Dr. William Novick paper in Annals of Thoracic Surgery. Novick WM, Sandoval N, Lazoryshynets VV, Flap valve double patch closure of ventricular septal defects in children with increased pulmonary vascular resistance. Ann Thorac Surg. 2005 Jan;79(1):21-8; discussion 21-8.
Another interesting paper from China. Unidirectional monovalve homologous aortic patch for repair of ventricular septal defect with pulmonary hypertension.
Zhang B, Wu S, Liang J, Zhang G, Jiang G, Zhou M, Li X.
Ann Thorac Surg. 2007 Jun;83(6):2176-81.
Message was edited by: Oleksandr Golovenko
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