Methods
We reviewed a series of patients who underwent surgical ventricular
septal defect closure between October 1, 2015, and October 1, 2018.
Patients with a concomitant atrial septal defect, patent ductus
arteriosus, patent foramen ovale, and stenotic/regurgitate semilunar
valves were included. Patients with all other complex cardiac anomalies
were excluded. Patients who received prior pulmonary artery banding were
included in this study.
One hundred eight patients met the inclusion criteria. We evaluated the
preoperative, perioperative, and postoperative data from the
echocardiography reports, perfusion reports, and clinical, inpatient,
and operative notes of all the patients.
The patients’ preoperative characteristics, including sex, cardiac and
non-cardiac comorbidities, age at operation, body weight at operation,
type of ventricular septal defect, and underlying genetic condition,
were examined. The ventricular septal defect types were subdivided into
three groups based on transthoracic echocardiography findings of
perimembranous, muscular, and infundibular defects. The outcome
variables in this study were as follows: in-hospital death, mechanical
ventilation (MV) duration in hours, pediatric intensive care unit (PICU)
stay duration in days, hospital stay duration in days, pediatric index
of mortality 2 (PIM-2), and pediatric risk of mortality 3 (PRISM-3). The
postoperative complications included acute kidney injury, pleural
effusion requiring chest tube placement, atelectasis, junctional ectopic
tachycardia, complete atrioventricular block, and major adverse events.
The significant major adverse events included unplanned reoperation,
complete heart block requiring implantation of a permanent pacemaker,
sudden cardiac arrest, and death. Acute kidney injury is defined in
accordance with the pRIFLE (pediatric risk, injury, failure, loss,
end-stage renal disease) criteria [5]. The MV duration was
considered to be prolonged if it lasted >6 hours, and an
extended PICU or hospital stay lasted >3 and 7 days,
respectively [3, 6].
The mediastinum was accessed through a median sternotomy in all the
operations. The operation was performed under a moderate hypothermic
cardiopulmonary bypass with aortic and bicaval cannulations and
antegrade blood cardioplegia. All the operations were performed by the
same two surgeons. All ventricular septal defect closures were
accomplished with a polytetrafluoroethylene patch using the interrupted
suture technique. The surgical approach to the ventricular septal defect
was through the right atrium in 104 patients, pulmonary arteriotomy in
2, and aortotomy in 2. Transesophageal echocardiography was routinely
used except in the patients with contraindications such as patient size
or esophageal stenosis. Concomitant atrial septal defect repair, patent
foramen ovale closure, patent ductus arteriosus ligation and/or
division, valvuloplasty, and vascular ring repair were performed when
indicated.
Statistical analyses were performed using the Statistical Package for
the Social Sciences version 24.0 software (Armonk, NY: IBM Corp). The
normal distribution of the variables was evaluated using visual
(histogram and probability graphs) and analytical methods
(Kolmogorov-Smirnov and Shapiro-Wilk test). A descriptive analysis was
performed using frequency tables for the categorical variables, while
means and standard deviations were used to describe the normally
distributed variables. Medians and ranges were used to describe the
variables with a non-normal distribution. The effects of genetic
syndrome on outcome variables were assessed with the Mann-WhitneyU test. Receiver-operating characteristic (ROC) analysis was
performed to determine the effects of age and weight, and the cutoff
values for the development of complications. The risk factors that
affected the patients’ outcomes were examined with a logistic regression
analysis.