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.