ORIGINAL ARTICLE

Double Flap Patch Closure of VSD with Elevated Pulmonary

Vascular Resistance: an Experience at AFIC/NIHD
Asif Mahmood Janjua, Kamal Saleem, Inamullah Khan, Azhar Rashid, Asif Ali Khan and Abid Hussain

ABSTRACT
Objective: To determine the 30 days outcome measured in terms of morbidity and mortality in cases of ventricular septal
defect (VSD) with increased pulmonary vascular resistance (PVR) managed with double flap patch closure.
Study Design: Case series.
Place and Duration of Study: Armed Forces Institute of Cardiology (AFIC/NIHD), Rawalpindi, from December 2005 to
December 2008.
Methodology: Forty patients with VSD having PVR 9.58 + 4.33 wood units underwent double flap patch closure. The
patch was fenestrated as one half of the expected aortic annulus diameter. A separate flap patch 5 mm larger than
fenestration was attached to superior upper one third margins of fenestration. The patch was placed with flap to open
towards the left ventricular apex. Modified ultra filtration (MUF) was employed in every case and sildenafil was given
postoperatively.
Results: The age of patients ranged from 1 to 28 years with a mean of 6.66 + 5.70 years. There were 22 males and 18
females. All patients were weaned off from inotropic and ventilatory support as earlier as possible postoperatively with
intensive care unit (ICU) stay of 77.15 + 54.56 hours. Postoperative pulmonary artery pressures were reduced to
42.63 + 10.86 mmHg as compared to pre-operative pulmonary artery pressures of 88.3 + 15.2 mmHg. Postoperatively 11
patients with suprasystemic pulmonary artery pressures and desaturation went into pulmonary hypertensive crisis in which
immediate 2D echo evidenced the functioning flap valve with right to left shunt. There was only one death (early) out of 40
patients with an overall mortality of 2.5% along with limited morbidity.
Conclusion: Double flap patch is an inexpensive, easy to construct technique with low morbidity and mortality in cases of
VSD with raised PVR.

Key words: Ventricular septal defect (VSD). Pulmonary vascular resistance (PVR). Double flap patch.

INTRODUCTION increased morbidity and mortality range from 22.7 to

Ventricular septal defect (VSD) is the commonest 50% is due to the pulmonary hypertensive crisis, acute
congenital heart disease repaired surgically.1,2 Large congestive heart failure and acute respiratory failure.6-11
VSD with left to right shunt gradually results in increased Nitric oxide (NO) and circulatory assist devices (extra
pulmonary vascular resistance (PVR) as the age corporeal membrane oxygenation - ECMO) are the
progresses. PVR of more than 8 wood units had been methods to deal with the problem of pulmonary
considered inoperable and VSD closure at this stage hypertensive episode. But no withdrawl can lead to
may be very hazardous and is associated with high rebound pulmonary hypertension while circulatory assist
mortality and morbidity. devices are costly for the developing countries like
Closure of VSD should be performed at an early age Pakistan.12,13 Gene transfer therapy and elastase
before the progression of PVR for optimal results.3 In inhibitors are still under trial.14
cases of adult VSDs with low PVR the results of surgical Since December 2005, this institute is advancing its
outcome are satisfactory.4 In Pakistan the patients paediatric cardiac surgical programme in collaboration
present late with this problem of increased PVR which is with International Children Heart Foundation (ICHF).
very commonly encountered in clinical practice. Post The technique of double flap patch closure of VSD with
operative prognosis depends upon the age and PVR at elevated pulmonary vascular resistance was introduced
presentation and pulmonary hypertensive episodes is by the chief surgeon of the organization. The technique
the major cause of morbidity and mortality.5 The has proved beneficial in reduction of morbidity and
mortality.15 During periods of postoperative pulmonary
Department of Cardiac Surgery, Armed Forces Institute of hypertensive crisis, the unidirectional double flap valve
Cardiology, National Institute of Heart Diseases, Rawalpindi.
act as a pop up for right ventricle resulting in right to left
Correspondence: Maj. Dr. Asif Mahmood Janjua, House No. 181, ventricular shunt thus maintaining cardiac output at the
Street No. 4, Askari-11, Rawalpindi. expense of oxygen saturation, thereby reducing the risk
E-mail: a.mjanjua@yahoo.com of early postoperative death. When pulmonary artery
Received April 19, 2010; accepted March 08, 2011. pressure gradually falls postoperatively and pressure

Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (4): 197-201 197
Asif Mahmood Janjua, Kamal Saleem, Inamullah Khan, Azhar Rashid, Asif Ali Khan and Abid Hussain

gradients between the right and left sides of the

circulation normalize, the valve closes and prevents a
significant left to right shunt.16 It acts as a safety
mechanism at the time of pulmonary hypertensive crisis.
The study was carried out to determine the early (thirty
days) morbidity and mortality in cases of VSD with
raised PVR managed with double flap closure.

METHODOLOGY
From December 2005 to December 2008, 40 patients
having VSD with increased PVR underwent VSD
Figure 1: Illustration of double flap patch in profile with open valve.
closure with double flap patch. Patients having VSD with
PVR more than 6 wood units were included in this study
In the ICU, patients were allowed to be extubated earlier.
with reversible PVR and the criteria for reversibility was
Inotropic agents and intravenous vasodilators were
post- oxygen reduction in PVR. Cases included solitary
discontinued according to clinical status. Inotropic
VSDs and VSDs along with other associated anomalies
support duration was recorded. Sildenafil first dose was
which were managed in the same sitting as well. Cases
given in OT at the time of induction through NG tube
of VSD operated by simple patch closure were excluded
(0.5 mg/kg with max upto 3 mg/kg). Its dose was
from this study. After clinical assessment all patients
increased in cases of PAP > 50% of systemic pressures.
were subjected to laboratory biochemical investigations
Serial PA pressures were measured in ICU through
along with chest radiography, electrocardiography, two
transvenous PA line and findings were recorded till the
dimensional doppler echocardiography and cardiac
patient was shifted from the ICU. Postoperative lowest
catheterization before surgery.
saturation was noticed in correlation to pulmonary artery
Routine cardiopulmonary bypass (CPB) with moderate pressure for determining shunting.
hypothermia was employed for all cases. Cold cardio- Statistical analysis was performed using SPSS version
plegic arrest with blood based cardioplegia was used in 12.0. All data were expressed as mean + standard
every case. The double flap patch VSD closure was deviation, frequency and percentages.
constructed of Sauvage Dacron (C.R.Bard, Murray Hill,
New Jersey) or Gore-Tex (W.L.Gore and associates, RESULTS
Newark, Delaware) depending upon the surgeon
Total number of patients were 40 in which there were 22
preference.
(55%) males and 18 (45%) were females. The age
The VSD patch was tailored according to the size of the ranged from 1 to 28 years (mean = 6.66 + 5.70 years)
defect and fenestrated half the size of expected aortic and weight ranged from 7 to 55 kg (mean = 19.85 + 9.27 kg).
root diameter. A separate flap patch 5 mm, larger than The diagnostic spectrum of anomalies and pre-operative
the fenestration was sewn onto the superior margin of variables are described in Table I and II respectively. All
the fenestration along one third of the circumference. A patients were weaned off from ventilatory support in the
separate tethering stitch was placed at the inferior apex early postoperative period with mean of 8.61 + 11.18
of the flap valve and tied loosely over a Hegar dilator that hours and mean ICU stay of 77.15 + 54.56 hours. As
was of the same size as the fenestration. Thus, the compared to pre-operative pulmonary artery pressures
tethering stitch length approximated the diameter of the 88.3 + 15.2 mmHg a marked reduction was noticed in
fenestration. The VSD patch was then sewn into place pulmonary artery pressures at post-bypass, at 6 hours
orienting the patch so that the flap valve was placed on and 24 hours in ICU (Table III).
the left ventricular (LV) side and directing the flap so that All patients were weaned off from inotropic supports
it would open toward the LV apex. Patch was sewn within 33.14 + 30.75 hours. Only one patient died out of
with continuous or interrupted polypropylene suture 40 patients in early postoperative period with a mortality
(Figure 1). No patient was left with an atrial level of 2.5%. He did not have a marked fall in PA pressures
communication. Cardiac support medications and inspite of good functioning of double flap patch on
vasodilators were started according to the requirements echocardiographic evaluation.
before weaning from CPB. All patients were weaned The morbidity in early postoperative period was
from CPB successfully and modified ultrafiltration (MUF) dysrhythmias in 5 (12.5 %) cases that were treated with
was employed in every case. Tansvenous pulmonary epicardial pacing and antiarhythmic pharmacological
catheter was passed through internal jugular vein in all agents, 2 (5 %) cases had pleural effusion managed
cases at the time of induction to monitor postoperative with chest intubation and 2 (5 %) had bleeding from the
pulmonary artery pressures. All the patients were periosteum of sternum who underwent reopening to
shifted to ICU. secure haemostasis.

198 Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (4): 197-201
Double flap patch closure of VSD with elevated pulmonary vascular resistance: an experience at AFIC/NIHD

Table I: The spectrum of cardiovascular anomalies. its own advantages and disadvantages. The VSD closure
Diseases Cases necessitates adequate sizing and shape of the patch.17
Solitary ventricular septal defect 30 (75%)
Charles P. Bailey applied flap-valves made of a
VSD + ASD 03 (7.5%)
compressed ring of polyvinyl sponge in 8 patients with
VSD + Patent ductus arteriosus 02 (5%)
atrial and ventricular septal defects in whom the
VSD + Supra mitral membrane 01 (2.5%)
Multiple VSD 01 (2.5%)
conventional closure appeared too risky because of
VSD + Sub aortic membrane 01 (2.5%)
severe pulmonary hypertension. Seven of the 8 patients
VSD + DORV 01 (2.5%) survived.18
VSD + Hypoplastic arch 01 (2.5%) Interatrial communication has been left in the form of
Total 40 patent foraman ovale (PFO) or made in cases of VSD
ASD = Atrial septal defect; DORV = Double outlet right ventricle.
with raised PVR. In the study by Inamullah et al. 16
patients had VSD as the primary lesion that underwent
Table II: Pre-operative haemodynamic data.
closure of large VSD with elevated PVR leaving PFO or
Variables Mean Std. deviation
Aortic systolic pressure (mmHg) 65.43 + 11.74
artificial ASD, with acceptable mortality and morbidity.
PA systolic pressure (mmHg) 57.31 + 12.47
The overall early mortality was 6.25% (1/16) and there
PAP / AOP (mmHg) 88.3 + 15.2 were no late deaths.19
Oxygen saturation (%) 91.53 + 5.84 A one-way, valved, atrial septal patch to serve as an
PVR (air) wood units 9.79 + 3.50 artificial one-way foramen ovale has been tested. By
PVR (oxygen) wood units 6.81 + 2.48
permitting right-to-left shunt, this device decompresses
PAP = Pulmonary artery pressure. AOP = Aortic pressure. PVR = Pulmonary vascular resistance.
the failing right ventricle and maintains systemic cardiac
output. This patch provides the same hemodynamic
Table III: Post-operative change in variables.
benefits as an ASD, together with the added advantages
Variable Mean Std. deviation
Aortic cross clamp time (min) 52.03 + 25.59
of a controlled opening pressure and the ability to close,
Cardiopulmonary bypass (min) 85.82 + 32.07
without the need for a subsequent invasive procedure.20
PAP/AOP post bypass (mmHg) 66.75 + 13.47 Zhou et al. described the closure of VSD with severe
PAP/AOP at 6hrs in ICU (mmHg) 54.75 + 9.93 pulmonary hypertension by using unidirectional valved
PAP/AOP at 24 hours in ICU (mmHg) 42.63 + 10.86 patches (UVP). Total 4 out of 24 patients (16.66%) died
Time to extubation (hours) 8.61 + 11.18
in early postoperative period.21
ICU stay (hours) 77.15 + 54.56
Inotropic duration (hours) 33.14 + 30.75 The first modification was by Novick et al., who used UVP
from sovage dacron. The weight of the child was used to
Postoperatively 11 (27.5%) patients went into pulmonary decide the size of fenestration. Out of the 18 patients
hypertensive crisis having suprasystemic pulmonary there were no early deaths and only one late death
artery pressures with low oxygen saturation in occurred.15 Later on Novick et al. used a modified
correlation to these raised pulmonary artery pressures technique with a fenestration size of half of the expected
depicting right to left ventricular shunt (pop off aortic annulus diameter for each patient. There were 7
phenomenon) confirmed by 2D echocardiography. early deaths and 7 late deaths. Postoperative echocardio-
Those patients were kept on ventilatory support along graphy studies revealed persistent pulmonary arterial
with sedation and muscle relaxation in addition to 100% hypertension (PAH) in 25 patients.22 The same
oxygen inhalation, keeping PCO2 < 35 mmHg and technique was practiced in this study in which only one
hematocrit > 0.30. Injection milrinon (0.7-1 µgm/kg) and early postoperative death was observed.
tablet sildenafil (upto 2 mg/kg/6 hours) were adjusted
accordingly. Oxygen inhalation continued for 10 days Zhang et al., used the aortic homograft along with the
even after shifting from ICU. attached mitral leaflet for the UVP construction. They
have 2 early deaths due to raised PAH out of 27 patients
After discharge from the hospital, follow-up consisted of
(7.40%).23
clinical examination and monitoring of PA pressure by
echocardiography. Thirty six (90 %) patients reported for Talwar et al., experienced modified UVP technique for
follow-up at 4 weeks with marked improvement clinically VSD closure by using a patch of knitted polyester fabric.
and on echocardiography. Long-term survival requires Out of 21 patients no early or late deaths were noticed.24
continued observation of these patients to determine Afrasiabi used a Gore-Tex patch with a 5-8 mm
any progressive pulmonary hypertension. longitudinal slit in the center in cases of VSD with raised
PVR. A piece of pericardium was sewn around the slit
DISCUSSION on one side of the patch, except for the upper quarter
Many techniques exists for the management of VSD and defect closure was done in such a manner that the
with elevated pulmonary vascular resistance. Each has pericardial aspect was placed on the left ventricular side

Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (4): 197-201 199
Asif Mahmood Janjua, Kamal Saleem, Inamullah Khan, Azhar Rashid, Asif Ali Khan and Abid Hussain

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