Management of a Residual Ventricular Septal Defect 60 Years after One of the First Surgical Closures Worldwide

Objectives: Surgery for ventricular septal defect (VSD) was one of the first domains in the history of cardiac surgery. Although surgical closure of VSDs remained as the gold standard treatment of those patients, however, they are subjected to clinical deterioration over the following decades. We are presenting here one of the first patients operated upon worldwide. To our knowledge, this is the first case in literature surviving 60 years after surgical VSD closure and presenting again for surgery.

Methods: A 68-year-old male patient presented to our clinic 60 years after surgical closure of a perimembranous VSD at the University Hospital Berlin in 1959. He showed postoperatively a small residual VSD, which was well tolerated over 60 years. His condition began to worsen in the last year, showing signs of right heart failure. The echocardiographic examination showed severe aortic and tricuspid valve regurgitation, moderate mitral valve regurgitation and a 3-mm residual VSD with left-to-right shunt. The right atrium was massively dilated, measuring 10.5 × 7 × 9.5 cm in computerized tomography (CT). The right side cardiac catheterization excluded significant pulmonary hypertension, showing a trivial nonsignificant left-to-right shunt (Qp:Qs <1.5:1). After interdisciplinary discussion, the patient was operated upon. We conducted biological aortic valve replacement, tricuspid valve reconstruction and a primary implantation of a peripheral veno-arterial Extracorporeal Life Support (ECLS) to prevent potential right heart failure. We unloaded the right ventricle using ECLS with a flow between 2 and 3 L/min. The small VSD was left intentionally unclosed to prevent right ventricular volume overload.

The patient was extubated 6 hours postoperatively and the fragile unloaded right ventricle was continuously monitored with transthoracic echocardiography. After six days, the right ventricle recovered completely and the ECLS could be weaned and explanted successfully. The patient could be discharged home 3 weeks postoperatively.

Conclusion: Regular follow-up of patients with surgically closed VSD is mandatory to avoid possible deterioration. In older patients with long standing residual VSD, the primary use of ECLS might be a feasible concept to prevent right heart failure in complex clinical situations.

Publication History

Article published online:
19 February 2021