• No results found

REPAIR OF VENTRICULAR SEPTAL DEFECT IN INFANCY

N/A
N/A
Protected

Academic year: 2020

Share "REPAIR OF VENTRICULAR SEPTAL DEFECT IN INFANCY"

Copied!
8
0
0

Loading.... (view fulltext now)

Full text

(1)

REPAIR

OF

VENTRICULAR

SEPTAL

DEFECT

IN INFANCY

961

John W. Kirklin, M.D., and James W. DuShane, M.D.

Sections of Surgery (J.K.) and Pediatrics (J.D.), Mayo Clinic and Mayo Foundation

E

ABLY in the experience with open

intra-cardiac surgery at the Mayo Clinic the

hospital mortality was high following

surgi-cal treatment of ventricular septal defect in

infants. In the last 2 years the mortality has

been markedly reduced. Therefore, it is at

present the policy in this institution to

operate upon sick, small babies with yen-tricular septal defect when it is thought that

they will fail to thrive or not survive until

the age of 3 to 4 years.

This paper presents the details of this

cx-perience. Factors important in securing high survival rates are emphasized.

MATERIAL

All 65 infants, 2 years of age or less,

operated upon by one of us for repair of

ventricular septal defect prior to October

1, 1960, are included in this study. Those

patients operated upon between April 1,

1955, and April 1, 1960, are also described

in less detail in a previous paper1 on the

surgical treatment of ventricular septal

de-feet in general during that period.

The patients operated upon constitute

ap-proximately 20% of all infants with

ventricu-tar septal defect seen at the Mayo Clinic

during this period. Operation in infancy was

considered indicated only when the infant

was in intractable or recurrent congestive

heart failure or when it was thought that

the baby would show severe failure of

growth. A few of the infants in the second

year of life were operated upon at this early

age because of the severity of their

pul-monary hypertension and the fear that

severe elevation of pulmonary vascular

re-sistance might otherwise develop.

Nearly all infants 1 year of age or less

were critically ill, with either intractable

or oft-repeated congestive heart failure

(Fig. 1). The degree of pulmonary

hyper-ADDRESS: Mayo Clinic, Rochester, Minnesota.

tension is indicated in Table I. Patients were

categorized as having mild pulmonary

hypertension when pulmonary-artery

sys-tolic pressure was 45% or less of

systemic-artery systolic pressure, moderate

pul-monary hypertension when it was between

45% and 75% of systemic-artery pressure, and

severe pulmonary hypertension when it was

75% or more of systemic-artery pressure

(Fig. 2). With one exception the patients

with mild pulmonary hypertension were

nearly 2 years of age and were operated

upon because of the cardiomegaly that was

present in spite of the mildness of the

dc-vation of pressure in the pulmonary artery.

METHODS AND SURGICAL TECHNIQUE

The technique employed in these infants

was in all ways similar to that used for older

patients and has recenfly been described in

detail.1 A Gibbon-Mayo pump-oxygenator

of the stationary vertical-film

type

was

em-ployed. The rate of blood flow was about

2.4

lit/min/m2. For the most part,

tempera-ture was maintained at 37#{176}Cby the use of a

Brown-Emmons heat exchanger.2 In a few

cases hypothermic perfusions were

em-ployed. In the last 2 years halothane

(

Fluothane) has been used as the anesthetic

agent.

A

median sternotomy incision has

TABLE I

DISTRIBUTION OF PATIENTS BY AGE AND DEGREE OF PULMONARY HYPERTENSION

Age

(tao)

Pulmonary-Artery

Hypertension Total Patients Mild MOderate Severe

-1

18-4

1 10 S

6* 7 18

84 81

aOne patient had pulmonic stenosis and severe right

ventricular systolic hypertension.

(2)

FIG. 2. Roentgenogram of 1 1-month-old infant with in-tractable heart failure and severe pulmonary hypertension.

This child survived operation and remained well.

E?IG. 1. Preoperative roentgenogram of 6-month-old infant operated upon in 1958. In addition to striking cardiac

en-largement, there are partial atelectasis of the left lung and pneumonitis in the right upper lobe. This patient died 12 (lays after operation because of continuing bilateral

pneumonitis.

been uniformly employed since October,

1958. Cardiac asystole has been regularly

used since August, 1956, and for the last 2

years this has been induced by simple ischemia.

Although in the early years a number of

techniques with and without a prosthesis were employed for repair of ventricular

(3)

Years

Patients -13 Months Old Patients 13-4 Months Old All Patients

Total Hospital Deaths No.

%

Total Hospital Deaths No. % Total Hospital Deaths

-No. % 1955 1956 1957 1958 1959 1960t 6 7 0 10 8 S 4 5 4 1 0 67 72 18 0 2 5 7 7 10 0 1 .50 S 60 0 0 2 29 0 0

* In this table and in the text the period designated by a year extends from April 1 of that year to April 1 of

the following year.

t April to October.

S 12 7 17 18 S 5 S 0 6 1 0 68 67 0 3.5 6 0 TABLE II

HOSPITAL MORTALITY AFrER REPAIR OF VENTRICULAR SEPTAL DEFECT

the bundle of His and yet to produce

com-plete and permanent repair.1

Postoperative management has been by

the methods generally used in this

institu-tion following open intracardiac

opera-tions.3

Hospital Mortality

RESULTS

The hospital mortality is indicated in

Table II. Total hospital mortality among

infants was high in 1955 and 1956, and for

this reason in the year 1957 no infants less

than 1 year of age were operated upon.

However, in that year seven patients

be-tween the ages of 1 and 2 years were

oper-ated upon without a death; for the same age

group the mortality had been 50% in 1955

and 60% in 1956.

The hospital mortality in the year 1959

and so far in 1960 has been 5%, there

hay-ing been one death among 21 infants

op-crated upon. This death occurred among the

11 infants less than 1 year of age.

Causes of Death (Table Ill)

In the years 1955 and 1956 most deaths

were from syndromes that are now

con-sidered to be the result of imperfect

per-fusion.

It

is the near absence of these corn-plications in the years 1958, 1959 and 1960

that has allowed a significant reduction in

hospital mortality in these patients.

Incomplete repair of a ventricular septal

defect and complete heart block each

con-tributed to a death. These are the result of

imperfect surgical technique. Their

occur-rence has been minimized in the last 2 years

by the adoption of direct suture done in a

specffic way as previously described.1

Two deaths were related to low cardiac

output in the early postoperative period,

which was inadequately managed. It is

be-lieved that proper management might have

saved these patients. In addition, three

deaths followed severe and progressing

tachycardia in the first 6 to 12 hours after

operation. These patients likewise by

pres-ent standards were inadequately managed.

The two patients dying from late chronic pulmonary complications died on the tenth

and twelfth postoperative days. Both of

these infants had had severe and repeated

respiratory infections prior to operation, and

these infections continued into the

post-operative period and ultimately caused

death.

COMMENT

The concepts and techniques for open

intracardiac operations in the small infant

are identical with those employed in larger

patients. Deviations from ideal therapy,

while often tolerated by large patients, in

the infant usually result in death. All

(4)

Group 1955 1956 1957 1958 1959

1960

(Apr.-Oct.)

Considered to be the result of perfusion Acute early pulmonary complications

Unexpected sudden death Respiratory failure (apnea)

2 S 2 3 2 .. .. .. .

.

I .. .. .. ..

Inadequate surgical procedures or improper postoperative care

Incomplete repair of ventricular septal defect

Low cardiac output, poorly treated

It

1 1

Disturbances of rhythm Complete heart block

Severe tachycardia early postoperatively

It 1

Other

Late, chronic pulmonary complications 2

* Operation done with profound hypothermia and circulatory arrest.

t Additional cause.

§One patient had resistant staphylococcal pneumonia and intractable heart failure preoperatively. Pneumonia

persisted, causing death on twelfth postoperative day. The other patient had recurrent pneumonia preoperatively.

TABLE III

CAUSES OF DEATH FOLLOWING REPAIR OF VENTRICULAR SEPTAL DEFECT

postoperative management must therefore

be more nearly perfect to ensure a high rate of survival in infants.

Considerable can be done in preparing

these infants for the operative procedure.

If possible the operation should be done

at a time when respiratory infections are

at a minimum. It is nearly always necessary

to achieve optimal digitalization and to

maintain it up to the time of operation. At

times, however, the cardiac failure and

pul-monary problems are refractory to therapy

and operation must be proceeded with in

spite of these (Fig. 3).

The management of the infant in the

operating room must be precise. The use of

an inhalation agent, halothane, has seemed

ideal for maintenance of anesthesia. The

patient is awake and breathing well

im-mediately after operation. Median

ster-notomy incision allows the operative

pro-cedure to be done with minimal mechanical

interference with ventilation in the

post-operative period. A totally adequate

whole-body perfusion seems essential in these sick,

small babies. The arterial cannula should be

placed in the common iliac artery rather

than in the external iliac or femoral artery

in order that high flow rates can be

main-tamed without a severe pressure gradient

across the cannula. Particular care must be

taken in the positioning of the venous

cannulas lest they become kinked or

ob-struct the delicate hepatic or innominate

veins. The sick, small heart must be handled

gently, and this is greatly facilitated by the

use of cardiac asystole. There continues to

be little if any clinical evidence that cardiac

asystole induced by ischemia is deleterious

to these patients. A small right

ventricu-lotomy produces minimal reduction of

cardiac output in the postoperative period.

Accurate visualization of the defect and its

complete and accurate repair without the

production of heart block offer the infant

the most favorable circumstances for

sur-vival.

Extremely close attention to the infant in

the early hours after operation is

manda-tory.

If

progressing tachycardia develops,

prompt use of digitalis to control it is

(5)

FIG. 3. Left) Preoperative roentgenogram of 9-month-old infant with intractable cardiac failure and persistent severe atelectasis of the left lung. It was necessary to proceed with operation in the face of this severe atelectasis. Right) Six months after operation. The heart has returned to its proper position

with re-expansion of the left lung. There is emphysema of this lung.

965

monitoring the electrocardiogram as small

doses of digitalis are injected intravenously until the desired effect is obtained.

Tracheotomy has been employed in none

of these patients treated in the last 3 years,

save in one infant who died 12 days after

operation of continuing chronic pulmonary infection. On about the tenth postoperative day, tracheotomy was done in this patient in

the hope that it would permit better

aspira-tion of the tracheobronchial tree.

The late results in infants operated upon

are excellent. Without exception the

pa-tients have been relieved of cardiac failure,

respiratory infections have cleared, and

gain in weight has been striking. The in-fants appear to be cured when seen 6 to 12 months after operation.

In view of these surgical results,

com-ment is indicated upon the fate of surgically

untreated infants. Those with large

yen-tricular septal defects frequently thrive in

the neonatal period but develop cardiac

failure at about the age of 2 to 3 months.

This course of events is presumably related

to pulmonary vascular resistance present in

the fetus and the normal involution of these

fetal characteristics in the small pulmonary

arteries with consequent reduced

pulmo-nary vascular resistance and increased

pul-monary blood flow. Untreated, such infants

may die as a result of pulmonary

conges-tion alone or in combination with

super-imposed pulmonary 5 The

mor-tality has been estimated to approach 50 to

60%. With vigorous medical measures to

combat cardiac failure, a substantial

num-her of such infants develop a favorable

balance between the abnormal

hemody-namics associated with the large

ventricu-lar septal defect and the ability of the heart

to adjust to these events. This favorable

response may result in resumption of weight gain and general good health. On the other hand the response may be minimal,

allow-ing survival of the infant but with failure to thrive and increased susceptibility to the

hazards of intercurrent pulmonary

infec-tions. In this latter group of infants the

mortality may approach 15 to 25%. Of equal

importance as to the ultimate prognosis is

the fact that gain in weight is slow, and

frequently such babies weigh only 14 or 15

lb (6,350 to 6,800 gm) at the age of 2 years.

Also, some are prone to develop high

(6)

SEPTAL DEFECT

in life with reduced pulmonary blood flow,

a situation producing an unfavorable

hemo-dynamic response to surgical closure of the

ventricular septal defect.

It is difficult to predict whether an

mdi-vidual infant first seen in cardiac failure

will respond promptly and satisfactorily to

medical treatment or will follow the

in-dolent course described above. Therefore,

an intensive medical regimen should be in-stituted. If the child thrives, surgical treat-ment is postponed until about 4 years of

age. If the infant does poorly after a fair

trial of an anticardiac-failure regimen,

prompt surgical treatment is recommended.

SUMMARY

Data on 65 infants treated surgically for

ventricular septal defect by open

intra-cardiac repair are presented, and important

features of the preoperative, operative and

postoperative care are discussed. The low

hospital mortality following surgical repair

during a 2-year period and the excellent

results support the present policy of

recom-mending operation

.

for infants who fail to

thrive under medical management.

REFERENCES

1. Kirklin, J. W., McCoon, D. C., and DuShane,

J. W. : Surgical treatment of ventricular septal

defect. J. Thor. Surg., 40:763, 1960. 2. Brown, I. W., Jr., Smith, W. W., and Emmons,

W. 0. : An efficient blood heat exchanger for

use with extracorporeal circulation. Surgery, 44:372, 1958.

3. Lyons, W. S., DuShane,

J.

W., and Kirklin,

J.

W. : Postoperative care after whole-body perfusion and open intracardiac operations: use of Mayo-Gibbon pump-oxygenator and Brown-Emmons heat exchanger. J.A.M.A., 173:625, 1960.

4. Dawson, B., Theye, R. A., and Kirklin, J. W.: Halothane in open cardiac operations : A

tech-nic for use with extracorporeal circulation.

Anesth. & Analg., 39:59, 1960.

5. Morgan, B. C., Grifliths, S. P., and Blumenthal, S.: Ventricular septal defect: I. Congestive

heart failure in infancy. Pviwrmcs, 25:54,

(7)

1961;27;961

Pediatrics

John W. Kirklin and James W. DuShane

REPAIR OF VENTRICULAR SEPTAL DEFECT IN INFANCY

Services

Updated Information &

http://pediatrics.aappublications.org/content/27/6/961

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

(8)

1961;27;961

Pediatrics

John W. Kirklin and James W. DuShane

REPAIR OF VENTRICULAR SEPTAL DEFECT IN INFANCY

http://pediatrics.aappublications.org/content/27/6/961

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

References

Related documents

In this section, we introduce notions of lacunary statistical convergence and lacunary summable in fuzzy normed linear spaces and we give some results.. The set of all

Classifications and key words: article 6 ECHR; article 47 Charter; article 41 Charter; fundamental rights as a general principle of EU law; public enforcement;

Financial Accounting teachers and students did not different significantly on their responses on the extent to which Information Technology is utilized in teaching

summarizes the development concerning the syntheses and structural aspects of neutral and cationic organonickel and palladium(2-phosphanyl)phenol(ate) complexes and

The assessment of digestive enzymes activity of gastric (pepsin), pancreatic (trypsin, chymotrypsin, α-amylase and lipase) and intestinal (alkaline phosphatase) revealed

In this study, we present the sorption kinetic experimental data and their interpretation in terms of diffusion rate of water molecules and mass of water absorbed in different

infinity, then we can use the asymptotic expansions of the Hankel function for large values of the argument. This expression completely coincides with the expressions obtained [18]