What is a Ventricular Septal Defect closure procedure ?
A ventricular septal defect is an abnormal opening in the wall (septum) that divides the two lower chambers of the heart (ventricles). A Ventricular septal defect closure is a procedure performed to correct this defect.
What happens on the day of surgery ?
For patients who are hospitalized the night before surgery, an intravenous (IV) catheter may be placed. This will allow intravenous fluids to be given once NPO (nothing by mouth) status begins.
All patients - whether they are admitted to the hospital or not - will be placed on "NPO" (nothing by mouth) status after midnight the night before surgery. Clear liquids may be allowed at the specific instructions of the anesthesiologist.
On the morning of surgery, your family will meet our staff on the 18th floor of the West Tower. You will be greeted by a receptionist and given a private waiting room. Approximately one hour prior to surgery, the patient will be taken to the holding area, dressed in hospital pajamas, and placed in a crib or bed. The anesthesiologist will order some medication to be given that reduces anxiety. This medication is given by mouth or IV, and will allow the patient to relax and become sleepy.
What type of anesthesia will be used ?
Anesthesiologists who specialize in pediatric cardiovascular anesthesia will manage the anesthetic care of the patient throughout the surgery. They collaborate closely with the surgeon and the rest of the OR team to monitor and manage the patient's care in the operating room. Based on their pre-operative assessment, they will individualize the anesthetic to meet each patient's physiologic needs. In most cases, a general anesthetic approach is used which results in the patient being completely unconscious and pain-free during the entire surgery as well as shortly afterward. During the surgery, several specialized neurophysiologic monitors are used to ensure that the anesthesia is effectively maintaining the patient in a fully unconscious and pain-free condition.
What happens during surgery and how is it performed ?
The type of surgery your child will undergo depends on your child's heart defect. Prior to the surgery, the surgeon will have a detailed consultation with the family to explain the specific surgical procedure, discuss risks and benefits, and answer any questions the family may have. Throughout the actual operation, a surgical nurse clinician will update the family approximately every hour during your child's surgery. These updates will be given in the private waiting room assigned by the receptionist.
The following steps are commonly followed in all types of congenital heart surgery : -
Step 1 ) Preparation : -
The anesthesiologist and the operating room nurses will escort the patient into the operating room. A heart monitor will be connected to the patient that will show the OR team a continuous read-out of the heart rate and rhythm throughout the surgery. The patient will be given a mask through which they will breathe a gas that causes them to fall deeply asleep.
Once the patient is asleep, the anesthesiologist will put a breathing tube (endo-tracheal tube or ET tube) into their windpipe. This tube is attached to a breathing machine (ventilator) that will do the breathing for the patient during their surgery. Once the ventilator is secured, the anesthesiologist will place several intravenous (IV) catheters in the patient's veins. The sites typically used are the large vein in the neck or the groin. There may be one or two more IVs placed.
Once the IVs are secured, intravenous fluids and medication are given through them throughout the operation. Another special catheter (arterial line) is placed in an artery (the blood vessel which has a pulse). The arterial line is used to monitor blood pressure during and after surgery. This special catheter is also used to draw samples of blood to obtain various laboratory values. The sites usually used are in the wrist or the groin. A nasogastric (NG) tube is placed in the nose and gently guided down to the stomach. The stomach will continue to produce juices even though there is no food in it. This may cause the patient to become nauseated and vomit. The NG tube will empty the stomach and prevent vomiting.
Another catheter (Foley catheter) is placed in the patient's urinary opening and guided gently to the bladder. This catheter is attached to a device that drains and measures the urine produced during surgery. All of these procedures are performed after the patient is deeply asleep. This whole process may take from one to one and a half hours.
Once all the lines and tubes are in place, a transesophageal echocardiogram (TEE) is performed. A cardiologist will place a probe into the patient's mouth and gently guide the probe down the esophagus. The TEE probe rests behind the heart and provides the surgeon with a continuous picture of the structures of the heart during the operation. When the TEE is completed, it is time for the surgeon to begin the operation.
Step 2) Incision and operation : -
A median sternotomy incision is used for "open-heart" surgery (surgery that occurs inside the heart). This incision usually begins at or below the top of the breastbone (sternal notch) and goes straight down the sternum (breastbone). The breastbone is then separated to expose the heart.
The patient is then placed on the heart-lung bypass machine, a device that provides blood flow to the body and "bypasses" the patient's heart and lungs. Diverting the heart's blood flow to the bypass pump allows the surgeon to open the heart and operate on the structures inside the heart. The heart-lung bypass machine provides continuous oxygenated blood to the other organ systems during the open-heart surgery. Depending on the location of the defect, an incision will be made in either the right atrium, the pulmonary artery, or the outflow tract of the right ventricle (infundibulum).
A patch is created by the surgeon from either the patient's own pericardial tissue or a synthetic material such as Dacron. The patch is then sutured into place to close the defect. The atrial, pulmonary artery or infundibular incision is then closed with sutures, and the remainder of the operation completed as per the procedures described in the overview.
If the patient has no other cardiac defects, this operation is usually considered a "cure," and no further operations should be needed.
Once the surgical procedure is completed, the patient will be weaned gradually off of the heart-lung bypass machine until the newly repaired heart is managing all the blood flow again. Chest tubes will then be placed to drain the surgical area. These tubes are positioned at the base of the incision. There will be 1-3 chest tubes placed for most surgical procedures. Temporary pacing wires are also placed at this time. These are very small wires that are positioned on one or both sides of the incision. These pacing wires may be used temporarily to pace the heart rate and rhythm if needed in the post-operative period.
Intracardiac monitoring lines may be placed depending on the type of surgical repair. These special catheters are placed in the chambers and vessels of the heart to provide the surgeon and the postoperative team with valuable information about the pressures within the heart and lungs. A postoperative TEE will be performed which provides the surgeon with valuable information after the surgical repair. Once the TEE is completed, the surgeon will close the sternum. The sternal bone is brought together, and stainless steel wire secures the sternum.
The type of skin closure the surgeon uses is dependent on age and weight : -
Clear, absorbable skin suture that runs the length of the incision on the inside of the chest. A clear knot is seen at the top and the bottom of the incision. To secure the outside of the incision, adhesive strips (steri-strips) are applied to the surface of the skin along the length of the incision.
Surgical staples (used occasionally in larger patients)
Step 3) Completion and transfer to recovery room
After closure of the incision, a dressing is placed that remains in place for the first 24 hours after surgery. The anesthesiologist and the operating room nurses then secure all the patient's tubes and lines, and prepare for transport from the OR. The patient is moved from the operating room table onto an intensive care bed and transported to the Cardiovascular Intensive Care Unit (CVICU).
What happens after the surgery ?
The patient will be transferred to the Cardiovascular Intensive Care Unit (CVICU) by the cardiovascular anesthesiologist and the team of operating room nurses. The CVICU is situated directly adjacent to the cardiovascular operating rooms to maximize patient safety. This makes the transition from the operating room to the CVICU a smooth process. Once the patient arrives in the CVICU, a thorough report of the surgical procedure is given to the Cardiologist and the CVICU nursing team who will be managing care in the CVICU. The surgeon will update the family on the operation once the patient is settled into the CVICU. Family members may usually visit the patient within an hour after arrival to the CVICU.
While in the CVICU, the patient will continue to be monitored closely. In addition to monitoring heart rate and rhythm, and respiratory rate, the monitor will also display other pressures and waveforms, which assist the cardiologist in managing care. A chest x-ray (CXR) and lab work will be performed on arrival and periodically throughout the stay in the CVICU.
The CVICU is open to visitation 24 hours a day. No more than two visitors are permitted to visit in the CVICU at a time. Children under the age of fourteen years are not allowed on the 18th floor in order to protect the patients and the children from infection. A limited number of rooms are available for sleeping at night, and they are assigned on a first come, first served basis. The receptionist will provide you with the CVICU visiting policy and the process for the use of the sleeping rooms.
The CVICU team will continually assess the patient's comfort level. Medication will be given to reduce any pain or anxiety they may experience after their surgery. These medications are initially given by IV and then gradually changed to medications that can be taken by mouth. Comfort measures provided by the family are encouraged. Talking quietly to the patient is important even if the ETT is still in place (the patient will not be able to speak when the ETT is in place). Hearing your voice usually will assure the patient that you are close by and may make them feel more secure. Other comfort measures such as listening to soft music or helping patients change their position in bed regularly may also decrease their anxiety or pain.
Once the patients are awake enough to breathe on their own, the breathing tube (ETT or endotracheal tube) is removed. Depending on the surgery performed, this may take anywhere from a few hours to a few days following surgery. Once the surgical dressing is removed, the incision will remain open to air. The nurses will cleanse the incision with a Betadine solution twice a day. A small gauze dressing will be placed over the insertion sites of the chest tubes, intracardiac lines, and pacing wires. Gradually the tubes, wires, and intravenous lines will be removed as the patient's condition improves.
When the patient has a stable blood pressure, a stable heart rate and rhythm, and can breath well on their own without the ventilator, they will be transferred to the cardiac inpatient floor, 15 Tower. As the patient improves, their activity level will gradually increase until they are doing well enough to be discharged from the hospital. Before leaving, the family will be instructed in how to care for the patient at home, including information on medications, incisional care, and activity limitations.
How long will we be in the hospital ?
The length of time in the hospital will depend on a variety of factors : -
The type of congenital heart defect, surgical repair and post-operative course
The patient's ability to maintain/gain weight and activity level
The family's understanding and ability to provide for the patient's post-operative needs
In general, patients can expect to stay anywhere from 3-10 days, depending on the above factors. Patients who live greater than an hour's drive from Houston may need to make arrangements to stay in the Houston area until after their 1st post-operative cardiology clinic visit (1 week after discharge).
What are the risks associated with congenital heart surgery ?
Risks associated with congenital heart surgery vary widely accor ding to the specific procedure and the patient's condition at the time of surgery.
They can include : -
Bleeding
Infection
Need for re-operation
Damage to nerves in the chest area
Brain damage
Death
Your surgeon will discuss the specific risks associated with your child's congenital heart surgery at the time of your consult. In our program, the risk of serious complications occurring, such as brain damage or death, is very low. Our surgeons have a very large experience and can provide specific data to you defining the surgical risk for your particular procedure. We believe this important information must be shared with parents to make the process less stressful.
What should we watch out for after surgery ?
Before the patient is discharged from the hospital, your family will be given detailed instructions that are individualized for the specific procedure performed.
However, in general, patients should contact their doctor for any of the following after congenital heart surgery : -
redness, swelling, or oozing/bleeding from incision
fever
altered mental status, excessive fatigue
feeding/eating problems
prolonged or worsening pain
Patients who have had a sternotomy should avoid any activity that causes strain on the chest for at least 6-8 weeks, so that the breastbone can heal. For infants, avoid picking them up by arms ("scoop" them up instead); for older children and adults, avoid activities that involve pulling or pushing with arms as well as contact games/sports.
Transcatheter Closure of Ventricular Septal Defect
Ventricular septal defect (VSD) accounts for approximately 30% of all congenital heart disease. Although many of these defects are small and close spontaneously, the larger defects often persist to cause significant shunt and right ventricular hypertension. Large apical muscular VSDs complicate management decisions, particularly when they occur in association with other congenital cardiac defects.
The results of surgery for apical muscular VSDs are often suboptimal owing to difficulties in defect visualization, residual shunting, and ventricular dysfunction . Since Porstmann et al reported the first transcatheter closure of a patent ductus arteriosus in 1967, several interventional techniques have been developed to treat various intracardiac defects, such as atrial septal defect, patent foramen ovale, fenestrated Fontan, and have yielded promising closure results.
VSD had also been targeted as the defect to close with a device 10 years ago, but their widespread use has been limited by several drawbacks such as large delivery sheaths, inability to recapture and reposition and a very high rate of residual shunts due to that devices used at that time were not originally designed for VSD closure. In recent years, with the advent of new devices and refinement of techniques, a number of reports on percutaneous closure of VSD have been published with encouraging results.
The list of of world class heart hospitals in India is as follows : -
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Patient Storys
Successful heart surgery at We Care India partner hospital allows Robert Clarke to live a normal life despite a rare genetic disorder We Care india helped Robert find best super specialised surgeon for his rare conditions.
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