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• W2344697286 abstract "Central MessagePrecise echocardiographic evaluation is essential for successful closure of intramural ventricular septal defect.See Article page 688. Precise echocardiographic evaluation is essential for successful closure of intramural ventricular septal defect. See Article page 688. Patel et al1Patel J.K. Glatz A.C. Ghosh R.M. Jones S.M. Ravishankar C. Mascio C. et al.Accuracy of transesophageal echocardiography in the identification of postoperative intramural ventricular septal defects.J Thorac Cardiovasc Surg. 2016; 152: 688-695Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar present an interesting article on intraoperative transesophageal echocardiography (TEE) to identify intramural ventricular septal defect (VSD) following the repair of conotruncal anomalies. The article raises a very important issue regarding the sensitivity of a well-established imaging technique to detect a rare, yet potentially life-threatening, complication. Intramural VSD is defined as a tunnel-like communication that may occur when the VSD patch is not sutured to the edge of the VSD proper, but rather to right ventricular (RV) trabeculations, so that blood can flow from the left ventricle around the trabeculations into the RV cavity (Figure 1). Intramural VSD often has multiple exit points through intertrabecular spaces into the RV free wall. Intramural VSD was originally described in children with conotruncal anomalies undergoing subaortic VSD closure.2Preminger T.J. Sanders S.P. van der Velde M.E. Castaneda A.R. Lock J.E. “Intramural” residual interventricular septal defects after repair of conotruncal malformations.Circulation. 1994; 89: 236-242Crossref PubMed Google Scholar It should be emphasized that similar VSDs may occur following closure of any VSD, provided that it is, at least, partially surrounded by trabeculations so that a residual VSD occurs underneath trabeculations with an exit point into the free wall of the RV. VSDs with additional exit points through the free wall of the RV are notoriously difficult to close and can be associated with increased morbidity and mortality.3Patel J.K. Glatz A.C. Ghosh R.M. Jones S.M. Natarajan S. Ravishankar C. Intramural ventricular septal defect is a distinct clinical entity associated with postoperative morbidity in children after repair of conotruncal abnormalities.Circulation. 2015; 132: 1387-1394Crossref Scopus (10) Google Scholar Furthermore, although residual intramural VSD may not appear hemodynamically significant immediately after surgery, the interventricular shunting may increase with regression of RV hypertrophy.2Preminger T.J. Sanders S.P. van der Velde M.E. Castaneda A.R. Lock J.E. “Intramural” residual interventricular septal defects after repair of conotruncal malformations.Circulation. 1994; 89: 236-242Crossref PubMed Google Scholar, 4Yang S.G. Novello R. Nicolson S. Steven J. Gaynor J.W. Spray T.L. et al.Evaluation of ventricular septal defect repair using intraoperative transesophageal echocardiography: frequency and significance of residual defects in infants and children.Echocardiography. 2000; 17: 681-684Crossref PubMed Scopus (47) Google Scholar Given the clinical importance of intramural VSDs, it is essential that surgeons have a high index of suspicion in all cases of contruncal defects where VSD margins are in proximity to trabeculae. The best way to resolve the problem would be to prevent it. Thus, preoperative echocardiography in those children with conotruncal anomalies would alert a surgeon of higher risk of postoperative intramural VSD. Once intramural VSD occurs, it would be extremely helpful to visualize its location intraoperatively. This can be achieved by thorough intraoperative TEE assessment. However, intraoperative TEE is not without flaws. Thus, Patel et al1Patel J.K. Glatz A.C. Ghosh R.M. Jones S.M. Ravishankar C. Mascio C. et al.Accuracy of transesophageal echocardiography in the identification of postoperative intramural ventricular septal defects.J Thorac Cardiovasc Surg. 2016; 152: 688-695Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar excluded 22.7% of patients (105 out of 462) because they did not have adequate imaging. Most importantly, the excluded children were younger and had lower weight. These children also had higher early mortality. It is these patients who would benefit most from intraoperative identification of intramural VSD. Unfortunately, performance of TEE in detecting intramural VSD—and even peripatch VSD—in older children was not perfect either. It was described by the authors as modest, with sensitivities of 56% for intramural VSD, which was not much different from that of 63% for peripatch VSD.1Patel J.K. Glatz A.C. Ghosh R.M. Jones S.M. Ravishankar C. Mascio C. et al.Accuracy of transesophageal echocardiography in the identification of postoperative intramural ventricular septal defects.J Thorac Cardiovasc Surg. 2016; 152: 688-695Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Moreover, patients with correct identification of intramural VSD made by TEE were more likely to be older than age 30 days and have higher body weight at operation. Thus, again, smaller children were disadvantaged. In nearly half of the children with missed intramural VSD, a subsequent transthoracic echocardiogram demonstrated residual intramural VSD > 2 mm. Is there a better alternative to TEE intraoperatively? Epicardial echocardiography is sensitive for the detection of residual VSDs.5Muhiudeen I.A. Roberson D.A. Silverman N.H. Haas G. Turley K. Cahalan M.K. Intraoperative echocardiography in infants and children with congential cardiac shunt lesions lesions: transesophageal versus epicardial echocardiography.J Am Col Cardiol. 1990; 16: 1687-1695Abstract Full Text PDF PubMed Scopus (87) Google Scholar, 6Dragulescu A. Golding F. Van Arsdell G. Caldarone C. Mertens L. Al-Radi O. et al.The impact of additional epicardial imaging to transoesphageal echocardiography on intraoperative detection of residual lesions in congenital heart surgery.J Thorac Cardiovasc Surg. 2012; 143: 361-367Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar At the Royal Children's Hospital in Melbourne, surgeons routinely perform epicardial echocardiograms on children with conotruncal anomalies after VSD closure, particularly in those with trabeculations obscuring the edge of the VSD and those with multiple VSDs.7Brizard C.P. Olsson C. Wilkinson J.L. New approach to multiple ventricular septal defect closure with intra-operative echocardiography and double patches sandwiching the septum.J Thorac Cardiovasc Surg. 2004; 128: 684-692Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar In our experience epicardial echocardiograms give superb imaging quality and are perfect for assessment of residual VSDs. This is of particular importance in small children. Clearly, a randomized controlled trial between TEE and epicardial echocardiography will not be feasible in neonates and smaller children. A surgeon with immediate knowledge of intraoperative anatomy is ideally suited to perform epicardial echocardiograms. The importance of proficient acquisition of high-quality epicardial echocardiographic imaging by cardiac surgeons during neonatal surgery cannot be overemphasized. Once the residual VSD is identified, the shunt is quantified by intraoperative assessment of Qp:Qs. Even if the residual VSD appears small on imaging, it is worth determining Qp:Qs to avoid any postoperative surprises. Once a significant intramural VSD is identified, it should be closed, because simple pulmonary artery banding may not be a safe option in the presence of large residual VSD and would likely put a child on a rocky postoperative course.8Alsoufi B. Karamlou T. Osaki M. Badiwala M.V. Ching C.C. Dipchand A. et al.Surgical repair of multiple muscular ventricular septal defects: the role of re-endocardialization strategy.J Thorac Cardiovasc Surg. 2006; 132: 1072-1080Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar If the large residual VSD is not closed, the echocardiogram, albeit with modest sensitivity, may simply document a very sensitive surgical failure. For successful closure, one must close the entry point into the VSD because the outlets can be multiple. In the transatrial approach, a VSD patch should be at least partially removed, the edges of the VSD reassessed, and adjacent trabeculations resected if necessary so that the entry point into the VSD can be closed. Any attempt to close the often multiple exit points from this approach would be notoriously imprecise, and would likely fail. Suturing trabeculations together8Alsoufi B. Karamlou T. Osaki M. Badiwala M.V. Ching C.C. Dipchand A. et al.Surgical repair of multiple muscular ventricular septal defects: the role of re-endocardialization strategy.J Thorac Cardiovasc Surg. 2006; 132: 1072-1080Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar may open yet another exit point. To overcome the above problem, a transaortic approach has been proposed for classical intramural VSD,9Belli E. Houyel L. Serraf A. Lacour-Gayet F. Petit J. Planché C. Transaortic closure of residual intramural ventricular septal defect.Ann Thorac Surg. 2000; 69: 1496-1498Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar so that the entry point is closed through the aortic valve. This approach is not foolproof because the entry point into the intramural tunnel may not be easy to visualize. For defects in the apical region of the septum a small incision in the apex of either ventricle may be performed, allowing the VSD to be closed from the left ventricular side. Whereas this approach provides excellent visualization of the VSD, an incision in the left ventricular apex is more likely to cause ventricular dysfunction.10Kitagawa T. Durham III, L.A. Mosca R.S. Bove E.L. Techniques and results in the management of multiple ventricular septal defects.J Thorac Cardiovasc Surg. 1998; 115: 848-856Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar Thus, we prefer to open the right ventricle to avoid risk of left ventricle dysfunction and aneurysm formation. Regardless of the approach, precise echocardiographic guidance would dramatically facilitate surgery. Praemonitus praemunitus! After all, failure to close intramural VSD occurs when surgeons do not realize how close they were to success when they gave up. Accuracy of transesophageal echocardiography in the identification of postoperative intramural ventricular septal defectsThe Journal of Thoracic and Cardiovascular SurgeryVol. 152Issue 3PreviewIntramural ventricular septal defects (VSDs), residual interventricular communications occurring after repair of conotruncal defects, are associated with poor postoperative outcomes. The ability of intraoperative transesophageal echocardiography (TEE) to identify intramural VSDs has not yet been evaluated. Full-Text PDF Open Archive" @default.
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• W2344697286 title "Intramural ventricular septal defect after repair of conotruncal anomalies: Is there light at the end of the tunnel?" @default.
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