Early and Late Results of Closure

Transcription

1 Early and Late Results of Closure of Ventricular Sepal Defect in Infancy Joachim G. Rein, M.D., Michael D. Freed, M.D., William I. Norwood, M.D., and Aldo R. Castaneda, M.D. ABSTRACT Fifty infants ranging in age from 13 days to 18 months (mean age 6 months) and weighing from 1.7 to 8.2 kg (mean weight 4.5 kg) underwent patch closure of a ventricular septal defect (VSD) with use of deep hypothermic circulatory arrest. Seventeen infants were under 3 months of age. The principal indication for operation was intractable chronic congestive heart failure. All infants were below the third percentile for weight preoperatively. Three patients (6%) died postoperatively within the second month of life. There was no late mortality. Seven infants (14%) had seizures; these were associated with a low output state in 2 infants, with hypoxic episodes in 4 infants, and occurred postoperatively in 1 infant. Postoperatively, 8 (17%) of the surviving infants developed right bundle-branch block and left anterior hemiblock, and 16 (32%) developed right bundle-branch block alone. One year postoperatively, catheterization studies in 24 children revealed normal pulmonary artery pressure and pulmonary vascular resistance in all; there were no significant residual ventricular septal defects. Because of these results we continue to be enthusiastic about primary closure of VSD irrespective of age or weight. Of 428 critically ill infants with ventricular septal defect (VSD) studied over a seven-year period in New England as part of the Regional Infant Cardiac Program, 130 (30%) required operation within the first year of life because of intractable From the Departments of Cardiovascular Surgery and Cardiology, The Children s Hospital Medical Center, and Departments of Surgery and Pediatrics, Harvard Medical School, Boston, MA. Supportedinpart by Project Grant No. 260 from the Maternal and Child Health Service, Health Service and Mental Fealth Administration, US Public Health Service, and by Grants No. HL and No. 5 PO1 HL OH from the National Institutes of Health. Presented at the Thirteenth Annual Meeting of The Society of Thoracic Surgeons, Jan 24-26, 1977, San Francisco, CA. Address reprint requests to Dr. Castaneda, Department of Cardiovascular Surgery, Children s Hospital Medical Center, 300 Longwood Ave, Boston, MA chronic congestive heart failure and growth failure.* Choice of operation has been between banding the pulmonary artery (PAB) and closing the VSD. In the past, PAB was generally favored; more recently, because of the development and popularization of deep hypothermic circulatory arrest techniques as well as improvements in the care of sick infants, one-stage closure of the VSD is being advocated in a number of centers [I, 4, 6, 17, 211. Primary correction potentially avoids the jeopardy of two surgical procedures and lessens the psychological and economic burden on the family. It also avoids a number of relatively common complications related to PAB [ Ultimately, however, the superiority of one-stage closure of VSD in symptomatic infants depends on documenting the benefits of early closure by an objective demonstration of improved long-term functional results without increased risk of mortality and morbidity. To this end, we have reviewed our experience with closure of isolated VSDs in infants using the technique of deep hypothermic circulatory arrest. Material and Methods From January, 1973, to December, 1976, 50 infants27 girls and 23 boys, ranging in age from 13 days to 18 months (mean age 6 months) and weighing from 1.7 kg to 8.2 kg (mean weight 4.5 kgbunderwent closure of VSD (major lesion) with use of deep hypothermic circulatory arrest (Fig 1). Five of these babies had been born prematurely and weighed from 1.7 to 2.5 kg at operation; 5 had had prior operations (Table 1). The principal indication for operation in all 50 patients was intractable congestive heart failure and failure to thrive. All patients were below the third percentile for weight. All had pulmonary artery hypertension, and many had had recurrent respiratory infections. All patients under- %yler DC: Personal communication,

2 20 The Annals of Thoracic Surgery Vol 24 No 1 July 1977 WEIGHT B 0 Died AGE (months) Fig 1. Age and weight at operation of 50 infants who underwent VSD closure with use of deep hypothermic circulatory arrest. The solid line represents the third percentilefor weight. went at least one preoperative heart catheterization study that included a left ventricular cineangiogram in the left anterior oblique projection. Operative Procedure All operations were done using deep hypothermic circulatory arrest with surface cooling and extracorporeal core cooling and rewarming. Details of this technique have been previously described [19, 201. Without exception, the VSD was closed with a knitted Dacron patch and interrupted sutures (5-0 Tevdek) reinforced with Teflon-felt pledgets. The location, type, and number of VSDs are listed in Table 2. In 47 patients (94'/0), including the 4 with multiple VSDs, the defects were closed through the right atrium. The septal and anterior leaflets of the tricuspidvalve were retracted but not incised. A left apical ventriculotomy was used in 2 patients who had defects of the low-lying portion of the muscular septum. The only subpulmonary defect (conal-septa1 hypoplasia) was exposed through a small transverse right ventriculotomy. Hypothermic circulatory arrest time ranged from 18 to 66 minutes (mean, 40 min). Early in our experience (February, 1973) a large atrioventricular canal type VSD in a 41/z-month-old infant was deliberately only partially closed to avoid heart block. This child required a PAB 24 hours later. The only other patient who had PAB during the period covered by this report had multiple VSDs (subaortic and two muscular defects). Attempts at closure of both muscular defects through the tricuspid valve at 7 months of age failed, and because of a large residual shunt (PA Sao, > 85%) the pulmonary artery was banded during the same operation. A patent ductus arteriosus was ligated in 6 patients prior to cardiopulmonary bypass. A patent foramen ovale in 14 patients and a secun- Table 1. Infants with Operations Prior to VSD Closure Patient First Second No. Operation Age Operation Age Coarct + PDA PDA + PAB PDA 3 days VSD 13 days 2 wk VSD + debanding 5 mo 4 wk VSD 3 mo 4 PDA 7 wk VSD 6 mo 5 Coarct + PDA + PAB 5 mo VSD + debanding 12 mo Coarct = resection of coarctation of aorta; FDA = interruption of patent ductus arteriosus; VSD = patch closure of ventricular septal defect; PAB = pulmonary artery banding.

3 ~~ 21 Rein et al: Results of VSD Closure in Infancy Table 2. Location, Type, and Numbers of VSDs Type of VSD Subaortic (conoventricular) Multiplea Atriovefitricular canal type Muscular Sub pulmonary (conal-septal hypoplasia) No. of Patients 41 (82%) 4 (8%) 2 (4%) 2 (4%) 1(2%) amultiple VSDs included: conoventricular and 2 muscular (1 patient); conoventricular and 1 muscular (1 patient); and conoventricular and atrioventricular canal type (2 patients). dum type atrial septa1 defect in 1 patient were also closed. Postoperative Management To facilitate postoperative care, we left a 19- gauge catheter in the left and right atria and in the main pulmonary artery and a 20-gauge catheter in a radial artery. Pressures were monitored continually, and blood samples were withdrawn to determine cardiac output (Fick method with assumed oxygen consumption) and to detect intracardiac or pulmonary shunts. Generally, these catheters were removed 24 hours postoperatively. Recently, we have also placed a 2F thermistor in the main pulmonary artery to measure cardiac output by thermodilution. All infants were kept on a volume-cycled respirator (Bennett MA-1) for at least 24 hours. The patients were weaned from the ventilator by progressively decreasing the inspired oxygen concentration and the frequency of intermittent mandatory ventilation. During these maneuvers, a 2 cm H20 positive end-expiratory pressure was maintained. Temporary epicardial pacemaker wires were placed in all patients and were connected to a demand pacemaker. Positive inotropic agents were not used routinely; only 3 of the 50 patients received isoproterenol or dopamine postoperatively. Two of these patients eventually died. We attempt to have all patients return for catheterization one year after operation in order to measure pulmonary artery pressure, calculate pulmonary vascular resistance (measured oxygen consumption), and verify whether the defect is completely closed. Results Hospital Mortality There were 3 hospital deaths (6%) and no late deaths (Table 3). All 3 deaths occurred in infants who were in the second month of life (34,48, and 60 days and 2.0, 2.5, and 2.9 kg, respectively). Two were premature; the 48-day-old infant was cachectic with bilateral pneumonia when admitted to the hospital, and was dependent on mechanical respiratory and ventilatory support preoperatively. This child remained in a lowoutput state postoperatively and died three days later. At postmortem examination the VSD (conoventricular type) was well closed. The second premature infant (34 days, 2.0 kg) died immediately postoperatively of bleeding from a laceration of the right upper pulmonary vein. The third child suffered a cardiac arrest shortly after returning to the intensive care unit. An emergency thoracotomy failed to show the suspected mediastinal tamponade. Although initially resuscitated, she remained in a lowoutput state and died three days postoperatively following several episodes of uncontrolled rapid junctional tachycardia. At postmortem examination the VSD was completely closed (conoventricular type). Other findings included acute Table 3. Relationship between Age at Operation and Death after VSD Closure Hospital Deaths No. of Age Patients No. YO Days a Total % Months Total '/o aage of infants who died was 34, 48, and 60 days, respectively.

4 22 The Annals of Thoracic Surgery Vol 24 No 1 July 1977 renal tubular necrosis and patchy liver necrosis as well as intradural, intraventricular, and subarachnoid hemorrhages and cortical necrosis. All these lesions were considered secondary to prolonged low cardiac output. Postoperative Complications Postoperative complications did not seem to be age related, and only a few patients required special treatment. Nineteen infants had persistent mild congestive heart failure postoperatively. This was readily controlled with digitalis and diuretics in 18, but 1 patient (previously discussed) required PAB because of an incompletely closed atrioventricular canal defect. Early postoperative cardiac rhythm disturbances, all supraventricular, were either of short duration or responded well to treatment. Of greater importance were the postoperative conduction disturbances (Table 4). All 8 patients who developed right bundle-branch block (RBBB) and left anterior hemiblock (LAH) postoperatively had a conoventricular VSD; only 1 had transient (24 hours) complete heart block postoperatively. No patient has required permanent pacing. Seven patients had seizures that responded readily to either sedation or diphenylhydantoin. Seizures associated with a low-output state developed in 2 who died. In all survivors the medications were discontinued during hospitalization, and none has required treatment after discharge. In addition, 7 infants developed athetoid movements that were short-lived and disappeared spontaneously. Table 4. Electrocardiographic Changes after VSD Closure in 47 Patients Fourteen patients (28%) had atelectasis postoperatively, but only 4 patients (8%) required ventilatory support beyond 48 hours. One 4-month-old infant was kept on the respirator for 21 days; he recovered fully. One patient developed chylothorax and right phrenic nerve palsy, neither of which necessitated operation. Mild transient (24 to 48 hours) hemoglobinuria was noted in 10 patients. Postoperative Weight Changes All infants were below the third percentile for weight before closure of the VSD. The postoperative change in weight in those with oneyear follow-up is shown in Figure 2. Of the 6 infants who remained below the third percentile, 1 had PAB and mild congestive heart failure, 1 developed subaortic stenosis and coarctation after VSD closure, 1 had psychomotor retardation documented preoperatively, and 1 had moderately severe aortic regurgitation. EarZy and Late Postoperative Hemodynamic Results Thirty patients had early (24 hours) postopera-. tive studies, including measurement of systolic pulmonary artery pressure and shunt calculations. Twenty-four patients had complete heart catheterization studies approximately one year postoperatively. Changes between the preoperative and the early and late postoperative values of pulmonarylsystemic flow ratios Fig2. Change in weight one yearafter closure of VSD for the 21 children in whom one-year follow-up is available. - 97% ECG Finding Preop Postop RBBB 0 16 (34%) LAD 4 4 (9%) RBBB + LAH 0 8 (17%) TCHB 0 6 (13%) PCHB 0 0 (0%) PERCENTILE FOR AGE VO % RBBB = right bundle-branch block; LAD = left axis deviation; LAH = left anterior hemiblock; TCHB = temporary complete heart block; PCHB = permanent complete heart block. Pre-op Post-op (1 yr)

5 23 Rein et al: Results of VSD Closure in Infancy (QJQJ, pulmonary artery pressure (PAP), and pulmonary vascular resistance (PVR) are shown in Figures 3,4, and 5. Preoperatively the QJQ, averaged (range, 2/1 to 711). Within 24 hours after operation this flow ratio decreased to a mean value of While 13 patients had no residual shunt, clinically insignificant QJQ, (l.l/l to 2.011) was measured in 16, probably due at least in part to leakage through the Dacron patch. The only patient with a significant residual shunt (QJQ, = 311) required PAB after the Fig3. Preoperative and postoperative pulmonarylsystemic flow ratios (Q,/Q,). Dashed lines indicate mean values. Re-op Post-op Post-op 04 hrs) (1 yr) N.50 N.30 N.24 atrioventricular canal type VSD was deliberately incompletely closed. One year postoperatively no residual shunt was detected in 20 of 24 patients (83%), and clinically insignificant pulmonarylsystemic flow ratios of less than were measured'in 4 patients. The average systolic PAP before closure of the VSD was 74.5 mm Hg, ranging from 27 to 110 mm Hg. Twenty-four hours postoperatively the peak pressure decreased to an average of 33 mm Hg (20 to 55 mm Hg), and one year postoperatively the PAP was within normal range in all patients studied. Five of the patients in whom one year postoperative studies are available for comparison had a preoperative PVR above 4.0 U1m2 (4.1 to 9.9 U/m2). Four of these infants were 12 months of age at the time of operation; their PVR ranged from 4.5 to 9.9 U/m2, while the PVR of the fifth patient, a 5-month-old infant, was 4.1 U1m2. One year postoperatively, PVR was within normal limits in all patients. Both patients who had undergone prior resection of coarctation (see Table 1) had residual gradients of 25 and 40 mm Hg across the anastomosis. Two other children developed mild coarctation with gradients of less than 30 mm Hg Fig4. Preoperative and postoperative pulmonary artery systolic pressure. Dashed lines indicate mean values, shaded area represents normal range " 100 c. Fig 5. Postoperative changes in pulmonary vascular resistance(rp)(u/mz). Sofar, 27of the44patients with preoperative values have been studied one year after VSD closure. 9.0 t t a (1 yr 1 N.50 Q4W fl Yr) N =29 N.21 N =44 N =17

6 24 The Annals of Thoracic Surgery Vol 24 No 1 July 1977 after closure of the VSD. One patient, who at the age of 6 weeks had had closure of multiple defects, developed a gradient of 150 mm Hg across a membranous type subaortic stenosis. The same child also developed a progressively increasing gradient across a coarctation of the aorta. The subaortic stenosis and the coarctation were repaired at 20 months and 3% years, respectively. Another child, who showed no evidence of left ventricular outflow gradient at catheterization preoperatively, had developed a 60 mm Hg gradient across a subaortic membrane at postoperative catheterization. Comment The pros and cons of pulmonary banding in infants requiring operation for a large VSD have been discussed amply, and it is not our intention to enter this polemic now. Suffice it to say that in our experience, PAB in early infancy carries a substantial risk [141, while subsequent debanding and closure of the VSD can be accomplished with an operative mortality of less than 10% [71. We were also disenchanted with the many sequelae of PAB; therefore, we became interested in developing our own experience with primary closure of VSDs. We have since learned that primary closure of the VSD, as opposed to the two-stage approach, can be done with a lower operative mortality. In our series 3 infants died. One death was due to a technical error (laceration of the right pulmonary vein). In another case a desperate and perhaps ill-advised attempt was made to save a dying infant with bilateral pneumonia who was dependent upon mechanical ventilatory support preoperatively. The third child had an unnecessary emergency thoracotomy for expected tamponade immediately postoperatively; this patient developed a rapid junctional tachycardia and never regained adequate cardiac output. There have been no deaths from closure of isolatedvsds in the last 32 patients. Although the 3 infants who died were aii 2 months of age and weighed less than 3 kg, 15 patients under 3 months old survived repair. While it must be concluded that repair in infants within the first three months of life carries an increased risk, we believe, based on these data, that the nature and severity of the hemodynamic abnormality and not age or weight per se determines mortality in this age group. Obviously, the younger the infant, the greater the demand for specialized facilities and for precision in postoperative care. We favor the transatrial approach for repair of all conoventricular (subaortic) and atrioventricular canal type VSDs and for some of the high-lying muscular VSDs, The exposure of the defect, particularly of its critical posteroinferior margin, is excellent. The concern expressed by Barratt-Boyes [21 of a possible higher incidence of residual VSDs or tricuspid incompetence related to this approach fortunately has not materialized. We are encouraged by the late (one year) postoperative hemodynamic results. As expected, in the patients studied one year postoperatively, PVR was within normal limits. Severe pulmonary vascular changes, although rare, can occur invsds before 2 years of age, and considering the extremely low risk of closure of VSDs earlier in life-even for critically ill infants-we now prefer to repair large VSDs with pulmonary artery hypertension electively at approximately 12 to 16 months of age. Thus the risk of pulmonary vascular obstructive disease developing in any child with a large VSD should be avoidable. The "catch-up" growth pattern of most of these infants after VSD closure is most gratifying [18]. From these data, inadequate postoperative weight gain strongly suggests the existence of either a residual or an additional lesion. We are concerned about the high incidence of RBBB and LAH in our series and in other reports [15, 22, 251. Additional efforts are necessary to identify exactly where the damage to the specialized atrioventricular conduction system occurs. Although it is theoretically possible for RBBB and LAH to be caused by operative trauma to the distal part of the bundle of His, one would expect a higher incidence of at least transient complete heart block (edema of the posterior left bundle) if this were true; but only 1 of the 8 patients with RBBB and LAH had transient (24 hours) complete heart block. It seems more likely that the damage occurs peripheral to the bundle of His. Thirty-five percent of all our patients developed RBBB alone after transatrial closure of the VSD, and those with RBBB and LAH had a normal P-R interval on their elec-

7 25 Rein et al: Results of VSD Closure in Infancy trocardiogram. Whether changes in technique will influence the incidence of these conduction abnormalities remains to be seen. Much concern has been expressed about the possible sequelae of deep hypothermic circulatory arrest. Reports in the early 1960s of brain damage following deep hypothermia [31 sensitized cardiac surgeons against this technique and essentially eliminated its use until Horiuchi [13] and later Hikasa [12] proved the safety of such procedures in children. However, seizures and choreoathetosis do occur in patients subjected to deep hypothermic circulatory arrest [5, 16, 201. In our experience hypothermic circulatory arrest has not contributed to mortality; however, questions still remain regarding short- and long-term effects of arresting the circulation to such flow-dependent organs as the central nervous system. Several authors [16,20,23,241 have attempted to evaluate behavioral and intellectual function in children who have undergone repair of cardiac lesions using this technique. Recognizing the limitations of intelligence tests in children less than 6 years of age (the majority of these patients), gross deviation from the normal distribution has not been reported. The incidence of seizures in our patients seems high. However, evaluation of the acute transient neurological disorders is difficult because factors other than hypothermic circulatory arrest influence the development of seizures in infants. In 2 children, both in a low-output state, seizures occurred shortly before death; in 3 others seizures were traced to respiratory failure that had required reintubation. One seizure episode occurred following suspected tamponade and open chest massage. A seventh child had seizures and opisthotonus preoperatively. Length of operation, and particularly length of hypothermic circulatory arrest, does not correlate with the appearance of postoperative seizures. In the 5 surviving infants the seizures were promptly controlled by either sedation or diphenylhydantoin. None of these patients required anticonvulsive treatment after discharge from the hospital. Our postoperative protocol includes neurological examination and psychometric testing five years postoperatively. We hope the initial results of this study will become available within one year. Based on our experience so far, we remain enthusiastic about primary repair of all types of VSDs in infants, irrespective of age or weight. We favor the use of deep hypothermic circulatory arrest in infants weighing less than 8.0 kg. References 1. Barratt-Boyes BG, Simpson M, Neutze JM: Intracardiac surgery in neonates and infants using deep hypothermia with surface cooling and limited cardiopulmonary bypass. Circulation 43,44:Suppl 1:25, Barratt-Boyes BG, Neutze JM, Clarkson PM, et al: Repair of ventricular septal defect in the first two years of life using profound hypothermia circulatory arrest techniques. Ann Surg 184:376, Bjork VD, Hultquist G: Brain damage in children after deep hypothermia for open heart surgery. Thorax 15284, Blackstone EH, Kirklin JW, Bradley EL, et al: Optimal age and results in repair of large ventricular septal defects. J Thorac Cardiovasc Surg 725, Brunberg JA, Reilly EL, Doty DB: Central nervous system consequences in infants of cardiac surgery using deep hypothermia and circulatory arrest. Circulation 49:Suppl 250, Castaneda AR, Lamberti J, Sade RM, et al: Open heart surgery during the first three months of life. J Thorac Cardiovasc Surg 68:719, Castaneda AR, Zamora R, Nicoloff DM, et al: High-pressure, high-resistance ventricular septal defect: surgical results of closure through right atrium. Ann Thorac Surg 1229, Dobell ARC, Murphy DA, Poirier NL, et al: The pulmonary artery after debanding. J Thorac Cardiovasc Surg 65:32, Freed MD, Rosenthal A, Plauth WH, et al: Development of subaortic stenosis after pulmonary artery banding. Circulation 47,48:Suppl3:7, Griepp E, French JW, Shumway NE, et al: Is pulmonary artery banding for ventricular septal defects obsolete? Circulation 49,5O:Suppl2: 14, Henry J, Kaplan S, Helmsworth JA, et al: Management of infants with large ventricular septal defects: results with two-stage surgical treatment. Ann Thorac Surg 15:109, Hikasa Y, Shirotami H, Satomura K, et al: Open heart surgery in infants with an aid of hypothermic anesthesia. Arch Jpn Chir 36:495, Horiuchi T, Koyamada K, Matano J, et al: Radical operation for ventricular septal defect in infancy. J Thorac Cardiovasc Surg 46:180, Hunt CE, Forrnanek G, Levine MA, et al: Pulmonary arterial banding results in 111 children. Circulation 43:395, 1971

8 26 The AM& of Thoracic Surgery Vol 24 No 1 July Jzukawa T, Sandheimer HM, Trusler GA, et al: Conduction disturbances after repair of ventricular septal defect and tetralogy of Fallot, The Child with Congenital Heart Disease after Surgery. Edited by BSL Kidd, RD Rowe. Mount Kisco, NY, Futura Publishing Company 1976, p Messmer BJ, Schallberger U, Gattiker R, et al: Psychomotor and intellectual development after deep hypothermia and circulatory arrest in early infancy. J Thorac Cardiovasc Surg 72:495, Okamoto Y: Clinical studies for open heart surgery in infants with profound hypothermia. Arch Jpn Chir 38:188, Rosenthal A, Castaneda AR: Growth and development after cardiovascular surgery in infants and children. Prog Cardiovasc Dis 18:27, Sade RM, Castaneda AR: Recent advances in cardiac surgery in the young infant. Surg Clin North Am 56:451, Sade RM, Williams RG, Castaneda AR: Corrective surgery for congenital cardiovascular defects in early infancy. Am Heart J 90:656, Sigmann JM, Stern AM, Sloan HE: Early surgical correction of large ventricular septal defects. Pediatrics 39:4, Steeg CN, Krongrad E, Darachi F, et al: Postoperative left anterior hemiblock and right bundle branch block following repair of tetralogy of Fallot. Circulation 51:1026, Stevenson JG, Stone EF, Dillard DH, et al: Intellectual development of children subjected to prolonged circulatory arrest during hypothermic open heart surgery in infancy. Circulation 49,5O:Suppl 2:54, Subramanian S, Vlad P, Fischer L, et al: Sequelae of profound hypothermia and cardiocirculatory arrest in the corrective treatment of congenital heart disease in infants and small children, The Child with Congenital Heart Disease after Surgery. Edited by BSL Kidd, RD Rowe. Mount Kisco, NY, Futura Publishing Company, 1976, p wo1ff induced right bundle-branch block with left anterior hemiblock: an ominous sign in postoperative tetralogy of Fallot. Circulation 46:587, 1972 Closure of VSDs can be achieved as safely through an atriotomy as through a ventriculotomy, though many prefer to close the supracristal type through the ventricle. On the other hand, in VSDs with displaced insertion of the tricuspid valve the atrial approach might be easier. Deep hypothermic circulatory arrest was employed without kng-lasting aftereffects in these 50 patients. However, late complications-yet unknown-may occur. In our own experience, we have restricted closure of VSD in the first year of life to infants who either have shunts above 60% or have a pulmonary arterylaortic pressure ratio greater than 0.8. It is of interest that RBBB, thought to be caused by ventriculotomy, also occurs with a high frequency after VSD closure through an atriotomy. There were 8 patients with RBBB and LAH. My question for Dr. Rein is: Did you consider prophylactic pacemaker treatment in any of these patients? DR. K. KWON (Fullerton, CA): I am particularly concerned with the technique for closure of VSDs. Speafically, I am speaking of patients in the 25- to 35-yearold age groups, those patients who have high pulmonary artery pressure and in whom the left-to-right shunt is greater than the right-to-left shunt. The use of the conventional right ventriculotomy approach may be detrimental to the survival of these patients. I have had success, however, using the transatrial approach repair with this type of patient. When an atrial approach repair is performed on an adult with congenital VSD, it is necessary to cause a complete ischemic arrest for 4 to 5 minutes. The heart then becomes like a rubber balloon, and the tricuspid valve can be opened easily by retracting the septal leaflet. Then a heavy traction suture can be placed on the septum and the entire area can be pulled upward. Thus the entire field is nicely exposed to facilitate a patch graft. I conclude with the belief that in VSD repair in an adult, with the exception of multiple muscular types, the transatrial approach should be considered. GS' Tw' RC: DR. HANS G. BORST (Hannover, Germany): We also endorse closing all single VSDs in infancy; I think the results are superb. For the last three years we have done no banding for single VSD. Discussion We have closedvarious VSDs in the first year of life in 33 patients: 20 were single and isolated, with 1 death; 6 DR. FRITZ SEBENING (Munich, Germany): I congratulate with associated anomalies, usually atrial septal defect or the authors on their interesting presentation, which I patent ductus arteriosus (the only other death); and 7 in had the pleasure to preview. The paper lends new conjunction with transposition of the great arteries. support to the concept of primary closure of VSD. In a Our policy has always been to close both supracristal recent report of 409 cases, a mortality of 16.4% was and infracristal defects through the right ventricle. We calculated for banding of the pulmonary artery, and believe this is technically easier, and we think it is just as 33% for the completed two-stage procedure. In con- rewarding as going through the atrium. If the angiogram trast, when we reviewed the literature of the last two shows that the defect is clearly infratricuspid and posteyears, we found 389 cases with a 12.9% early mortality rior, however, we prefer to go through the atrium. This for primary closure of VSD in infants under 1 year of is especially true for transposition, but we are careful not age. to touch the tricuspid annulus, taking instead the limbus

9 27 Rein et al: Results of VSD Closure in Infancy underneath the ring so as not to produce tricuspid insufficiency. These patients have had no complete block, no recurrence of the VSD, no tricuspid insufficiency, and no seizures. All operations were performed using extracorpored circulation at 28"C, which we prefer in all infants. We think that cardioplegia is extremely helpful in exposing these defects. DR. REIN: I would like to thank all the discussants for their interesting comments. As stated, we are very concerned about the high incidence of RBBB and LAH in these children. So far this conduction disturbance has been well tolerated, and we have not implanted any pacemakers for this complication. Although Grace WOWS report of a 12.5% incidence of sudden death with RBBB and LAH after tetralogy of Fallot repair is very alarming, subsequent reports in the literature seem to suggest that this complication is significantly less dangerous. Nevertheless, more longterm observations are necessary. We might have to modify our present views. More important, we must strive to eliminate RBBB and LAH as a surgical complication related to VSD closure. Notice from The Society of Thoracic Surgeons Call for Abstracts-1978 Meeting (Deadline: August 31, 1977) Abstracts for papers to be presented at the 1978 Annual Meeting of The Society of Thoracic Surgeons are now being accepted. The meeting is to be held at the Sheraton Twin Towers Hotel, Orlando, Florida, January 23-25, The deadline for receipt of abstracts is August 31, An original and eight copies should be submitted on the official society abstract form to Marvin M. Kirsh, M.D., Chairman, Program Committee (Abstracts), The Society of Thoracic Surgeons, 111 E Wacker Dr, Chicago, IL The forms are available upon request from the Society. Abstracts must summarize an original contribution not presented or submitted elsewhere. Abstracts received after the deadline will not be considered. It is requested that the covering letter indicate the author who is to receive notice of acceptance or rejection and the author who will present the paper. The Program Committee reserves the right to select papers for either regular or forum-type presentation. The author may also designate his preference for presentation in the forum. Essayists are reminded that the complete manuscript must be submitted in duplicate either to the Editor of The Annals of Thoracic Surgery before the meeting or to the Secretary of the Society at the meeting, immediately prior to presentation. Call for Surgical Films (Deadline: September 7, 1977) The popular surgical movie program will again be presented at the Orlando meeting. The Program Committee hereby solicits the submission of surgical films, which may portray a surgical procedure or simply a technical maneuver that the surgeon thinks will be of interest to the Society. The film may not exceed 10 minutes in length. Sound movies are acceptable but not necessary, and live narration by the principal surgeon is a requirement for participation in the movie night program. The movies may be on Super-8 or 16-mm film. The deadline for submission of films is September 7,1977. Films also should be sent to Marvin M. Kirsh, M.D., Chairman, Program Committee, at the Society office, 111 E Wacker Dr, Chicago, IL Application for Membership (Deadline: September 1, 1977) Requests for membership application forms should be addressed to Charles R. Hatcher, M.D., Chairman, Membership Committee, The Society of Thoracic Surgeons, 111 E Wacker Dr, Chicago, IL The completed application forms and supporting letters must be in the hands of the Membership Committee by September 1, 1977, for the applicant to be considered for election at the Orlando meeting next January. Thomas D. Bartley, M.D. Secretary