How to treat ventricular septal defect? ​​Open chest surgery or minimally invasive closure?

Author: Lv Zhenyu, deputy chief physician, Beijing Children's Hospital, Capital Medical University

Reviewer: Jin Mei, Chief Physician, Beijing Children's Hospital, Capital Medical University

Ventricular septal defect is a common congenital heart disease.

Usually, patients with small ventricular septal defects have milder conditions and more subtle symptoms, which are not easy to detect. Occasionally, heart murmurs may be heard during physical examinations, and further examinations at the hospital will reveal the presence of ventricular septal defects.

When the ventricular septal defect is relatively large, the left-to-right shunt volume is larger, and corresponding symptoms will appear two or three months after birth, or even one or two months later.

Due to the presence of ventricular septal defect, the pressure in the left ventricle (left heart chamber) is high, and blood flows to the right ventricle (right heart chamber and pulmonary circulation) with lower pressure, resulting in increased pulmonary circulation blood volume and decreased systemic circulation blood volume, resulting in different clinical symptoms:

Symptoms of increased pulmonary blood volume:

Rapid or shortness of breath

Frequent respiratory tract infections (such as chronic rhinitis, bronchitis, pneumonia, etc.)

Symptoms of decreased systemic blood volume:

Pale complexion and cool skin

Numbness or coldness in your hands and feet

Straining when feeding or pumping (or lack of weight gain due to breathing difficulties)

When parents find that their children have these symptoms, they should highly suspect that they may have congenital heart disease and whether it is ventricular septal defect. They need to go to the hospital for a doctor's diagnosis.

Because in addition to ventricular septal defect, there are other diseases that can also cause left-to-right shunt, such as patent ductus arteriosus and aortopulmonary window, which can cause similar symptoms as mentioned above.

When doctors see these special symptoms and hear heart murmurs in clinical practice, they will do some auxiliary examinations to make further judgments. The most commonly used auxiliary examinations include electrocardiogram, chest X-ray and echocardiogram. Generally, through echocardiogram, the heart malformation can be clearly seen, thus confirming the diagnosis.

Currently, the treatment of ventricular septal defect is divided into two categories: traditional open-chest surgery and minimally invasive closure.

Among them, thoracotomy, whether it is a median thoracotomy or a lateral thoracotomy (a small incision under the armpit), is a traditional treatment method.

Figure 1 Original copyright image, no permission to reprint

So at present, the traditional median thoracotomy is the recognized method, and the vast majority of patients require a median thoracotomy.

For some patients, the heart malformation is not very complicated, the defect is not very large, and the heart function status before the operation is not very bad. At this time, the so-called cosmetic incision can be considered, that is, an incision from the armpit. Especially for girls, after the operation, after putting their arms down, the incision cannot be seen.

The median incision is exposed to the outside, which can easily cause some psychological trauma to the patient. However, it is also emphasized that lateral thoracotomy, or minimally invasive thoracotomy through the axilla, is not suitable for all patients.

Whether to choose a minimally invasive thoracotomy must be decided by the doctor. The doctor should not simply choose a cosmetic incision to add icing on the cake without considering the safety of the surgery. For any surgery, surgical safety is the first priority.

Attempts to minimally invasively occlude ventricular septal defects abroad can be traced back to the 1980s, and the technology was gradually introduced in China in the early 1990s. The earliest minimally invasive occlusion surgery was limited to muscular ventricular septal defects, because there are no important tissue structures around this area, and the placement of metal occluders will not damage surrounding organs. With the advancement of technology and the accumulation of clinical experience, this method has gradually been extended to membranous ventricular septal defects. There are also some cases of residual shunts after thoracotomy for ventricular septal defects, which can also be occluded by intervention.

In addition, when choosing a surgical method, surgical safety must be considered. Any surgery should ensure its controllability and effectiveness to reduce the risk of complications and ensure the patient's treatment effect. In actual application, doctors need to make a comprehensive assessment based on the patient's condition, tissue structure, and postoperative possibilities, and choose the most appropriate surgical method.