|Illustration by Steven P. Goldberg, MD|
Copyright © 2012 STS
What is a Ventricular Septal Defect?
A ventricular septal defect (VSD) is the most common type of congenital heart disease that requires surgery. A VSD is a hole (defect) in the wall (septum) separating the pumping chambers of the heart (the right and left ventricles). Patients usually have 1 VSD, but may have more than 1.
Why do the surgery?
In a normal heart, blood does not pass directly between the two pumping chambers of the heart (the left and right ventricles). When there is a hole in the wall separating the ventricles, the heart cannot work efficiently. The pressure is usually greater in the left ventricle than the right ventricle because the left ventricle needs to pump oxygen-rich blood to all areas of the body while the right ventricle only pumps oxygen-poor blood to the nearby lungs. Since blood follows the path of least resistance, it will generally flow through the hole in the ventricular septum from the left ventricle to the right. This means that too much blood is pumped to the lungs and not enough to the body.
A VSD can lead to serious problems. If the hole between the ventricles is large enough, too much blood will go to the right ventricle. This extra blood flow will overwhelm the lungs with blood, and the child will go into congestive heart failure (CHF). If this CHF is not treated, the lungs will be damaged by the high blood flow. Specifically, the walls of the blood vessels of the lungs will get thicker and create high blood pressure in the lungs (pulmonary hypertension). If pulmonary hypertension is left untreated, the blood vessels in the lungs will become damaged and the child will turn blue (cyanotic) from the lack of oxygen in the blood. This problem puts the child at risk of death. If this is still not treated, the damage to the lungs can become irreversible and a condition called Eisenmenger syndrome occurs, which may require treatment with a heart and lung transplant. (Eisenmenger syndrome is acquired severe pulmonary vascular disease associated with congenital heart disease.)
So, any child with symptoms of congestive heart failure should usually have surgery early in life. Meanwhile, if the hole or holes in the wall between the ventricles are small, and the child shows no signs of congestive heart failure, then medication can be used to treat the condition for six months up to several years without surgery. How long the condition can be safely treated with medication depends on how it progresses during that time. It is possible for the hole(s) in the walls between the ventricles to close on their own. It is generally accepted that if the hole(s) do not close by the time the child is 4 to 5 years old, then the child should have surgery to correct the condition.
What to ask your surgeon
The following are questions that you should ask your surgeon before any surgical procedure is performed:
- What can happen if we do not do the surgery?
- Will my child be in pain?
- When should we do the surgery?
- What is the experience of the surgical team?
- Where will the incision be made? What will it look like?
- Do you have specialized Intensive care staff?
- How long does the surgery take?
- Can I stay in the hospital with my child?
- What is the risk of the surgery?
- What should be bring to the hospital?
- How long will my child be in the hospital?
- Will my child be on any medications after surgery?
- What will my child look like right after surgery?
- Will my child need another surgery later on in life?
- What can I expect during the hospital stay?
The surgical procedure
|Illustration by Steven P. Goldberg, MD|
Copyright © 2012 STS
The surgery to correct VSD usually involves placing a patch to close the hole between the left and right ventricles. The surgeon makes an incision down the front of the chest (called a median sternotomy) and divides the breastbone (sternum) in half to get access to the heart. The heart is placed on cardiopulmonary bypass, meaning that a machine takes over the heart’s job of pumping of the blood so the surgeon can enter the heart to close the hole(s). The hole(s) are usually closed with a patch of fabric made of Gore-Tex™ or Dacron™. Both fabrics are strong woven materials that are accepted by the body. The child’s own heart cells will grow over the patch, making it part of the child’s body. When the breastbone is put back together, stainless steel wires are usually wrapped around the bone to make it very sturdy. The surgery will take an average of three hours from start to finish.
Risks and benefits of the surgery
The benefit of the surgery is for the child to have a normally functioning heart.
Risks of any heart surgery include: bleeding, infection, stroke, organ damage, requirement for a temporary or permanent pacemaker, or possibly death. For 99% of all pediatric heart disease surgical procedures, the risk of these occurring is 5% or less. The VSD patch can come loose, requiring another operation to repair it, but this is extremely rare.
What to expect during the hospital stay
Just after surgery, the child will be sleepy while recovering from anesthesia and will be under the influence of strong pain medications. It is normal for a child to be confused, thirsty, and nauseated. The child may have nothing but glue over the outside over the surgical incision in the chest and will have many tubes and wires attached.
Over the next few days, the child’s chest will be x-rayed daily and more of the wires and tubes will be removed. By the second day after surgery, the child should be up and moving around as much as possible. Usually, by the third day after surgery, the only pain medications the child will need are acetaminophen or ibuprofen. Typically, the child should go home on within one week after surgery.
The hospital will supply specific discharge instructions, and all instructions from the hospital, cardiac surgeon, and cardiologist should be strictly followed. The child should get back to his or her normal routine upon arrival at home. For the first week, the child may wish to take more frequent naps or wake up occasionally at night, and will need to take acetaminophen or ibuprofen every six hours or so. The child should be seen by his or her cardiologist within two weeks after discharge from the hospital. After that visit, the child should be able to return to daycare or school. The incision should be kept clean and dry until it is healed. It should also be protected from the sun for a full year. The child should not be picked up under the arms for four weeks following surgery. Any of the following symptoms should be reported immediately to the cardiologist: (1) fever greater than 101, (2) redness, puffiness, discharge from the incision, or (3) unusual nausea or flu-like symptoms.
Usually, the child’s heart should be permanently fixed after one surgery. Once recovered from the surgery and cleared by the cardiologist, the child can usually be treated as any other healthy child, without restrictions.
Written by Jeffrey P. Jacobs, MD and Heidi Hess, RN - Reviewed September 2012