Ventricular septal defect repair

Kiruthiga1*, Ranjitha1, Pushpa2

1OT Staff Nurse, Kauvery Hospital, Heart city, Trichy, Tamil Nadu

2OT Incharge, Kauvery Hospital, Heart city, Trichy, Tamil Nadu

*Correspondence

Abstract

This case report details the successful surgical management of a 2-month-old female with a large peri-membranous ventricular septal defect (VSD) presenting with symptoms of heart failure and respiratory distress. Following an echocardiogram confirming a significant left-to-right shunt and good biventricular function, the patient underwent definitive surgical closure of the defect using a pericardial patch under cardiopulmonary bypass. The postoperative course, managed with inotropic support and mechanical ventilation, showed gradual recovery, resulting in successful extubation on POD 3, subsequent chest tube removal, and discharge with stable cardiac status.

Key words: Ventricular septal defect (VSD); Downs syndrome

Introduction

A ventricular septal defect (VSD) is a hole in the wall between the two lower chambers (ventricles) of your child’s heart. A VSD from an incomplete wall can allow oxygen-rich blood from one side of the heart to mix with oxygen-poor blood from the other. The heart works best when the wall keeps blood from mixing. This condition is the most common kind of congenital heart disease (present at birth). It often happens along with other types of heart problems. A small VSD is usually minor and has few or no symptoms. But a larger hole may need a repair to avoid permanent damage and complications. Almost all VSDs are present when a child is a newborn. A VSD diagnosis happens most often during childhood. Rarely, one can get a diagnosis as an adult. This is much less likely because the defect closes on its own during childhood in most cases.

VSD types

There are four main types of ventricular septal defects. They differ in their location and the structure of the hole (or holes). The types of VSDs are:

Membranous: This is the most common type of VSD. These VSDs happen in the upper section of the wall between your ventricles.

Muscular: These happen in the lower part of the wall. With this type, there’s often more than one hole.

Inlet: This is a hole just below the tricuspid valve in your right ventricle and the mitral valve in your left ventricle. When blood enters your ventricles, it must pass a VSD that connects them.

Outlet: This kind of VSD creates a hole just before the pulmonary valve in your right ventricle and just before the aortic valve in your left ventricle. Blood has to go by the VSD on its way through both valves.

Case presentation

A 2-month-old female child who was diagnosed to have ACHD 2 weeks back (Large ventricular septal defect). On diuretics for 2 weeks, now brought with complaints of cough and coryza for 4 days, which was wet cough, intermittent, not relieved by medication. H/O fast breathing for 1 day. No H/O cyanosis/vomiting/loose tools/cry during micturition

On examination

Patient conscious, oriented and Afebrile

Temp 98.2 F
HR120 b/min
RR62 b/min
BP90/60mmHg
SpO296%
CVSS1S2+, Pansystolic murmur in left lower sternal border
RSBAE+, Tachypnea present
P/ASoft
CNSB/L PERL+
Height55cms
Weight4.2kgs

Pre OP Medications

Nil

Pre OP Investigations

Hb10.9g/dl
RBC Count4.07ml/10^9
WBC Count10030 cells/mm3
Urea18mg/dl
Creatinine0.34mg/dl
Na131mmol/L
K5.00mmol/l
SerologyNegative
CAGNot done

Pre OP ECG

X-Ray

ECHO Report

Impression

  • A cyanotic congenital heart disease: large peri membranous VSD with muscular extension left to right shunt
  • Good Biventricular function
  • Increased QP: QS (>2:1)

Operation Notes

Diagnosis: Moderate sized peri membranous VSD

Surgical closure of VSD with pericardial patch 

Procedure

  • Midline sternotomy
  • Pericardium harvested
  • Heparin given
  • Aorta, SVG, IVC cannulation done
  • CPB cooled to 340C
  • Aorta clamped antegrade blood cardioplegia given
  • RA opened – PFO created LA Vent
  • VSD closed with glutar / aldehyde treated pericardium with 6-0 prolene interrupted sutures.
  • Tricuspid valve checked normal
  • Patient rewarded. LA deaired
  • RA sutured
  • Aortic root deaired
  • Clamp off, Heart in Sinus rhythm
  • OFF CPB. Hemostasis achieved
  • 1 Mediastinal, 1 right pleural drain
  • 1 Right atrium, 2 RV pacing wires
  • Sternum approximated with 5-0 Ethibond
  • Routine closure.

Surgery image

Benefits of Peri membranous VSD closure surgery

Correction of symptoms: Repairs the defect to stop left-to-right shunting, allowing children to stop suffering from fatigue, frequent pneumonia, and failure to gain weight.

Prevention of complications: Stops progression to pulmonary artery hypertension (PAH) and prevents further left ventricular overload.

Improved life expectancy: Successfully closed VSDs allow most patients to live a normal life span.

Permanent cure: Surgical repair provides a durable, long-term solution, with a success rate of around 96%

Post operative period

0 – POD

  • Patient received from HCOT with AMBU bag ventilation then connected with mechanical ventilator.
  • Mode – SIMV/PC
  • Fio2 -100%, PEEP- 5 cm of H2O, TV-40ml
  • Patient vitals were stable.
  • He was managed with necessary support
  • Adrenaline 0.7ml/hr
  • NTG 1ml/hr
  • Dobutamine 2ml/hr
  • Fentanyl 0.5ml/hr
  • Soda bicarbonate 3ml/hr
  • Dexmid 4ml/hr
  • Total Intake -745.4ml and Output – 213.6ML
  • Baby care given.

1st – POD

  • Baby ventilated with mechanical ventilator.
  • Mode – SIMV/PC
  • Fio2 -40%, PEEP- 5cmof H2O, TV-40ml I : E Ratio – 1:2
  • Baby vitals were stable.
  • She managed with necessary support
  • Adrenaline 0.5ml/hr
  • Dobutamine 2ml/hr
  • Fentanyl 0.5ml/hr
  • Dexmid 4ml/hr
  • To stop the infusion Inj.NTG, Inj. Soda bicarbonate
  • Cefuroxime 70mg, Inj. Para 4ml IV 6 hourly Fluids – 5% Dextrose 5ml/hr
  • Continue the NPO status.
  • Baby care given.

2nd – POD

  • Baby ventilated with mechanical ventilator.
  • Mode – PRVC
  • Fio2 -40%, PEEP- 5cmof H2O, TV-40ml I : E Ratio – 1:2
  • Baby vitals were stable.
  • She managed with necessary support
  • Adrenaline 0.3ml/hr
  • Dobutamine 0.3ml/hr
  • Fentanyl 0.7ml/hr
  • Dexomid 1ml/hr
  • Lasix 0.7ml/hr
  • Calcium 1.5ml/hr
  • Continue the NPO status.
  • Total ICD – 40ML.
  • Baby care given.

3rd – POD

  • Baby Extubated done. 8 liters of O2 with High flow nasal cannula.
  • Baby conscious and oriented.
  • Baby vitals were stable.
  • She managed with necessary supports
  • Adrenaline 0.6ml/hr
  • Miltrone 0.5ml/hr
  • Lasix 0.3ml/hr
  • Calcium 1ml/hr
  • Nebulization Given
  • Chest Physio Given.
  • Feeding -30ml given with Ryles tube.
  • ICD Removed.
  • Baby care given.

4th – POD

  • Baby conscious and oriented. 5 liters of O2 with High flow nasal cannula.
  • Baby vitals were stable.
  • She managed with necessary support
  • Miltrone 0.5ml/hr
  • Lasix 0.2ml/hr
  • Nebulization Given
  • Chest Physio Given.
  • Feeding given with Ryles tube.
  • Baby care given.

5th – POD

  • Baby vitals are stable.
  • Right side chest ICD insertion done.
  • Total ICD Drain – 60ml.
  • Chest Physio Given.
  • Nebulization Given.
  • Baby care given.

6th – POD

  • Baby vitals are stable.
  • Chest Physio Given.
  • ICD Removed.
  • Nebulization Given.
  • Feeding given.
  • Baby care given.

7th – POD

  • Baby vitals are stable.
  • ICD Removed.
  • Chest Physio Given.
  • Nebulization Given.
  • Feeding given.
  • Baby care given.
  • Patient shift to ward with stable status and no complaints.

Advice on Discharge

Nursing challenges

Decreased cardiac output

Related to altered heart structure (VSD) and surgical manipulation, characterized by hypotension, weak pulses, and tachycardia.

Intervention: Monitor vital signs frequently, assess heart rhythm for arrhythmias, and administer inotropic medications as ordered.

Impaired gas exchange/ineffective breathing pattern: Related to cardiopulmonary bypass and potential pulmonary congestion, indicated by low and respiratory distress.

Intervention: Monitor respiratory rate/effort, provide oxygen as needed, and manage ventilator settings post-operatively.

Risk for infection: Related to surgical incision, indwelling catheters, and invasive lines.

Intervention: Strict aseptic technique, monitor incision sites for infection signs (redness, drainage), and check temperature.

Acute pain: Related to sternotomy/surgical trauma, evidenced by crying, irritability, and tachycardia.

Intervention: Assess pain using pediatric scales (e.g., FLACC) and administer ordered analgesics.

Imbalanced nutrition: less than body requirements: Related to increased metabolic demand of heart failure and fatigue during feeding.

Intervention: Monitor weight daily, use high-calorie formulas, and implement gavage feedings if necessary to support growth.

Risk of ineffective peripheral tissue perfusion: Related to decreased flow from heart failure or potential post-op complications

Nursing Management

Pre-operative Nursing Management

Heart failure management: Monitor for signs of congestive heart failure (CHF) such as tachypnea, tachycardia, feeding difficulties, and sweating. Administer diuretics (e.g., furosemide) and ACE inhibitors as prescribed.

Nutritional support: A 2-month-old with a large VSD often has high metabolic needs. Provide high-calorie formula or frequent, small feedings to reduce energy expenditure. Monitor daily weights carefully to assess growth.

Respiratory monitoring: Monitor for increased respiratory effort, tachypnea, or signs of lung infection, which are common in pulmonary over-circulation.

Parent education & support: Educate parents on medications, signs of distress, and prepare them for surgical procedures.  

Post-operative Nursing Management (ICU & Ward)

Continuous monitoring: Immediately post-op, maintain continuous cardiac, blood pressure, and oxygen saturation monitoring. Watch for arrhythmias, especially heart block or junctional tachycardia.

Hemodynamic stability: Monitor for low cardiac output syndrome. Manage inotropes and fluid intake as ordered.

Wound and tube care: Monitor the chest incision site for signs of infection, and manage chest tubes for drainage volume and characteristics.

Pain management: Provide appropriate analgesia as infants cannot express pain directly.

Preventing complications: Monitor for potential complications like residual shunt, infection (endocarditis), or pericardial effusion.

Long-term and discharge planning

Follow-up care: Ensure appointments are scheduled for echocardiograms (ECGs) to confirm closure and assess cardiac remodeling.

Antibiotic prophylaxis: Teach parents about the need for antibiotic prophylaxis for dental work, as there is a risk of endocarditis for at least 6 months after surgery.

Preventive hygiene: Emphasize good oral hygiene.

Infants generally have excellent outcomes after peri membranous VSD repair, often leading normal lives following this procedure.

Discharge education 

Follow-up: Crucial monitoring for heart block, especially in the first few weeks, is standard.

Recovery & feeding: Babies may tire easily during feeding initially. Proper weight gain is a key indicator of recovery.

Activity: Strenuous activity should be avoided for roughly one month.

When to seek immediate medical attention

  • Fussiness, excessive sweating, or severe fatigue.
  • Difficulty breathing or rapid heartbeat.
  • Signs of infection at the incision site

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