Short- and long-term outcomes
The overall reported perioperative mortality for patients undergoing conventional repair of multiple septal defects, including the Swiss-cheese variety, has been cited to be between zero and 14.2%.1-15,29-62 The causes of death were due to intractable pulmonary hypertensive crises, residual defects, and congestive cardiac failure. The requirement of reoperation for residual defects has been between 6 and13%, with a reoperative mortality of around 33%.1-15,29-62 The STS Congenital Heart Surgery Spring 2017 Database provides results from 116 participating centers on 7322 operations for ventricular septal defects over 4 years with a mean operative mortality of 0.6%, mean cardiopulmonary bypass time of 77 minutes and cross-clamp time of 49 minutes.29-32 Repair for multiple defects, their “category 2”, accounted for 4.5% of operations, with an operative mortality of 2.6%, requirement of mechanical circulatory support in 2.6%, and the need for a permanent pacemaker in 3.4% of cases. When compared with isolated perimembranous defects, the rate of mortality was thrice as high with multiple defects, the rate of reoperation was over 4 times higher with muscular defects, and the rate of heart block was 3 times higher with muscular and multiple septal defects.1,29-32 It is not possible, however, to interrogate the registry according to outcomes for the different anatomical subsets.
Opinion is divided on the recommendation of limited apical left ventriculotomy for closure of apical defects. Although favorable short- and long-term results have been reported by some investigators, others have reported left ventricular dysfunction apical aneurysm formation, and ventricular arrhythmia in long-term survivors undergoing left ventriculotomy.2,41,43,46,47,57-60,61,65
Recent results of use of devices inserted percutaneously to close multiple septal defects have allegedly been encouraging.19-28,54,55,66,75,76 In terms of outcomes, nonetheless, in some of these small series rates of mortality have been between 14 and 24%, with rates of failure between 20 and 40%.53,75,76 In a combined series, Holzer and associates reported the results of a multicentric trial involving 14 tertiary referral centers in the United States of America. They collected outcomes from 75 treated patients, finding a total of 59 (45%) adverse events, and 10.7% major procedure-related complications, including device embolization, cardiac perforation, stroke. There were two deaths (2.7%).20-28,60,66-70,75