Journal of Clinical Research and Case Studies

Preliminary Results of Ventricular Septal Defect Surgery in Festoc Center in Bamako

Diarra BI^1*, Doumbia M¹, Coulibaly B^1,3, Daffe S¹, Coulibaly B¹, Doucoure O¹, Diallo B¹, Traore S¹, Coulibaly M¹, Koita S¹, Keita A², Toure M^2,3, Diarra MB², Togola B², Togo S², Ouattara MA², and Yena S²

¹Cardio-Pediatric Andre Festoc Center, Mother-Child Hospital Luxembourg, Mali 
²Department of Cardiology, Mother-Child Hospital Luxembourg Bamako, Mali 
³Faculty of Medicine and Odontostomatology, University of Technical Sciences and Technologies of Bamako, Mali

*Corresponding author
Baba Ibrahima Diarra, Cardio-Vascular and Thoracic Surgeon, Mali. Tel: +223-93336396.

ABSTRACT
Interventricular septal defects are dehiscences of the interventricular septum connecting the systemic and pulmonary circulations. 

The aim of this study is to report the preliminary results of the first series of intraventricular septal defects managed at the Festoc centre in Bamako.  This is a mono-centric, descriptive retrospective study taking place at the FESTOC Centre in the period from 10 September 2018 to 30 April 2023. Patients of any age and sex, operated for IVC were included. Patients operated abroad were not included.  

We recorded 74 cases of IVC, i.e. 23.19% out of 300 cases. 61% of the patients were male, with a sex ratio of 1.56. The average age was 11 years. Symptoms were dominated by dyspnoea and recurrent bronchitis in 67.21% and 49.18% respectively. Peri-membrane and admission topography were dominant, with rates of 84% and 10% respectively. The mean duration of ECG was 122 min. In our series of 74 patients, there were 4 in-hospital deaths, representing a mortality rate of 5%.

Keyword: Surgery, Ventricular Septal Defect, Festoc Center, Bamako Keyword: Surgery, Ventricular Septal Defect, Festoc Center, Bamako

Introduction
Interventricular septal defect (VSD), one of the most common congenital heart defects, is the presence of a more or less large orifice in the interventricular septum, resulting in a high-pressure left-to-right shunt and the risk of pulmonary arterial hypertension [1]. Despite the difficulties of screening for congenital heart disease in sub-Saharan Africa, a number of patients are diagnosed and treated before irreversible complications occur [2,3].

In Mali, some work has been carried out on congenital heart disease, with prevalence reaching 56.7%, or 39.4% of CIV. [4,5].

Materials and Methods
This is a prospective and retrospective, mono-centric descriptive study that took place at the André FESTOC centre of the Mother and Child University Hospital Centre “le Luxembourg” in Bamako, Mali.

It took place over a 4-year period from 10 September 2018 to 30 April 2023.

Inclusion Criteria
Patients of any age and sex operated for IVC were included in the study.

Non-inclusion Criteria

• The following were not included  
• Patients admitted for non-operated IVC;
• Patients operated on for CIV operated on abroad.

Data analysis: Data were entered and analysed using EPI INFO software.

Results
A total of 80 patients underwent surgery during this period. Socio-demographic data Sixty-one percent (61%) of the patients were male and 39% female, with a sex ratio of 1.56. The 0-5 age group was the most affected, at 47.54%, with a standard deviation of 1.84. The 6-10 age group accounted for 34.43%, the 11-15 age group for 13.11%, and the over-16 age group for 4.92%. The mean age was 11 years, with extremes of 2 and 21 years. Clinical signs Circumstances of discovery. The circumstances of discovery were dominated by dyspnoea and recurrent bronchitis in 67.21% and 49.18% of cases respectively. The other circumstances of discovery were a murmur on cardiac auscultation (27.87%), cough (26.23%) and growth retardation (6.56%) (Figure 1).

Tachycardia and crepitus were the most common physical signs in 63.93% and 16% of cases respectively.

Paraclinical Signs
Cardiomegaly was found in 67.30% of cases and hypervascularised lung parenchyma in 92% of cases.

All patients had sinus rhythm, but 70.49% of these patients presented with tachycardia. Left ventricular hypertrophy was noted in 3.28% of cases and left atrial hypertrophy in 1.64%.

Perimembranous and admission topography were dominant, with rates of 84% and 10% respectively. It was just arterial in 6% of cases.

The majority of our patients had an interventricular septal defect with a diameter greater than 7 mm (87%) (Figure 2 and 3).

On pre-operative cardiac ultrasound, the left ventricular ejection fraction was preserved in all patients. Pulmonary hypertension was found in 50.04% of patients, pericardial effusion in 18% and dilated vena cava in 11.48%.

Ventricular septal defect was associated mainly with mitral insufficiency in 75.41% of cases. The other associated pathologies were atrial septal defect (11.47%), aortic insufficiency (75.41%), tricuspid insufficiency (36.06%), patent ductus arteriosus (9.83%), patent foramen ovale (11.7%) and subaortic diaphragm (19.67%) (figure 3).

The IVC was closed using either an autologous patch (62%), a heterologous patch (35%) or direct suture (3%). (Figures 4 and 5)

Resection of the sub-aortic membrane was associated with cure of VSD (18.03%) and tricuspid plasty (16.39%) (Figure 6).

All procedures were performed under conventional extracorporeal circulation, with an average duration of 122 min (51min to 194min). In 9.84% of cases it was less than 60 minutes, in 67.21% between 60 and 140 minutes and in 22.95% of cases more than 140 minutes. The majority of patients underwent aortic clamping for 60 minutes or less (44.26%).

Table 1:

Clamp Time	Frequency	Percentage
< 60	37	44,26%
60-80	18	21,31%
> 80	25	34,43%
Total	80	100%

Right ventricular dysfunction was noted in 91.23% of cases and residual IVC in 54% of cases. There was minimal pericardial effusion in 47.54% of patients and minimal tricuspid insufficiency in 22.95% of patients.
Echocardiography performed one month after the operation showed right ventricular dysfunction in 87.27% of patients, 52.67% had residual IVC and 1 patient had endocarditis at 1 month post-op (table 2).

In our series of 80 patients, there were 4 in-hospital deaths, giving a mortality rate of 5%.

Table 2: Distribution of Transthoracic Echocardiographic Abnormalities at One Month Post-Operatively

Parameter	Fréquency	Percentage
Left ventricular Dysfunction	0	0%
Right ventriculaire Dysfunction	48	87,27%
NO pulmonary arterial hypertension	12	20,68%
Moderate pulmonary arterial hypertension	36	62,06%
hight pulmonary arterial hypertension	10	17,24%
CIV résidual VSD	30	52,67%
Infective endocarditis	1	1,72%
Pericardial effusion	1	1,72%
Aortic regurgitation	11	18,96%
Mitral regurgitation	25	43,10%
Tricuspid regurgitation	10	17,24%

Two (2) patients died between 1 and 6 months, 1 after more than 6 months and 1 in intensive care after less than one month. 

Deaths were due to sepsis in 2 cases, infective endocarditis in 1 case and low cardiac output secondary to a pulmonary hypertensive crisis in 1 case.

Discussion
Isolated IVC is the most common cardiac malformation, accounting for at least 30-40% of all cardiovascular malformations in infants. [7-10]. 

In our study we found a clear male predominance. The same deduction was made by Lupoglazoff et al [6]. However, other studies have found no gender predominance [6]. In our study, the age of diagnosis varied between 6 and 12 years, with an average age of 8 years. However, the majority of patients in KANGAH K.M were under 5 years of age [11]. In a study carried out in Paris between March 1988 and March 1993, the diagnosis was made early, and 84% of patients were less than one year old. In previous years, the diagnosis was made much later, with a mean age of diagnosis of 20 +/- 8 months for certain series [12]. It should be noted that the prevalence of VIC in premature newborns seems to be similar to that found in children born at term [13].

The cause of VIC is unknown in the majority of cases. A Finnish study showed that maternal alcohol consumption during the first trimester was the primary factor in inducing VIC, followed by occupational exposure to organic solvents [14]. However, the risk of developing VIC does not seem to be linked to maternal smoking habits, coffee, tea or cola consumption, or the use of aspirin or diazepam.

According to Hernández-Díaz folic acid antagonists, including trimethoprim, triamterene, carbamazepine, phenytoin, phenobarbital, and primidone, may increase the risk of IVC, whereas folic acid may reduce the risk [15]. 

Recent studies conclude that exposure to ACE inhibitors during the first trimester of pregnancy cannot be considered safe and should be avoided while others are investigating the influence of gene factors on VIC. At present, therefore, there is no consensus on the aetiopathogenesis of VIC [16,17].

It should be noted that in trisomy 21, VIC is the most frequent cardiac malformation after the atrioventricular canal. It should be noted that these patients develop PAH earlier, necessitating more rapid surgical management [14]. 

The indication for IVC surgery depends on: - the anatomical type, - the size of the defect, - the degree of shunt, - pulmonary vascular resistance, - functional tolerance, - associated anomalies such as aortic insufficiency, pulmonary infundibular stenosis, etc [14].

Surgical closure reduces the risk of infective endocarditis, reduces PAH, improves functional symptomatology and long-term survival [11]. Young age is no longer a limiting factor for a complete cure, which can be achieved even in the first six months of life, with results identical to those of patients operated on later in life [18].

Perimembranous VSMCs have a different evolutionary profile to that of trabeculated muscular VSMCs. They constitute the vast majority of large or medium-sized VICs requiring surgery before the age of 1 year but the proportion of perimembranous VICs operated on varies from 10 to 40% depending on the series [19-21]. In our study, perimembranous VICs were in the majority, representing 66% of VICs operated on.

The most commonly used approach is median sternotomy although some teams use thoracotomy [22,23].

In our series, a conventional median sternotomy was performed in all cases. The choice of approach to the lesion depends on the location and size of the IVC.

Most perimembranous septal defects and many trabeculated septal defects can be closed by the right atrial approach [24]. This approach significantly reduces the incidence of complete right bundle branch block, frequently encountered after ventriculotomy [25]. 

The IVC was approached by right atriotomy in 98.36% of cases in our series and by right ventriculotomy in 1.64% of cases.

In that of KANGAH K.M., the IVC was approached by right atriotomy in 87.4% and right ventriculotomy in 12.6% [26].

In our study, all the procedures were performed under conventional extracorporeal circulation, with a mean duration of 122 min and a range of 51 to 94 min.

Our results are consistent with those of KANGAH in ROI, where the mean duration was 113 min with a range of 45 to 330 min [26-28].

References

1. Lucile Houyel (1998) Embryologie Cardiaque. EMC Cardiologie 11-001-C-10
2. Kramoh KE, Anzouan-Kacou JB, Harding-Tanon DE (2007) Facteurs concourants au diagnostic tardif des cardiopathies congénitales. Cardiol Trop 33: 29-31.
3. Mc Daniel NL (2001) Ventricular and atrial septal defects. Ped Rev 22: 265-270.
4. Traoré B (1977) Les cardiopathies congénitales. Th Med Bamako 22.
5. Terra AW (2012) Cardiopathies juvéniles opérables et/ou opérées au service de cardiologie de l’hôpital Gabriel Touré. Th Méd 96.
6. Lupoglazoff JM, Magnier S, Olivier B, Casasoprana A (1994) Indications et résultats opératoires de 50 communications interventriculaires isolées, mal tolérées, dans la première année de vie. Archives des maladies du cœur 87: 667-672.
7. Reller MD, Strickland MJ, Riehle-Colarusso T, Mahle WT, Correa A (2008) Prevalence of congenital heart defects in metropolitan Atlanta, 1998-2005. J Pediatr 153: 807-813.
8. Ejim EC, Ike SO, Anisiuba BC, Onwubere BJ, Ikeh VO (2008) Ventricular septal defects at the University of Nigeria Teaching Hospital, Enugu: a review of echocardiogram records 2008 Royal Society of Tropical Medicine and Hygiene. Trans R Soc Trop Med Hyg 103: 159-161.
9. Lewis DA, Loffredo CA, Correa-Villaseñor A, Wilson PD, Martin GR (1996) Descriptive epidemiology of membranous and muscular ventricular septal defects in the Baltimore-Washington Infant Study. Cardiology in the Young 6: 281-290. 
10. Bosi G, Scorrano M, Tosato G, Forini E, Chakrokh R (1999) The Italian multicentric study on epidemiology of congenital heart disease: first step of the analysis. Working party of the Italian Society of Pediatric Cardiology. Cardiol Young 9: 291-299. 
11. Ellis 4th JH, Moodie DS, Sterba R, Gill CC (1987) Ventricular septal defect in the adult: natural and unnatural history. Am Heart J 114: 115-1120.
12. M’pemba Loufoua LE, Johnson EA (2005) Les cardiopathies congénitales observées dans le service de pédiatrie grands enfants du CHU de Brazzaville, à propos de 73 cas :aspects épidémiologiques.Médecine d’afrique noire 52: 173-177.
13. Zhong-Dong Du, Nathan Roguin, Mila Barak, Sandra Glusman Bihari, Mordechai Ben-Elisha (1996) High Prevalence of Muscular Ventricular Septal Defect in Preterm Neonates - The American Journal Of Cardiology 78: 1183.
14. Tribak M, Marmade L, El kouache M, El Moktadir K, Abdallah H, et al. (2008) Résultats de la fermeture chirurgicale des communications interventriculaires à tous les âges. À propos de 30 cas. Annales de Cardiologie et d’Angéiologie 57: 48-51.
15. Sonia Hernández-Díaz, Martha M Werler D, Alexanderm Walker, Allen A Mitchell (2000) Folic Acid Antagonists During Pregnancy and the Risk of Birth Defects - New England Journal of Medicine 343: 1608-1614.
16. William O Cooper, Sonia Hernandez-Diaz, Patrick G Arbogast, Judith A Dudley, Shannon Dyer, et al. (2006) Major Congenital Malformations after First-Trimester Exposure to ACE Inhibitors - The New England Journal of Medicine 354: 2443-2451.
17. Hao Zhang, Lei Zhou, Rong Yang, Yanhui Sheng, Wei Sun, et al (2006) Identification of differentially expressed genes in human heart with ventricular septal defect using suppression subtractive hybridization - Elsevier - Biochemical and Biophysical Research Communications 342 : 135-144.
18. Chambran P, Maatouk M, Bruniaux J, Lacour-Gayet F, Binet JP, et al. (1989) Réparations des communications interventriculaires avant l’âge de 6 mois. À propos d’une série de 194 nourrissons. Arch Mal Coeur 82: 723-728.
19. Vaillant MC, Chantepie A, Cheliakine C, Nashashibi M, Pottier JM, et al. (1992) Apport de l’échocardiographie bidimensionnelle dans la prédiction de fermeture spontanée des communications interventriculaires du nourrisson. Arch Mal Cœur 85: 597-601.
20. Turner SW, Hunter S, Wyllie JP (1999) The natural history of ventricular septal defect. Arch Dis Child 81: 413-416.
21. Joly H, Dauphin C, Motreff P, Boeuf B, Lusson JR (2004) Communication interventriculaire du nourrisson. Évolution à court terme (série prospective de 89 cas). Arch Mal Coeur 97: 540-545.
22. Jonah Odim, Raj Vyas, Hillel Laks, Azie Alikhani, Umang Mehta, et al. (2005) Redo Submammary Incision for Median Sternotomy and Cardiac Repair – Ann Thorac Surg 79: 163-167.
23. Yi-Cheng Wu, Chau-Hsiung Chang, Pyng Jing Lin, Jaw-Ji Chu, Hui-Ping Liu, et al. (1998) Minimally invasive cardiac surgery for intracardiac congenital lesions – European Journal of Cardio-thoracic Surgery 14: S154-S159.
24. Demetre M Nicoloff, Rolando Zamora, Aldo R Castaneda, James H Moller, Carl E Hunt, et al. (1971) Transatrial Closure of High-Pressure, HighResistance Ventricular Septal Defects – Journal of Pediatric Surgery 6: 650-656.
25. Susan M Hobbins, Teruo Izukawa, Dorothy J Radford, William G Williams, George A Trusler (1979) Conduction disturbances after surgical correction of ventricular septal defect by the atrial approach – British Heart Journal 41: 289-293.
26. Kangah KM, Souaga KA, Amani KA, Kirioua-Kamenan A, Kendja KF (2008) Résultats du traitement chirurgical des communications inter ventriculaires dans un pays en développement (experience de l’institut de cardiologie d’abidjan) Rev Int Sc Méd 10: 60-64.
27. Tikkanen J, Heinonen OP (1991) Risk Factors for Ventricular Septal Defect in Finland - Public’ Health 105 : 99-112.
28. Jianrong Li, Yinglong Liu, Cuntao Yu, Bin Cui, Ming Du (2008) Comparison of Incisions and Outcomes for Closure of Ventricular Septal Defects. Ann Thorac Surg 85: 199-203.