Abstract
Background: Ventricular
septal defect (VSD) is one of the most common congenital cardiac
defects, However, in some cases VSD sites are difficult to expose due to
obstruction from chordal attachments and leaflets of the tricuspid valve
(TV)6. To systematically review the efficacy and
safety of tricuspid valve detachment,( TVD) versus conventional surgical
repair ( non-TVD) in the treatment of ventricular septal defect ( VSD)
.This article is aimed to compare the many outcomes from existing
studies and provide evidence regarding the necessity of performing TVD.
Methods: We searched the following databases: PubMed via NCBI,
the Cochrane Central Register of Controlled Trials (no date
restriction),Medline via Ovid (from 1966 to May 2020); Embase via Ovid
(no date restriction) and China National Knowledge Infrastructure for
studies comparing the efficacy of tricuspid valve detachment (TVD) and
other surgical techniques in VSD repair. Cardiopulmonary bypass time,
Cross-clamp time; postoperative complications including residual defect
,Postoperative atrioventricular block ,Implantation of pacemakers,
tricuspid regurgitation ;Length of stay, Length of ICU stay were
analyzed.
Results: Only 9 studies were included after selection (Table
1), including 7 retrospective cohort studies, 1 respective cohort study
and 1 prospective observational stud,a patient pool of 1404 patients
with 374 underwent TVD and 1030 underwent non-TVD procedures,met the
inclusion criteria.Meta analysis has drawn to the following
conclusions. Firstly, TVD prolongs CPB time (MD=7.75, 95%
CI=2.60-12.89, p=0.003) and cross-clamp time(MD=7.77, 95%
CI=4.76-10.78, p<0.001) compared with non-TVD techniques in
VSD repair surgeries. Secondly, no significant difference exists in LOS,
length of ICU stay, postoperative atrioventricular block, implantation
of pacemakers, incidence of ≥mild TR postoperatively and at discharge,
as well as incidence of ≥small residual VSD after surgery and during
follow-up( all P > 0. 05). Thirdly, application of TVD increases the
risk of TR during follow-up(OR=2.42, 95% CI=1.55-3.76,
p<0.001).
Conclusion: VSD closure using TVD technique results in longer
CPB and cross-clamp time, and increases risk of TR during follow-up. TVD
provides equally viable and safe alternative in treating VSD.
【Key words】Ventricular septal defect; Tricuspid valve detachment; Meta
analysis
Introduction
Ventricular septal defect (VSD) is one of the most common congenital
cardiac defects, occurring in 3570 infants per million live births on
average1. Surgical closure of VSD was first attempted
by Lillehei and colleagues in 19552, and after six
decades of surgical practice and technical iteration, nowadays cardiac
surgeons can minimize the mortality rate after VSD repair thanks to
comprehensive application of cardiopulmonary bypass (CPB) practices,
myocardial preservation techniques, improved anesthesia and careful
postoperative care3-5.
The transatrial approach for VSD repair is most widely accepted surgical
technique and can enable adequate exposure of the margins of the defect,
thus facilitate complete repairs. However, in some cases VSD sites are
difficult to expose due to obstruction from chordal attachments and
leaflets of the tricuspid valve (TV)6. Incomplete
repair of VSD increases the incidence of morbidities like complete heart
block, tricuspid valve regurgitation (TR) and residual VSD, leading to
compromised surgical efficacy or even death5-7.
To achieve optimal visualization of hard-to-expose VSD, detachment of
the TV, radical incision of the TV from leaflet edge to the annulus or
detachment of chordal have been suggested, and existing data shows
promising results8-10. However, controversies
surrounding whether or not tricuspid valve detachment (TVD) procedure
should be performed on patients still exists, some specialists argue
that TVD may prolong CPB time and cross-clamp time5,7;
whereas some others believe when following certain inclusion criteria
for TVD, the procedure can significantly improve surgical
efficacy11. This article is aimed to compare the many
outcomes from existing studies and provide evidence regarding the
necessity of performing TVD.
Methods