Ventricular Septal Defect with Patent Ductus Arteriosus
A Clinical and Hemodynamic Study
Twenty-two patients with the combined lesions of ventricular septal defect and patent ductus arteriosus, proved at cardiac catheterization, are reviewed in detail in regard to their clinical profile, hemodynamic data, and indications for, and results of, surgical repair.
The incidence of this combination of lesions is not so uncommon as would be anticipated by the paucity of the reports in the medical literature. The diagnosis of both lesions is important for management and surgical technic.
The striking findings by physical examination are the gross undernourishment and the wide pulse pressure in the great majority. Almost all have harsh systolic murmurs along the mid left sternal border and only 2 had continuous Gibson murmurs. Consequently, auscultation is of little help in delineating the presence of an associated patent ductus arteriosus.
The electrocardiogram is of minor importance in the diagnosis of this combination of lesions. Roentgenograms in the majority show features common to either lesion alone although the frequency with which left atrial enlargement is found appears to be greater in this combination of lesions.
Careful hemodynamic studies are crucial in the diagnosis of these 2 lesions. At the ductal level passage of the catheter establishes the diagnosis, or an increase in oxygen saturation greater than 5 per cent in comparison to the right ventricular blood strongly suggests the presence of a patent ductus arteriosus. The great majority of the ventricular septal defects were diagnosed by an increase in the oxygen saturation of 10 per cent or greater at the ventricular level. Almost all had pulmonary artery hypertension.
Thirteen patients had surgical intervention; 9 had only closure of the patent ductus arteriosus alone and 4 had complete repair of the lesions. In the former group there were 2 deaths and 2 improved significantly. In the latter group there were 2 surgical deaths and 2 were markedly improved. The 2 surgical deaths appear to be directly related to the massive hemorrhage through the unsuspected patent ductus arteriosus while on cardiac bypass and the subsequent technical difficulty of closing both defects from an anterior thoracotomy.
The relationship of calculated pulmonary vascular resistance to surgical closure of the defects is discussed.
It is suggested that if the patent ductus arteriosus is diagnosed on the basis of a typical machinery murmur, correction of this lesion is indicated, irrespective of the associated ventricular defect. If, on the other hand, the clinical picture is suggestive of a ventricular defect alone and the presence of the combination of lesions is discovered only at catheterization, then simultaneous correction of the 2 lesions is recommended. In small infants in whom the combined operation is particularly difficult at the present time, a preliminary trial of medical management is recommended; only if this fails to accomplish the expected result should division of the ductus be undertaken.
- © 1960 American Heart Association, Inc.