When is the best time for children with ventricular septal defect to undergo surgery? What should be paid attention to after the operation?

Author: Lv Zhenyu, deputy chief physician, Beijing Children's Hospital, Capital Medical University

Reviewer: Jin Mei, Chief Physician, Beijing Children's Hospital, Capital Medical University

Ventricular septal defect is a congenital heart disease with a relatively good prognosis. With timely diagnosis and treatment, most patients can resume normal life like ordinary healthy people after surgery, including future education, employment, marriage and childbirth, and life expectancy, without being significantly affected.

If not discovered and treated in time, severe pulmonary hypertension will occur, and the surgical effect will be poor or the opportunity for surgery will be lost. Long-term or lifelong medication to reduce pulmonary artery pressure will be required. The exercise tolerance of such children, including marriage and childbearing, will be affected, and their long-term life expectancy will also be shortened.

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1. When is the best time to undergo surgery for children with ventricular septal defect?

The timing of surgery for children with ventricular septal defect (VSD) requires a comprehensive assessment of defect size, location, symptoms, age, and risk of complications. The following are general principles:

1. Small defect (diameter <5mm)

Watch and wait: Check for the possibility of natural shrinkage or closure. Perform echocardiograms regularly every 3-6 months, and have a specialist assess whether surgery or interventional treatment is needed.

2. Medium to large defects (diameter ≥ 5 mm)

Indications for early surgery:

Symptoms are obvious: recurrent respiratory tract infections, feeding difficulties, developmental delay, and heart failure (when not well controlled by medication).

Pulmonary hypertension: Ultrasound or cardiac catheterization shows a progressive increase in pulmonary artery pressure, requiring surgery before irreversible pulmonary hypertension (Eisenmenger syndrome).

Age: If symptoms are severe, surgery may be performed at 3-6 months of age; if there are no symptoms but the defect is large, it is recommended to complete the surgery before 1-2 years of age.

3. Special circumstances

Severe heart failure in the neonatal period: Urgent surgery is required (eg, within the first few weeks of life).

Combined with other heart malformations (such as aortic valve prolapse, right ventricular outflow tract obstruction): surgery is required as early as possible (possibly as early as 3-6 months of age).

Interventional occlusion: Suitable for muscular or partial perimembranous defects. It is usually recommended that children weigh ≥ 10 kg (approximately over 3 years old) to reduce the risk of vascular complications.

Recommendation: Most symptomatic VSDs should be surgically performed between 6 months and 2 years of age to avoid pulmonary vascular disease.

Tip: Parents should avoid blindly waiting for "self-healing", especially for children with medium or large defects or at risk of complications. Timely surgery can significantly improve the prognosis.

2. What preparations need to be made before ventricular septal defect surgery?

1. Ultrasound of the heart (echocardiogram)

Purpose: To determine the defect location, size, shunt direction, cardiac function, and whether there are other malformations (such as pulmonary hypertension, aortic valve prolapse, etc.).

Frequency: At least one detailed ultrasound examination should be completed before surgery, and some complex cases may require multiple evaluations.

2. Electrocardiogram (ECG)

Assess the heart's electrical activity to rule out arrhythmias or myocardial ischemia.

3. Chest X-ray

Observe the size of the heart and the increase in pulmonary blood flow to assist in determining pulmonary hypertension.

4. Cardiac catheterization (necessary for some children)

Applicable situations: suspected severe pulmonary hypertension or need to accurately measure pulmonary vascular resistance.

Evaluation indicators: pulmonary vascular resistance (PVR), pulmonary circulation/systemic blood flow ratio (Qp/Qs).

5. Blood test

Routine blood tests, coagulation function, liver and kidney function, electrolytes, infection screening (such as hepatitis B, syphilis, HIV), etc. are performed to assess the overall condition.

6. Infection Control

Respiratory tract infection: Before surgery, you need to ensure that you do not have any infection such as cold or pneumonia, otherwise the surgery will need to be postponed.

Skin infection: Check the skin for damage or infection (such as eczema, impetigo).

Oral infection: Dental caries and gingivitis need to be treated in advance to avoid postoperative bacteria entering the blood and causing endocarditis.

7. Nutritional support

Children with malnutrition or developmental delay need to strengthen their nutrition (high-protein, high-calorie diet) and, if necessary, improve their physical condition through nasogastric or intravenous nutrition.

8. Medication Adjustment

Anti-heart failure drugs: such as digoxin, diuretics (furosemide), and ACEI drugs (such as captopril) should be used continuously until the day of surgery as prescribed by the doctor.

Stop taking anticoagulants: If the child is taking anticoagulants such as aspirin, they should be stopped one week before surgery (follow the doctor's advice).

Of course, parents of children with the disease should be fully prepared mentally and understand the corresponding risks of the surgery:

First, residual shunt: The incidence rate is about 5%-10%. Most of them can close on their own, but severe cases require secondary surgery or interventional closure.

Second, valve damage: if the defect is large, surgery will cause aortic valve insufficiency and aortic valve regurgitation; it will also partially affect the function of the tricuspid valve and cause tricuspid valve regurgitation.

Third, damage to the transmission system: atrioventricular block may occur after surgery, such as third-degree atrioventricular block, with a probability of about 1%. In severe cases, a pacemaker may be required.

3. What issues should be paid attention to after ventricular septal defect surgery?

First, postoperative environmental management

1. Reduce the risk of cross infection

Environmental requirements: Keep the room quiet and well ventilated within 1 month after surgery, and disinfect and clean it daily (especially toys and bedding that the child comes into contact with).

Visiting restrictions: Avoid crowded visits by relatives and friends, and those with symptoms such as cold, fever, herpes, etc. are not allowed to contact the sick children.

Protection when going out: Do not go to crowded places unless necessary, and wear a mask when going out (can be tried by people over 2 years old).

Second, postoperative feeding and nutrition

1. Total feeding quantity control

Principle: Follow the principle of "small amounts and frequent feedings" within 1 month after surgery, and the amount of milk/food consumed at a single feeding should not exceed the stomach capacity (infant stomach capacity ≈ 30ml/kg).

Reference standards:

Total fluid volume: 80-120 ml/(kg·d) (including milk, water, etc.), which needs to be adjusted individually according to cardiac function and urine volume.

Example: The total daily intake for a 6kg infant is approximately 480-720ml, divided into 8-12 feedings.

Abnormal signs: If choking, sweating, or rapid breathing occurs while feeding, stop feeding and contact a doctor.

2. Nutritional fortification

Breast milk/formula: Breast milk fortifiers or high-calorie formula (such as premature infant formula) can be added to promote postoperative recovery.

Addition of complementary food: Postpone the introduction of new complementary food within 1 month after surgery to avoid indigestion that increases the burden on the heart.

Third, core infection prevention measures

1. Respiratory protection

Warmth and breathability: Choose clothes made of pure cotton, and add or remove clothes flexibly according to the room temperature (warm neck and back without sweat is best) to avoid heatstroke syndrome.

Air purification: Use an air purifier or open windows for ventilation regularly to avoid exposure to smoke and dust.

2. Skin and oral care

Wound protection: Avoid getting the incision wet within 2 weeks after surgery, and observe the incision daily for redness, swelling, and exudation.

Oral cleaning: After feeding, give the baby a small amount of warm water to "rinse the mouth". You can use a sterile cotton swab dipped in saline to gently wipe the gums (especially for those taking cardiotonic medications).

Fourth, drug management standards

1. Medication that must be strictly followed

Cardiotonic drugs (digoxin): Measure the heart rate before taking. If the heart rate is less than 90 beats/minute for infants or less than 70 beats/minute for children, stop taking the drug and seek medical attention. Avoid taking the drug with calcium-containing foods (two hours apart).

Diuretics (furosemide): Record daily urine volume and weight. If urine volume decreases suddenly or eyelid edema occurs, follow-up consultation is required. Supplement potassium-containing foods (such as mashed bananas and orange juice) to prevent hypokalemia.

2. Special medications for pulmonary hypertension

Targeted drugs (such as bosentan, sildenafil): Regular monitoring of liver function (every 3 months) and pulmonary artery pressure (ultrasound follow-up) is required.

Important reminder: Do not reduce or stop taking medication without authorization. Even if symptoms improve, a doctor's evaluation is required.

Fifth, wound care and cleaning

1. Timing of stitch removal and bathing

Chest incision: The stitches will be removed 7-10 days after surgery. After the stitches are removed, you need to wait for the scab to fall off naturally (usually another 5-7 days) before you can take a shower.

Alternative cleaning plan: Before removing the stitches, you can wipe your body with a warm and wet towel, avoiding the incision. Do not take a bath in a tub within 2 weeks after the operation.

2. Warning signs of infection

If the incision becomes red, swollen, exudates, the fever is >38°C, or the child cries abnormally, you should seek medical attention immediately to rule out infective endocarditis.

Sixth, activity and rehabilitation guidance

1. Within 1 month after surgery:

Do not engage in behaviors that increase chest pressure, such as lying on the stomach, crying violently, running and jumping, and do not support the head, neck and back when picking up the baby.

2. 1-3 months after surgery:

The amount of activity can be gradually increased, but falls and collisions (such as slides and trampolines) must still be avoided.

Seventh, long-term management of children with pulmonary hypertension

1. Medication compliance:

Those who take medication for life need to set up mobile phone reminders and make a medication record sheet (time, dosage, adverse reactions).

2. Home monitoring:

Record the breathing rate when the baby is at rest every day (be vigilant if the baby is >50 times/minute). Observe whether the lips and nail beds are cyanotic (transient cyanosis during crying requires reexamination).