Fluorescein dye-guided intraoperative identification and closure of muscular ventricular septal defect

Objective: Various techniques for intraoperative identification of muscular ventricular septal defects (VSDs) are cumbersome, difficult to use in infants, and inefficient in confirming the completeness of closure. We used simple technique of intraoperative fluorescein saline injection into the left ventricle to locate the muscular VSDs and to confirm their closure.

Methods: This is a prospective observational study conducted between April 2013 to December 2013, involving 22 patients with multiple VSDs either in isolated form or in association with other congenital cardiac anomalies. Following the closure of all visible VSDs, an 8F infant feeding tube was introduced into the left ventricle through the fossa ovalis and fluorescein saline was injected. Right ventricle was observed for saline leakage and VSD site tracking. Saline injection was repeated till appearance of no significant leak.

Results: A total of 63 defects were closed in 22 patients. Only two patients required re-endocardialization or septal exclusion technique for Swiss cheese septum. None of them required division of moderator band or major trabeculae. Eleven patients had insignificant residual shunting found on postoperative echocardiography. There were two deaths. In the remaining 20 patients, the mean of intensive care unit (ICU) and hospital stay was 5.4 ± 3.72 and 10.2 ± 4.64 days, respectively. Comparative study between patients with and without residual VSD showed no significant difference in mean inotropic score, ICU, and hospital stay, confirming the absence of significant residual shunting.

Conclusions: Intraoperative fluorescein saline injection into the left ventricle is safe, effective in precisely localizing muscular VSDs and confirming the completeness of their closure.