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eComment. Ventricular septal defect correction in patients with severe pulmonary hypertension.

Pulmonary hypertension secondary to increased pulmonary vascular resistance (PVR) is one of the most important determinants of operative morbidity and mortality as well as long-term survival after repair of a left-to-right shunt. We read with interest the paper of Talwar et al. [1] about the use of a unidirectional valved patch (UVP) for ventricular septal defect (VSD) correction in patients with severe pulmonary hypertension. The reported result looks very optimistic. We have also had some experience with such an approach but ours was not so impressive. Since 1997, 15 patients have been operated on with a similar technique. There were two hospital deaths and one case of the infective endocarditis on follow up. 
 
Now, there is no doubt that the survival of patients with Eisenmenger's syndrome is much better with UVP than after corrective surgery with residual high pulmonary hypertension. This is why the indication for VSD closure even with valved patch must be precisely verified. Sometimes it is very difficult to make a decision. Indications for open heart surgery in our centre are completely based on acute vascular reactivity test data. If the increased PVR is found to be “‘reactive,” the shunt may usually be closed, but the risk of surgical repair is high. In our practice, we use the two-stage approach proposed by Batista et al. [2] in 1997. The hospital mortality after banding procedure was less than 4% (78 cases) and there were no deaths after total correction of VSD (46 cases). 
 
Nevertheless, the excellent results of this series suggest that the unidirectional valve patch technique may be a valuable surgical tool.