Download Morphologic demonstration of spontaneous and

Morphologic demonstration of spontaneous and surgical
closure of membranous ventricular septal defect
Jong Mi Ko, BA, Joseph E. Guileyardo, MD, Jun Zhang, MD, and William C. Roberts, MD
This report demonstrates morphologic features of membranous ventricular septal defect that was closed spontaneously in one patient and
operatively in the other.
R
elatively few reports have illustrated morphologically
either spontaneous or surgical closure of membranous
ventricular septal defect (VSD) (1–10). Such is the
purpose of this report.
DESCRIPTION
Certain findings in each of the two patients are summarized in Table 1. Patient 1 died from multisystem failure,
primarily consequences of severe obesity. Necropsy disclosed
an isolated membranous VSD that had closed spontaneously
by the adhesion of the septal tricuspid valve leaflet to the
margins of the defect (Figure 1). A small, thin layer of fibrous
Table 1. Certain clinical and necropsy findings in the two white
men with a membranous ventricular septal defect that was
closed by two different mechanisms
Variables
Type of closure
Patient 1
Patient 2
Spontaneous
Surgical
Age (years) at examination of heart
71
48
Age (years) at surgical closure of VSD
–
5
44.5
19.8
0
+
Body mass index (kg/m2)
Precordial murmur
Heart block
Complete
–
ICD/pacemaker
+
+
Died
+
0 (Transplant)
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600
Myocardial infarct
0
+*
Heart floated in formaldehyde
+
0
Heart weight (g)
*Secondary to operative damage of the left circumflex coronary artery at the time of
mitral valve replacement for severe mitral regurgitation at age 32.
ICD indicates implantable cardioverter defibrillator; VSD, ventricular septal defect;
–, not available.
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tissue presumably produced by the left-to-right shunt jet
flow through the VSD was present on the mural endocardium in the right ventricular outflow tract in apposition to
the “VSD.”
Patient 2 had an atrioventricular canal defect, which was
closed at age 5 years. At age 31 years, he was found to have
severe mitral regurgitation and underwent mitral valve replacement with inadvertent left circumflex coronary artery injury,
resulting in one-vessel coronary artery bypass grafting. He developed heart failure symptoms at age 47 and underwent heart
transplantation a year later. Pathologic examination of the native heart revealed the surgically closed previous membranous
VSD (Figure 2).
DISCUSSION
Both patients presented in this report had VSDs located
immediately caudal to the right aortic valve cusp. One closed
spontaneously and the other by operative insertion of a patch.
Spontaneous closure of VSD appears to be much more common
than operative closure. Although this report focuses exclusively
on the membranous location of VSD, muscular VSD, although
much less common than the membranous variety, probably
has a higher rate of spontaneous closure than does the membranous variety. The result of spontaneous closure can easily
be missed at necropsy if the entire ventricular septum is not
carefully examined.
1.
2.
3.
4.
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atresia. Circulation 1963;27:90–94.
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Suzuki H, Lucas RV Jr. Spontaneous closure of ventricular septal defects.
Anatomic evidence in three patients. Arch Pathol 1967;84(1):31–36.
From the Baylor Heart and Vascular Institute (Ko, Zhang, Roberts) and the
Department of Pathology (Guileyardo, Roberts), Baylor University Medical Center
at Dallas.
Corresponding author: William C. Roberts, MD, Baylor Heart and Vascular
Institute, Baylor University Medical Center at Dallas, 3500 Gaston Avenue, Dallas,
TX 75246 (e-mail: [email protected]).
Proc (Bayl Univ Med Cent) 2015;28(4):514–515
a
b
Figure 1. Case 1. Photographs of the basal portion of the heart. (a) Membranous ventricular septal defect (VSD) located immediately below the right aortic valve
cusp was spontaneously closed by the septal tricuspid valve leaflet. (b) A close-up of spontaneous closure of VSD showing the adherence of the tricuspid valve leaflet
(arrow) to the margins of the defect and a dead-end tunnel-like space between the top and bottom portion of the defect. AML indicates anterior mitral leaflet; ATL,
anterior tricuspid leaflet; AV, aortic valve; PML, posterior mitral leaflet; RV, right ventricle; STL, septal tricuspid leaflet; VS, ventricular septum.
a
b
c
Figure 2. Case 2. Photographs of the basal portion of the heart. (a) Membranous ventricular septal defect (VSD) located immediately below the right aortic valve
cusp was closed surgically at age 5 years. (b) A close-up of the surgically closed VSD shows a Teflon patch (arrow) located at the junction of the anterior and septal
tricuspid leaflet just below the aortic valve. (c) A deeper cut of the surgically closed VSD shows the relation of the “defect” to the aorta and aortic valve. ATL indicates
anterior tricuspid leaflet; AV, aortic valve; LV, left ventricle; STL, septal tricuspid leaflet; TV, tricuspid valve; VS, ventricular septum.
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septal defect: necropsy study of five subjects. Am J Med 1967;43(6):846–
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septal defect. Can Med Assoc J 1969;100(16):737–743.
Tandon R, Edwards JE. Aneurysmlike formations in relation to membranous ventricular septum. Circulation 1973;47(5):1089–1097.
October 2015
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10. Gaines JJ, Rao RN. Closure of membranous ventricular septal defect of heart
by septal leaflet of tricuspid valve. Hum Pathol 1983;14(12):1082–1084.
Morphologic demonstration of spontaneous and surgical closure of membranous ventricular septal defect
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