Feasibility and 1-year outcome of transcatheter closure of perimembranous ventricular septal defects with different devices.

OBJECTIVE: To analyze feasibility of closing perimembranous ventricular septal defect (pmVSD) with different devices by percutaneous approach and determining initial 1-year outcome of the procedure. BACKGROUND: Transcatheter closure of pmVSD remains controversial due to a previous higher incidence of complete heart block (CHB), especially with the Amplatzer pmVSD occluder. Recently, several devices have been used to minimize the procedure-related complications. METHODS AND MATERIALS: A retrospective longitudinal cohort study of 133 patients who underwent transcatheter closure of pmVSD from September 2009 to March 2015. The median age and weight at intervention were 7.1 years (ranging from 9 months to 28 years) and 21.2 kg (ranging from 6.4 to 93 kg). RESULTS: Transcatheter pmVSD closure was successfully performed in 129 cases (97%) using 13 different devices. There were two new onset severe aortic regurgitation (AR) (1.5%), one new onset severe tricuspid regurgitation (0.7%), and one CHB (0.7%). Immediately after procedure, 41 patients (30.8%) had mild to moderate residual shunt and 27 patients (20.8%) had trivial to mild AR. At 1 year, there was no CHB and 10 patients (9.6%) had tiny to mild residual shunt and 10 patients (9.6%) had trivial AR. CONCLUSION: With proper case selection, good expertise, and judicious use of various devices with respect to anatomic details of pmVSD, transcatheter closure is feasible with satisfactory early outcome.

Percutaneous pulmonary valve implantation with the Venus P-valve: clinical experience and early results.

BACKGROUND: At present, the exclusion for percutaneous pulmonary valve implantation for free pulmonary regurgitation after tetralogy of Fallot repair includes an unfavourably large right ventricular outflow tract. OBJECTIVE: To report feasibility and early experience with a recently developed transcatheter heart valve, Venus P-valveTM, implanted in six patients with severe pulmonary regurgitation with large right ventricular outflow tracts. Patients There were two female patients and four male patients. The median age of the patients was 18.5 years, and the mean body weight was 53.8 kg. All the patients were in NYHA class II and had severe pulmonary regurgitation after previous transannular patch repair of tetralogy of Fallot. The median time after the last surgical operation was 13.5 years. RESULTS: The Venus P-valveTM was successfully implanted in all the patients with implanted valve diameters ranging from 24 to 32 mm. The mean fluoroscopy time was 29.8 minutes. None of the patients had significant outflow tract gradient or pulmonary regurgitation immediately after valve implantation. Only one patient had unexpected mild proximal valve migration to the right ventricular body during withdrawal of the delivery system. It caused mild paravalvar leak and significant tricuspid regurgitation. At 6 months follow-up, the median of right ventricular end-diastolic volume indices decreased from 146 to 108 ml/m2 (p-value=0.046). The Doppler systolic peak gradient across the valve ranged from 4 to 40 mmHg, and there was no evidence of stent fracture on fluoroscopy or structural valve failure. CONCLUSION: The Venus P-valveTM can be implanted successfully and effectively in patients with severe pulmonary regurgitation and a large right ventricular outflow tract. The early results with this valve are encouraging.

Survival analysis of Down syndrome with congenital heart disease: a 5-years registry at QSNICH.

BACKGROUND: Down syndrome (DS) is the most common chromosomal abnormality in children. Atrio-ventricular septal defect (AVSD) is the most common congenital heart disease (CHD) reported in DS. The mortality rate of DS with congenital heart disease (CHD) is 5-7 times higher than normal population. The survival rate in DS has improved with time and has reported up to 91% and 85% at one and ten years of age, respectively. OBJECTIVE: To study the prevalence of CHD, clinical course, treatment, the overall survival in patients with DS compare with those who are associated with CHD. STUDY DESIGNS: DS registry, multidisciplinary approach, single centre. MATERIAL AND METHOD: All DS patients at QSNICH with parental signed consent were enrolled in the registry. The study was conducted for 5 years starting from May 2007 to April 2012. All patients were followed-up according to schedule modified from American Academic of Pediatrics (AAP) health supervision guideline. Standard treatment was given to all those children with diagnosis of CHD and/or other associated diseases. RESULTS: Four hundred and two cases of DS were enrolled. Two cases were excluded due to the parental inconvenience. The mode and mean age of the patients at registration were 1 and 7 months (1-62). Two hundred and seventy-one cases had an initial echocardiographic diagnosis of CHD, which included 91 of Patent ductus arteriosus (PDA), 49 of Ventricular septal defect (VSD), 34 of AVSD, 34 of secondum Atrial septal defect (ASD), 6 of Tetralogy of Fallot (TOF), 2 of Coractation of Aorta (CoA), 11 of other CHD and 44 of combined lesions. During the follow-up period, spontaneous closure of PDA, VSD and ASD occurred in 46, 12 and 15 cases, respectively. After the exclusion of those who had spontaneous closure, the prevalence rate of CHD in DS was 49.8%. VSD was the most common lesion, slightly more than PDA. Ninety-eight cases underwent cardiac surgery; including 39 of associated VSD, 24 of AVSD, 26 of PDA, 3 of TOF, 4 of CoA/AA repaired, one each of Cor triatriatum and primum ASD. Twelve cases had catheter interventions, including PDA occlusion (10 cases), and 1 case of balloon dilatation of re-CoA and coils embolization of isolated major aorto-pulmonary collateral artery. Seven cases were lost at follow-up. By using the hospital information and National Health Security Office (NHSO) database, 47 infants died during the follow-up period. The causes of death were immediate post cardiac surgery in 10 cases (AVSD in 9, VSD in 1) and not associated with surgery in 37 cases including CHF in 8, pneumonia in 7, leukemia in 4, airway disease in 3, others 7 and unknown 8 cases. The overall survival at 1 and 5 years of age were 96% and 86%, respectively. DS with CHD had a significantly lower survival rate than those without CHD (p < 0.001). CONCLUSION: According to this study, the prevalence rate of CHD in DS was high. VSD was the most common lesion and has better prognosis than AVSD. The main cause of death was a cardiac problem. Follow-up patients by using modified AAP guideline and standard treatment can improve their overall survival.

Double-balloon aortic valvuloplasty at Queen Sirikit National Institute of Child Health.

BACKGROUND: Balloon aortic valvuloplasty is the treatment of choice in moderate and severe valvular aortic stenosis. In order to reduce the risk of vascular complications, a double-balloon technique has been used with good results. OBJECTIVE: To present the results od double-balloon aortic valvuloplasty at QSNICH. MATERIALS AND METHOD: Consecutive cases of severe valvular aortic stenosis treated with double-balloon aortic valvuloplasty at QSNICH were recruited in the study. Data were obtained from the medical records starting from the day of presentations to December 2011. RESULTS: There were six cases of severe valvular aortic stenosis treated with double-balloon aortic valvuloplasty at QSNICH from 2004 to 2011. The age and weight ranged from 7 months to 12 years and 6 to 53.8 kilograms, respectively. The presenting symptoms were dyspnea in 3 (50%) and asymptomatic heart murmur in 3 cases (50%). Peak-to-peak pressure gradient (PG) before the procedure ranged from 48-104 mmHg (mean 70.00, SD 18.92 mmHg). Immediately after the procedure, PG significantly decreased to 15-52 mmHg (mean 34.33, SD 14.98 mmHg, p < 0.01). On the following day after the procedure, peak instantaneous pressure gradient (PIPG) obtained from echocardiogram ranged from 17-47 mmHg (mean 36.50, SD 10.93 mmHg). PIPG were not significantly different from PG immediately after valvuloplasty. There were two cases with partial femoral occlusion. The duration of follow-up ranged from 6-54 months (median 24 months). In the follow-up period, all of the patients were asymptomatic with functional class I. Echocardiogram after the procedure revealed no significant aortic regurgitation in any of the cases. CONCLUSION: Double-balloon aortic valvuloplasty can be performed safely with very good intermediate term outcome in selected patients. Long-term outcome in Thai children should be further studied.

An unusual cause of progressive cyanosis post Fontan operation: congenital extra-hepatic porto-systemic shunt.

OBJECTIVE: To report an unusual case of progressive cyanosis post Fontan operation due to porto-systemic venous shunt and the result of its treatment. MATERIAL AND METHOD: A patient with diagnosis of progressive cyanosis post Fontan operation from porto-systemic venous shunt at QSNICH RESULTS: This is a case of twelve years old girl, who had diagnosis of situs solitus, levocardia, atrio-ventricular concordant, ventriculo-arterial concordant, hypoplastic right ventricle with large ventricular septal defect. She had pulmonary artery banding at 4 months of age followed by a non-fenestrated extra-cardiac conduit Fontan performed at 7 years and 7 months of age. During the first year of post operation, her systemic oxygen saturation (SpO2) was 93-94% after which it decreased to 87%, 84%, 75% at 1.5, 2.5 and 3 years after surgery, respectively. Clinically she also had progressive dyspnea on exertion. Diffuse pulmonary arterio-venous malformation was demonstrated by contrast echocardiogram during cardiac catheterization. Cardiac magnetic resonance angiography showed abnormal extra-hepatic portal vein to inferior vena cava shunt. After balloon test occlusion in the cath lab, which showed no change in the portal venous pressure, complete occlusion of this porto-systemic venous shunt was performed by using Amplatzer Vascular Plug II. Her systemic oxygen saturation increased to 83% with functional class I at one-year post occlusion. CONCLUSION: The present report an unusual case of progressive cyanosis post Fontan operation due to pulmonary arteriovenous malformation, which was secondary to congenital extra-hepatic porto-systemic shunt. The venous blood from the intestinal and splenic veins was partially bypassing the liver into inferior vena cava. The patient's clinical condition and SpO2 improved after transcatheter occlusion of the shunt with the device.

Outcomes of straightforward extracardiac Fontan operation in advanced-age group.

INTRODUCTION: Fontan operation is a palliative procedure used in patients with univentricular heart (UVH). There have been numerous modifications to the technique. The appropriate strategy for treating patients with UVH in Thailand is still a major concern. OBJECTIVE: To describe the outcomes of patients after straightforward Fontan operation at advanced-age and evaluate their post-surgical cardiac performance. MATERIAL AND METHOD: A cross sectional study was performed in post-Fontan operation patients at Rajvithi Hospital between 2000 and 2009. Post-operative cardiac performance was analyzed using the echocardiogram and treadmill exercise stress test (EST). RESULTS: Thirty-nine patients were enrolled in the present study. The mean age was 11.7 years and the mean age at operation was 7.4 years. The predominant systemic chamber was morphologic left ventricle. Straightforward Fontan operation was performed in 60% of cases. Mean of Fontan index, mean of McGoon ratio, and mean of Nakata index were 2.63, 2.32, and 414.15 sqmm/sqm, respectively. Mean of the PVR and PAP were 1.98 U/m2 and 11.05 mmHg. Eighteen percent of patients died in the early post-operative period. Most of the patients died from septicemia. The mean EFwas 58.43%. Systolic dysfunction in 17.9% of the cases was abnormal, whereas diastolic dysfunction was present in half of the cases. Thirty-nine percent had MPI abnormality. During EST three cases developed arrhythmias and 3 cases had hypotension. Patients were categorized into 3 groups (Group 1: normal systolic and diastolic functions, Group 2: diastolic dysfunction, Group 3: impairment of both systole and diastole). Pre-operative cardiac catheterization parameters, surgical data and cardiac performance showed no statistical significance. However, there was a significant correlation between those with abnormal cardiac performance and arrhythmias or hypotension during EST (p = 0.003). CONCLUSION: The selection of suitable cases and good pre-operative evaluation could decrease the morbidity and mortality in patients undergoing the Fontan procedure. This study also found a correlation between abnormal cardiac performance and transient cardiac arrhythmia during exercise. The evaluation of cardiac performance and EST remains to be performed for following-up of patients who have undergone the Fontan operation, even for the asymptomatic cases.

Cardiac CT angiography in children with congenital heart disease.

Cardiac imaging plays an important role in both congenital and acquired heart diseases. Cardiac computed tomography (angiography) cCT(A) is a non-invasive, increasingly popular, complementary modality to echocardiography in evaluation of congenital heart diseases (CHD) in children. Despite radiation exposure, cCT(A) is now commonly used for evaluation of the complex CHD, giving information of both intra-cardiac and extra-cardiac anatomy, coronary arteries, and vascular structures. This review article will focus on the fundamentals and essentials for performing cCT(A) in children, including radiation dose awareness, basic techniques, and strengths and weaknesses of cCT(A) compared with cardiac magnetic resonance imaging (cMRI), and applications. The limitations of this modality will also be discussed, including the CHD for which cMRI may be substituted.

Outcome of oral sildenafil therapy on persistent pulmonary hypertension of the newborn at Queen Sirikit National Institute of Child Health.

BACKGROUND: Persistent pulmonary hypertension of the newborn (PPHN) is a common problem in the neonates with a high mortality rate. The prevalence ranges from 0.38-0.99 per 1,000 live births at Queen Sirikit National Institute of Child Health. The survival rate has improved after the advent of high-frequency ventilation and inhaled nitric oxide. However, inhaled nitric oxide is expensive and unavailable in most neonatal centers in Thailand. Sildenafil is a phosphodiesterase inhibitor type 5 that selectively reduces pulmonary vascular resistance and hence may play a role in the treatment of PPHN. OBJECTIVE: To evaluate effectiveness and short-term side effects of oral sildenafil for infants > 36 weeks gestational age who have PPHN. MATERIAL AND METHOD: The present study was conducted between January 2006 and December 2008 in the neonatal intensive care unit (NICU) at Queen Sirikit National Institute of Child Health. All infants > or = 36 weeks gestational age who were diagnosed as PPHN by echocardiogram and had an oxygenation index > or = 20 were included in the study. Oral sildenafil was given as per study protocol with a starting dose of 0.25-0.5 mg/kg/dose. Oxygenation index (OI), oxygen saturations (SpO2), alveolar arterial oxygen gradient (A-aDO2) and mean arterial blood pressure (MAP) were monitored serially. RESULTS: A total of 40 infants were diagnosed with PPHN during this period. Eleven infants were included in the present study. The initial median OI was 31.95 (24.25-48.25). All infants received standard therapy with mechanical ventilation, sedation and inotropic drugs. OI decreased 4.6% from base line after the first hour of starting oral sildenafil and progressively decreased by 13%, 27%, 37%, 41% and 90% at 2, 4, 6, 12 and 24 hours respectively. Oral sildenafil was discontinued in one infant. It was combined with inhaled iloprost in 2 infants due to systemic hypotension and with inhaled nitric oxide in one infant due to deterioration. One infant died during the present study. CONCLUSION: Oral sildenafil may be effective in improving oxygenation in some infants with persistent pulmonary hypertension of the newborn. Systemic hypotension was a cause for concern in the present study. Further studies are needed to assess the pharmacokinetics, efficacy and long-term side effects of this drug.

Combined aortic and pulmonic valvular stenosis: report of 2 cases.

OBJECTIVE: To report 2 cases of severe combined aortic and pulmonic valvular stenosis. MATERIAL AND METHOD: To find patients with a diagnosis of severe combined aortic and pulmonic valvular stenosis, the authors searched in the patient profile at the cardiology unit, Queen Sirikit National Institute of Child Health (QSNICH) from 1995 to 2010. RESULTS: There are 2 cases of severe combined aortic and pulmonic valvular stenosis from 19,416 case records of pediatric cardiac patients. The first one is a 9-year-old girl and the other is a male neonate. The interval between the presentations of these two cases was 10 years. The older patient, who had associated moderate aortic regurgitation, underwent aortic root replacement and pulmonic valvulotomy in the year 2000. The neonate, who presented in 2010 had undergone bilateral percutaneous balloon aortic and pulmonic valvuloplasty and required repeated balloon aortic valvuloplasty at the age of two months. Both patients responded well to treatment and were asymptomatic at the last follow-up of 10 years and 6 months respectively after treatment. CONCLUSION: Combined aortic and pulmonic valvular stenosis is a very rare congenital heart disease. The prevalence is 0.01% of congenital heart disease at QSNICH. Bilateral balloon valvuloplasty of aortic and pulmonic valve is effectively performed in this rare congenital heart disease and can be done safely in a sick neonate.

A comparison of oral chloral hydrate and sublingual midazolam sedation for echocardiogram in children.

OBJECTIVE: To compare the efficacy and safety of oral chloral hydrate and sublingual midazolam to sedate the children undergoing echocardiography. MATERIAL AND METHOD: A double-blind, randomized trial study in the children judged to require sedation prior echocardiogram were performed. Two hundred sixty-four patients between 6 months and 5 years of age were randomized to chloral hydrate or midazolam groups. Either 50 mg/kg of chloral hydrate orally or 0.3 mg/kg of midazolam sublingually was given in each groups. If the child was not responded within 30 minutes after the first dose, another half dose of each drug for the second dose will be required. The action duration time, sedation score level and the ability to complete echocardiogram were collected. RESULTS: Both groups were comparable with respect to age, sex, body weight, underlying heart disease, baseline O2 saturation and functional heart classification. The children in chloral hydrate group needed the second dose for sedation more than midazolam group (10.6%, 5.3% p = 0.111). The onset, action duration and total study time were significantly shorter in midazolam than in chloral hydrate group (p < 0.001). The number of the patients who had the action duration within the optimal time (< 45 min) were significantly more cases in midazolam than in chloral hydrate group (93.1%, 43.5% p < 0.001). Success rate of echocardiogram was 99.2% in each group. There was no difference in echocardiographic time performed in both groups. The children in chloral hydrate group had deeper in level of sedation (p < 0.001). Both groups showed no significant difference in term of the ability to complete echocardiographic examination. The reaction of the children to take the medication and the number of the patients who had systemic O2 saturation change more than 5%from the baseline were higher in chloral hydrate group significantly (14.4%, 4.5% p = 0.006 and 9.9%, 3.1% p = 0.025). CONCLUSION: Sublingual midazolam at the dose of 0.3 mg/kg can be used to sedate the children at age group between 6 months to 5 years who undergoing echocardiogram with comparable rate of success and safety as 50 mg/kg of chloral hydrate orally. The less depth in the level of consciousness after sedation with midazolam compare to chloral hydrate may be advantage in a high risk patient to avoid deep sedation but may be disadvantage in case who need more comprehensive echocardiographic evaluation.

Natural aortic valve complications of ventricular septal defect: a prospective cohort study.

OBJECTIVE: To study the incidence and onset of aortic valve prolapse (AVP) and aortic regurgitation (AR) in the ventricular septal defect (VSD). STUDY DESIGN: A prospective cohort study POPULATION: The less than one-year-old children with diagnosis of isolated VSD were studied from October 2000 to September 2006 at Queen Sirikit National Institute of Child Health. Clinical follow-up and echocardiographic studies were scheduled every 2-3 months in the first year of age and then every 6 months to evaluate the size, location, flow across VSD, aortic valve morphology and aortic regurgitation. RESULTS: Three hundred and twenty-one cases of VSD were followed up. One was excluded due to associated hypoplastic RV An overall of 2,644 echocardiograms were performed. The percentage of perimembranous, subpulmonic, muscular inlet and multiple types were 70.3%, 19.4%, 5.6%, 3.1% and 1.6%, respectively. Size of the VSD was diagnosed to be small, moderate, and large VSD in 62.5%, 15.9% and 21.6% respectively. At the end of the study, the incidence of AVP in subpulmonic VSD was 87.1% compared to 16.4% in perimembranous VSD, with a relative risk of 5.30 and the incidence of AR in subpulmonic VSD was 37.1% compared to 5.3% in perimembranous VSD, with a relative risk of 6.95. From the survival analysis, the patient with subpulmonic VSD developed AVP at 46%, 77%, 90% and 94% compare to 8%, 13%, 20% and 23% of perimembranous VSD at 12, 24, 36 and 48 months of age respectively (p < 0.001). The patient with subpulmonic VSD developed AR at 8%, 17%, 35% and 38% compare to 2%, 4%, 5% and 7% of perimembranous VSD at 12, 24, 36 and 48 months of age respectively (p < 0.001). At the end of the study, ninety-six cases (30%) underwent cardiac operation with the indication of heart failure or the occurrence of AR. Sixty one cases (19.1%), including two cases of subpulmonic type had spontaneous closure of VSD. Seven cases (2.2%) had lost to follow up and five cases (1.6%) died during the follow up period. CONCLUSION: The incidence of AVP and AR are high in subpulmonic VSD being much higher than perimembranous VSD with a relative risk of 5.30 and 6.95 respectively. These complications are significantly from infancy period and are an indication for early cardiac surgery.

Comparison of the acute pulmonary vasodilating effect of beraprost sodium and nitric oxide in congenital heart disease.

BACKGROUND: Congenital heart disease patients who have pulmonary hypertension (PH) require an evaluation for pulmonary vascular reactivity before surgical repair. In the present study the acute pulmonary vasodilating effects of 100% oxygen (O2), beraprost sodium (BPS) and 40 ppm inhaled nitric oxide (iNO) during cardiac catheterization were compared. METHODS AND RESULTS: There were 90 patients who underwent cardiac catheterization for evaluation of PH (mean age, 16.5+/-16 years). The baseline mean pulmonary artery (mPA) pressure was 69.6+/-14.8 mmHg and the pulmonary arteriolar resistance (Rpa) was 13.8+/-8.3 Wood unit m2. Change in pulmonary vascular reactivity was defined as a decrease in mPA or Rpa>20% from baseline. The response to 100%O2, iNO and BPS during cardiac catheterization was 84%, 72.7% and 64%, respectively. Pair comparisons among each hemodynamic parameter showed no difference between the acute vasodilating effect of BPS and iNO. In some patients BPS showed a stronger effect than iNO in lowering Rpa. CONCLUSIONS: BPS has a similar pulmonary vasodilating effect to iNO and can be used as an acute pulmonary vasodilating agent during cardiac catheterization with potential benefits over iNO.

Pediatric heart surgery waiting time in Thailand and its effect on mortality: A cooperative study from Chulalongkorn, Children and Chiang Mai University hospitals.

BACKGROUND: Thai children who need cardiac surgery are often put on a waiting list. The waiting time and mortality during waiting have not been previously systematically studied. MATERIAL AND METHOD: A cooperative study was conducted at King Chulalongkorn Memorial hospital (Chula), Children hospital (CH), and Chiang Mai University hospital (CMU). The status of children who were referred for cardiac surgery at these hospitals in the year 1999-2000 (Chula and CMU) and the year 2000 (CH) were analyzed by Kaplan-Meier survival curve. The patients who lost to follow up and could not be contacted were censored at the time of last clinic visit. Log-Rank test was used to compare the survival curve and waiting time between three hospitals. RESULTS: The averaged annual referrals for cardiac surgery at the three hospitals were 846 cases (205 for Chula, 462 for CH and 179 for CMU). Mean age was 4.3 +/- 4.2 years and 51% were male. Follow up data were complete in 96.3%. Surgical procedures were correction of simple shunt lesions (ASD, VSD, AV canal) in 33.9%, close heart surgery (PDA ligation, coarctation repair, BT shunt) in 29.9%, total repair TOF in 19.6%, complex surgery in neonate and infants (arterial switch, TAPVR repair, Norwood procedure, truncus and interrupted aortic arch repair) in 4.2% and others in 12.3%. Median waiting time was 195 days and was significantly different between the three hospitals (p < 0.01). Mortality while waiting were approximately 5% at 2 years at Chula and CH, which was significantly higher than CMU (0%, p = 0.02). Further analysis revealed difference in age (lower Chula than CH than CMU) and types of surgery (more complex at Chula and CH) which may be the causes for difference in the mortality observed. CONCLUSION: Waiting time for cardiac surgery for children in Thailand is long and should be viewed as a problem in public health policy. Optimal waiting time at each hospital may not have to be the same, depending on the type and severity of the disease seen at each particular center Attempt should be made to solve this problem at the national level.

Aortic valve prolapse in subpulmonic ventricular septal defect.

BACKGROUND: Ventricular septal defect (VSD) is the most common congenital heart disease worldwide. Subpulmonic type VSD is an interesting subtype due to the aortic valve complications rate, which can change the prognosis of the VSD. Higher prevalence rates have been reported with this subtype in Eastern countries but there has been no report from Thailand so far. OBJECTIVE: 1. To determine the prevalence of subpulmonic VSD. 2. To determine the prevalence and demographic data of aortic valve prolapse (AVP) and aortic regurgitation (AR) in subpulmonic VSD. METHOD: A retrospective study of 1,977 patients with isolated VSD, diagnosed from January 1995 to June 2002 at the Cardiology Unit, Queen Sirikit National Institute of Child Health was reviewed to differentiate types of VSD. Color flow doppler echocardiogram was performed in all cases to confirm the diagnosis and differentiate the types of VSD. Patients with subpulmonic VSD were studied to find out the presence of the aortic valve prolapse and aortic regurgitation. Those who had subpulmonic VSD were called for reevaluation of aortic valve complications, from January 2000 to June 2002. MAIN OUTCOME MEASURE: Subpulmonic VSD, aortic valve prolapse (AVP) and aortic regurgitation (AR). RESULTS: Subpulmonic VSD was diagnosed in 312 cases (17.5%). At the mean age of 3.47 yr, AVP was found in 101 cases (32.4%) and AR was found in 54 cases (17.3%) at the first echocardiogram. Subsequent echocardiography follow-up showed that the overall number of AVP cases was 153 (49%) and AR was 84 (26.9%) at the mean age of 5.5 and 6.3 year respectively. CONCLUSION: The prevalence of subpulmonic VSD was high among Thai children. Aortic valve complication is common in this group and can occur from early infancy. The present findings support the progressive increase in this complication with age.