Related Experiment Videos
Atrioventricular discordance: results of repair in 127 patients
T Yeh1, M S Connelly, J G Coles
1Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto Congenital Cardiac Centre for Adults, University of Toronto, Toronto, Ontario, Canada.
Insights
Conventional management of atrioventricular discordance shows high reoperation rates and mortality. Alternative strategies are needed for better outcomes in patients with this complex congenital heart defect.
Area of Science:
- Cardiology
- Congenital Heart Disease
- Pediatric Cardiac Surgery
Background:
- Atrioventricular discordance presents unique challenges in pediatric cardiac surgery.
- Conventional management often relies on physiologic correction, but long-term survival data are crucial.
Purpose of the Study:
- To analyze institutional outcomes of biventricular repair for atrioventricular discordance.
- To evaluate survival rates and complications associated with conventional management.
Main Methods:
- Retrospective analysis of 127 patients with atrioventricular discordance undergoing biventricular repair (1959-1997).
- Exclusion of patients with functionally univentricular hearts.
- Detailed review of associated lesions, surgical procedures, and long-term follow-up data.
Main Results:
- Operative mortality was 6%; 20-year survival was 48%.
- 56% of patients required reoperation within 20 years, often for atrioventricular valve issues or pulmonary stenosis.
- 50 patients required pacemakers, with a high incidence in the early post-repair period.
Conclusions:
- Conventional management of atrioventricular discordance is associated with significant long-term morbidity, including increased mortality, reoperations, and complete atrioventricular block.
- The need for systemic atrioventricular valve replacement and pacemaker implantation is substantial.
- Alternative management approaches for atrioventricular discordance warrant further investigation.
Objective:
The conventional management of patients with atrioventricular discordance is directed at associated lesions, taking advantage of physiologic "correction"; however, the morphologic right ventricle and tricuspid valve support the systemic circulation. Questions surrounding survival using this approach led us to analyze our institutional results.
Methods:
All patients with atrioventricular discordance undergoing biventricular repair were analyzed (n = 127, 1959-1997), excluding those with functionally univentricular hearts. The ventriculoarterial connection associated with atrioventricular discordance varied and was most commonly discordant (87%), but occasionally concordant (6%), double-outlet right ventricle (6%), or double-outlet left ventricle (1%). At initial presentation, the most common lesions associated with atrioventricular discordance were ventricular septal defect (86%), pulmonary stenosis (64%), tricuspid regurgitation (28%), and atrioventricular block (12%). Nine patients underwent a double switch procedure to create ventriculoarterial concordance and the remainder were managed conventionally without correcting discordant connections.
Results:
Operative mortality was 6% and did not vary by associated lesion. Twenty years after repair, survival was 48%. Within 20 years, 56% of patients required reoperation, usually for atrioventricular valve incompetence (n = 16), pulmonary stenosis (n = 16), or both (n = 3). Pacemakers were required in 50 patients, 4 before repair, 40 within 2 months of repair, and 6 remotely after repair. In early follow-up, the double switch procedure (n = 9) had equivalent mortality and a high pacemaker requirement for atrioventricular block.
Conclusions:
Analysis of conventional management of atrioventricular discordance revealed cumulative increases in mortality, systemic atrioventricular valve (tricuspid) replacement, complete atrioventricular block, and incidence of reoperation. Alternative management should be examined.