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Variations of atrioventricular septal defects predisposing to regurgitation and stenosis
Makoto Ando1, Yukihiro Takahashi
1Department of Pediatric Cardiac Surgery, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu-shi, Tokyo 183-0003, Japan. maando@shi.heart.or.jp
Insights
Additional atrioventricular valve malformations in complete atrioventricular septal defect patients complicate surgical repair. These complex cases often result in postoperative left valvular issues, regardless of repair timing or pulmonary banding.
Area of Science:
- Cardiology
- Pediatric Cardiac Surgery
- Congenital Heart Disease
Background:
- Complete atrioventricular septal defect (CAVSD) is a congenital heart condition.
- Additional atrioventricular valve malformations can complicate surgical correction of CAVSD.
Purpose of the Study:
- To analyze the impact of additional atrioventricular valve malformations on the surgical outcomes of CAVSD repair.
- To identify specific valve abnormalities associated with increased postoperative complications.
Main Methods:
- Retrospective review of 138 pediatric patients undergoing CAVSD repair using a two-patch technique (1992-2008).
- Analysis of operative records to identify additional atrioventricular valve malformations and their impact on surgical repair.
- Comparison of outcomes between patients with and without these malformations, and assessment of factors like age and pulmonary banding.
Main Results:
- 45 patients had additional atrioventricular valve malformations complicating septal patch placement and cleft approximation.
- Four specific types of malformations (papillary muscle abnormalities, dense chordal insertion, double orifice valve, severe cleft length disparity) were associated with a higher incidence of postoperative left valvular problems (moderate or worse regurgitation/stenosis).
- Neither older age at operation nor prior pulmonary arterial banding reduced the incidence of left valvular problems in the malformed group.
Conclusions:
- Surgical correction of CAVSD with additional atrioventricular valve malformations requires individualized techniques.
- These complex valve abnormalities are often not fully correctable, leading to persistent valvular issues.
- Delaying complete repair with pulmonary banding does not mitigate postoperative left valvular problems.
Background:
An additional malformation of the atrioventricular valve is occasionally encountered in patients with complete atrioventricular septal defect, and this may compromise accurate correction.
Methods:
We reviewed 138 patients undergoing complete repair with two-patch technique between 1992 and 2008. The mean age was 7.1 + or - 8.3 months, and the mean body weight was 5.1 + or - 2.1 kg. Preceding pulmonary arterial banding was performed in 23 patients.
Results:
The operative record delineated additional malformations of the atrioventricular valve that posed difficulty in positioning the ventricular septal patch and in accurately approximating the cleft in 45 patients. Of them, four types (n = 40) were associated with increased incidence of postoperative left valvular problems (moderate or worse regurgitation or stenosis). These included abnormalities of the papillary muscles that accompanied hypoplastic mural leaflet or incomplete opening of one commissure in (n = 15; p = 0.0054), dense insertion of the chords of the superior leaflet that obscured the right side of the ventricle septal crest in (n = 13; p = 0.0004), double orifice valve (n = 7; p = 0.0225), and severe length disparities of the cleft that resulted from either disproportional size of superior against inferior leaflets or redundant chord supporting the left extremity of one of these leaflets (n = 5; p < 0.0001). Neither greater age at operation (more than 6 months) nor preceding pulmonary arterial band reduced the incidence of left valvular problems in the malformation group.
Conclusions:
An individualized technique is required to maintain coaptation of the atrioventricular valve, but in many cases, they are not completely correctable. Deferring complete repair by placing a pulmonary arterial band did not reduce left valvular problems.
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