Cleft-to-commissure conversion in atrioventricular septal defect using artificial chordae: Technical report and case...

Primary repair of complete atrioventricular septal defect (cAVSD), typically performed at age 3 to 6 months, is associated with favorable early survival and long-term outcomes. However, a significant incidence of reoperation persists, predominantly for left atrioventricular valve (LAVV) regurgitation (LAVVR) and left ventricular outflow tract obstruction. Optimal management of the LAVV cleft remains controversial. Although routine cleft closure is frequently used to mitigate progressive LAVVR and subsequent reoperation, this approach can be complicated by LAVV stenosis, especially in LAVV with single papillary muscle. The optimal management of the LAVV in patients with single papillary muscle remains challenging. Although artificial chordae have been described for this anatomy, detailed technical descriptions and contemporary outcomes remain limited.

We present a case report of an 8-year-old patient (20.5 kg) with complex congenital heart disease, including VACTERL association, heterotaxy syndrome, and prior cAVSD repair, who presented with severe LAVVR. The surgical technique is described, involving the creation of artificial chordae to provide support to the bridging leaflets, effectively converting the cleft into a commissure. This was followed by annuloplasty. Postoperative echocardiography demonstrated a marked reduction in LAVVR, with only mild residual regurgitation and no evidence of stenosis. The patient exhibited stable hemodynamics postoperatively. Institutional Review Board approval was not required. The patient consented for publication of study data and images.

This case illustrates the potential of artificial chordae to optimize LAVV repair, especially in complex scenarios like single papillary muscle or closely spaced papillary muscles, facilitating a more physiologic reconstruction that addresses inherent anatomic problems with usual cleft closure in those cases.

Although these initial results are promising, further investigation, including long-term follow-up and application in larger cohorts, is warranted to evaluate the durability and generalizability of this technique, particularly in younger patients, in whom growth dynamics are a critical consideration.