Operation for partial atrioventricular septal defect: a forty-year review

[Surgery of 56 patients having a partial atrioventricular septal defect]

Between January 1991 and December 2006, 56 patients having a partial atrioventricular septal defect (AVSD) were operated. The purpose of this retrospective study is to analyze the immediate and long-term results of the surgery by granting of the importance to two main problems which are the disturbances of the rhythm and the conduction and the residual mitral regurgitation (MR). The mean age of our patients is of 10 and a half years with a net feminine ascendancy. Ninety-three percent of the patients were in regular sinus rhythm. No case of complete atrioventricular block (AVB) was noted. The MR was of grade I in 28.5% of the cases, grade II in 60% of the cases and grade III and IV in 7.5% of the cases. The MR was mild in 4% of the cases. The correction was made under cardiopulmonary bypass (CPB) and consisted of a suture of the mitral cleft in most of the cases with lock of the ostium primum by a patch of pericardium. The perioperative mortality was 1,8% of the cases. The disturbances of the rhythm and the conduction were noted in 34% of the cases. All the patients were controlled with a mean follow-up of six years and seven months. The secondary mortality was nil. The MR, at mid-term follow-up, was mild in 78% of the cases. The partial AVSD is a congenital heart disease, the spontaneous evolution of which can be burdened by complications, notably the disturbances of the rhythm and the conduction, as well as the heart failure. This justifies a premature surgical repair.

Atrial septal defect: spectrum of care

Atrial septal defect (ASD) is a common congenital heart defect. Variability in management of this lesion exists among clinicians. A review of the literature reveals that there is lack of standard guidelines for the evaluation and management of patients with different types of ASDs. This survey-based study was conducted to test the uniformity of diagnostic and therapeutic approach to management of children with secundum, sinus venosus, and primum ASDs. Survey questionnaires were prepared to include questions regarding follow-up, diagnosis, and therapeutic intervention of different types and sizes of ASDs. Questions addressed follow-up visitations, type and frequency of investigative studies, pharmacological therapy, and choice of repair method. Surveys were sent out to all pediatric cardiology academic programs in the United States (n=48) and randomly selected international programs from Europe, Asia, and Australia (n=19). A total of 23 programs (34%) responded to the survey (15 from the United States and 8 internationally). A separate questionnaire was prepared for secundum, primum, and sinus venosus ASD. In each questionnaire, lesion types were subdivided into small, moderate, and large defect sizes to address differences of management approaches to each defect type and size. Results indicate that in secundum ASD, most participants use size of the defect and/or evidence of right-sided volume overload as criteria for defining small, moderate, and large defects. Frequency of follow-up does not vary with the type of lesion but is more frequent with larger defects. Most participants see patients with small defects at intervals of 6 months to 1 year and those with large defects at 3- to 6-month intervals. Age of patient and presence of symptoms determined the frequency of follow-up across all defects. Echocardiography was the most frequently used investigative modality in all defect sizes and types during follow-up visits (used by >80% for follow-up), followed by electrocardiography (ECG). There is a striking preference for the use of pharmacological therapy in primum ASD compared with secundum and sinus venosus ASD. The timing of repair was mainly dependent on patient age and symptomatology in different defects, with the presence of associated anomalies contributing to that in primum and sinus venosus ASD. Most participants use percutaneous approach to close secundum ASD (either as a first choice or as one of two choices depending on the presence of certain features). Before repair, participants use MRI or cardiac catheterization to fully evaluate a secundum ASD if it is large. These investigative modalities are not commonly used in primum and sinus venosus ASD. There is agreement on postoperative follow-up in different types of defects, with most participants continuing follow-up indefinitely, especially in larger defects.

Adult congenital heart disease: a 2008 overview

INTRODUCTION

During the past decades, health care of patients born with congenital heart disease (CHD) has improved substantially, leading to a growing population of adult survivors.

SOURCE OF DATA

Using the recently published and relevant data on adult CHD (ACHD), we reviewed the most common congenital heart defects and discussed important related issues.

AREAS OF AGREEMENT

Adults with CHD most often require specialized medical or surgical care in a tertiary centre. However, this population also need local follow-up; general practitioners and other specialists therefore have to face the complexity of their disease. AREAS OF CONTROVERSIES: Management of pregnancy, non-cardiac surgery, arrhythmias and endocarditis prophylaxis may be challenging in patients with CHD and should be adapted to their condition.

GROWING POINTS

The present article summarizes key clinical information on ACHD for the benefit of physicians who are not specialized in this field. Areas timely for developing research Research efforts and education strategies are greatly needed in order to optimize the care of patients with ACHD.

Population-Based Perspective of Long-Term Outcomes After Surgical Repair of Partial Atrioventricular Septal Defect

BACKGROUND

This investigation was designed to determine long-term survival, reoperation rates, and functional status after surgical repair of partial atrioventricular septal defect (PAVSD).

METHODS

This population-based cohort study with cumulative, prospective follow-up by questionnaire and medical record review included all patients aged younger than 19 years old in the state of Oregon who underwent surgical repair of a PAVSD from 1958 to 2000. The incidence of early death, late death, and reoperation for left atrioventricular valve pathology were determined. Patient-reported health status as measured by the Medical Outcomes Study Short Form 12 (SF-12) was obtained for patients without Down syndrome when they were aged older than 15 years.

RESULTS

Repair of PAVSD was done in 133 patients. Median follow-up was 8.7 years for a total of 1541 person-years. Mean age at the initial operation was 5.2 +/- 5.1 years (median, 3.4 years). Mean weight was 19.2 +/- 16.0 kg (median, 13.2 kg). Survival was 95% at 30 days, 87% at 10 years, and 78% at 30 years. Reoperation for left atrioventricular valve pathology was done 15 patients (11.3%). Lower weight, absence of Down syndrome, and lack of mitral valve cleft repair were significantly associated with undergoing reoperation. Patient-reported health status was obtained in 35 patients. For this group, the mean SF-12 summary scores for the physical component (52.8 +/- 9.0) and the mean mental component (50.3 +/- 11.0) were not significantly different from age-adjusted norms.

CONCLUSIONS

The survival rate for this simple cardiac defect is lower than the general population. In addition, the reoperation rate is significant. Despite this, in general, patients without Down syndrome can expect normal functional health status.

Partial atrioventricular canal: pitfalls in technique

Partial atrioventricular (AV) canal represents approximately 25% of all AV septal defects. While often grouped with secundum ASD from the perspective of cardiopulmonary physiology, clinical presentation, and timing of surgical correction, their optimal management truly requires an understanding of their anatomic similarities to other forms of common AVC defects. By most measures, outcomes for surgical management of partial AV canal has improved over the last four decades, though some aspects of these defects continue to pose important challenges. Current experience has witnessed the reduction in early mortality and only rare complete heart block. Left AV valve dysfunction remains the most common indication for reoperation (10%) with LVOT stenosis the next most common reason (10% to 15% incidence, 5% to 10% reoperation rate). It is important to understand in this population that postoperative left AV valve problems and LVOT stenosis may be intimately linked, both from an etiologic standpoint, and with respect to their management.

Complex atrioventricular canal

Complex forms of atrioventricular (AV) canal (C) such as; AVC with left ventricular outflow tract obstruction, tetralogy of Fallot with complete AVC, double orifice left AV valve, unbalanced complete AVC, and single ventricle patients with common AVC valve require careful preoperative planning and special techniques. This review will explore these technical modifications and outcomes for repair of complex variants of AVC. Optimal results will be achieved using an individually tailored approach that is guided by careful evaluation of the preoperative studies, precise operative technique, and intraoperative assessment of the reconstructed AV valve, as well as a willingness to re-intervene should the postoperative course not proceed as anticipated.

Three-dimensional Echocardiography Improves the Understanding of the Mechanisms and Site of Left Atrioventricular Valve Regurgitation in Atrioventricular Septal Defect

OBJECTIVES

The purpose of this study was to determine whether 3-dimensional echocardiography (3DE) provides additional information regarding the mechanisms and sites of left atrioventricular valve regurgitation in atrioventricular septal defect compared with transesophageal 2-dimensional echocardiography (2DE).

METHODS

Eleven patients with a median age of 5.4 years (2.9-11.6 years) and a median weight of 16.8 kg (13.7-38.3 kg) with an atrioventricular septal defect underwent simultaneous transesophageal 2DE and 3DE before operation.

RESULTS

The 2DE-3DE agreement for the assessment of the superior and mural leaflet size was 72.7%. The 2DE-3DE agreement for coaptation failure, a residual or primary cleft, and commissural abnormalities as a mechanism of regurgitation were 72.7%, 63.6%, and 36.4%, respectively. For jet sites the 2DE-3DE agreement was 63.6% for a commissural and central location.

CONCLUSION

Three-dimensional echocardiography provides new and superior data regarding the mechanisms and sites of left atrioventricular valve regurgitation in atrioventricular septal defect.

Utilization of double-orifice valve plasty in correction of atrioventricular septal defect

BACKGROUND

Atrioventricular valve regurgitation represents the principal indication for reoperation after repair of atrioventricular septal defect. Deciding how to correct atrioventricular valve regurgitation is challenging in some cases because of the complexity of the anatomic features. This report deals with our surgical experience in using a double-orifice valve plasty technique in cases with atrioventricular septal defect.

METHODS

From August 2002 to August 2004, 8 patients underwent double-orifice valve plasty in surgical correction of atrioventricular septal defect. Anatomic types were partial (6 patients), intermediate (1 patient), and complete (1 patient). After the mitral cleft was closed, moderate to severe atrioventricular valve regurgitation was still present in these patients. Double-orifice valve plasty was used in the mitral valve in 7 patients and in the tricuspid valve in 1.

RESULTS

No hospital deaths or postoperative morbidity occurred. The follow-up ranged from 6 months to 30 months (median, 14.4 months). No or trivial atrioventricular valve regurgitation was found in 6 patients and mild atrioventricular valve regurgitation was present in 2.

CONCLUSIONS

Double-orifice valve plasty is an easy and effective additional procedure for children and for adult patients who have moderate or severe atrioventricular valve regurgitation after repair of atrioventricular septal defect.

Surgical validation of real-time transthoracic 3D echocardiographic assessment of atrioventricular septal defects

BACKGROUND

The purpose of this study was to evaluate the accuracy of AV valve morphology assessed by real-time transthoracic 3D echocardiography (RT-3DE) compared to surgical findings and to assess whether RT-3DE is applicable in clinical practice.

METHODS

Between June 2004 to May 2005, 19 patients with an atrioventricular septal defect (AVSD) undergoing surgical treatment at our institution were enrolled in the study. RT-3DE was performed with Philips Sonos 7500 echo-system and off-line analysis with TomTec Echoview software. The AVSD was assessed for the morphology of AV valve, with particular interest to the superior and inferior bridging leaflets. 3D data were compared with measurements and descriptions acquired during the surgical procedure.

RESULTS

Acquisition of RT-3DE datasets was feasible in all patients. Of the 19 patients, there were 11 infants (age <1 year). The duration of 3D data acquisition was 12+/-3 min for patients above 1 year and 4+/-2 for infants. Reconstruction time was 22+/-8 min. In all patients the AV valve orifice and RT-3DE observations of the superior and inferior bridging leaflets were all correctly identified by RT-3DE compared with the surgical findings.

CONCLUSION

Real-time transthoracic 3D echocardiography provides accurate assessment of AVSDs and correctly depicts the AV valve morphology. After a short learning curve, RT-3DE is easily applicable during daily clinical practice.

Three-dimensional echocardiography improves the understanding of left atrioventricular valve morphology and function in atrioventricular septal defects undergoing patch augmentation

OBJECTIVES

We sought to address the role of 3-dimensional echocardiography in the evaluation of the left atrioventricular valve in children with an atrioventricular septal defect who underwent patch augmentation of their valve for either regurgitation or left ventricular outflow tract obstruction.

METHODS

Five children whose ages ranged between 4.5 and 9.2 years and who underwent patch augmentation of their left atrioventricular valve had a preoperative and postoperative transesophageal echocardiogram with 3-dimensional reconstruction to evaluate the left atrioventricular valve. The indication for operation was left atrioventricular valve regurgitation in 3 patients and left ventricular outflow tract obstruction in 2 patients. Three were rerepairs, and 2 were primary repairs. Both 3-dimensional morphology and color Doppler data were obtained. Two- and 3-dimensional findings were correlated with surgical observations through the use of direct inspection and video images obtained with a head-mounted super-VHS camera.

RESULTS

In each case there was precise correlation between the 3-dimensional and surgical findings as to the cause of leaflet failure in those with regurgitation. The site that would require leaflet augmentation could be determined by means of 3-dimensional echocardiography. Three-dimensional echocardiography provided more specific detail as to the morphology and function of the left atrioventricular valve than did its 2-dimensional counterpart.

CONCLUSIONS

Three-dimensional echocardiography provides detailed information about the status of the left atrioventricular valve in the atrioventricular septal defect and can aid in the planning of either primary or secondary repair.

Complete versus partial atrioventricular canal: equal risks of repair in the modern era

OBJECTIVE

To assess the authors' hypothesis that with modern techniques, the current risks of repair for both complete and partial atrioventricular canal (AVC) are equal.

SUMMARY BACKGROUND DATA

Repair of complete AVC in infancy has traditionally carried a substantial mortality. In contrast, partial AVC has been considered low-risk for repair and can be performed later in childhood.

METHODS

This was a retrospective review of 63 infants and children who underwent complete (n = 40) or partial AVC repair (n = 23) from 1990 to 2001. Among complete AVC patients, the ventriculoseptal defect was repaired via an individualized approach according to each patient's specific anatomy: direct suturing without a patch (n = 5) and/or interposition of a small pericardial patch with a running suture (n = 35). In all 63 patients the left AV valve cleft was closed with interrupted sutures, and all atrial defects were closed with a pericardial patch. Data were analyzed with the Student test and Fisher exact test.

RESULTS

Results are expressed as the mean +/- SEM. Age at operation was 6.3 +/- 2.0 months for complete AVC and 47.5 +/- 6.1 months for partial AVC (P <.001). Bypass time was 65.2 +/- 2.3 minutes for complete AVC and 58.3 +/- 3.9 minutes for partial AVC ( P=.1). Reoperation rate was 7.5% (3/40) for complete AVC and 13.0% (3/23) for partial AVC ( P=.6). Early mortality was 2.5% (1/40) for complete AVC and 0% (0/23) for partial AVC ( P=.6).

CONCLUSIONS

Compared to partial AVC, patients presenting for complete AVC repair are significantly younger and manifest more complex anatomy and pathophysiology. However, utilizing modern techniques, including an individualized surgical approach to the ventricular component, repair of complete AVC yields reoperation and early mortality rates similar to those of partial AVC.

Long-term results after surgical correction of atrioventricular septal defects

OBJECTIVE

Review of the results of surgical correction of atrioventricular septal defects (AVSD), identification of risk factors for mortality and failure of left AV valve repair and determination of the impact of cleft closure on postoperative AV valve function.

METHODS

Between 1975 and 1995, 121 consecutive patients (55 males, 66 females) underwent surgery for biventricular correction of AVSD with a median age of 1.2 years and a median weight of 7.6 kg. Sixty-five patients had a complete AVSD, 17 patients an intermediate type, and 39 patients a partial AVSD. The left AV valve (MV) cleft was closed in 53 patients (43.8%). The mean follow-up time is 7.2+/-4.6 years.

RESULTS

Actuarial survival of the whole group after 1 year was 80%, after 10 and 20 years 78 and 65%, respectively. There were 18 early deaths (7-day mortality, 10.7%; 30-day mortality, 14.9%) and eight late deaths. In a univariate analysis, risk factors for early or late death were diagnosis of complete AVSD (P=0.006), no cleft closure (P=0.024), postoperative complications (P<0.0001), age <1.2 years (P=0.017), weight <7.6 kg (P=0.002), PA/Ao pressure ratio >0.7 (P<0.0001), and ECC time >110 min (P=0.002). In the multivariate analysis, postoperative complications (P=0.003) and PA/Ao pressure ratio >0.7 (P=0.001) had parallel effects on the postoperative risk for mortality. Moderate or severe MV regurgitation was present in six patients (6.0%) in the first evaluation after discharge and in 20 patients (20.4%) in the most recent postoperative control. There were 25 reoperations in 17 patients, of which 15 had to be performed for MV regurgitation and two for MV stenosis. Freedom from reoperation was 91% at 1 year, 79% at 10 years, and 76% at 15 and 20 years. We could not identify a statistically significant risk factor for reoperation.

CONCLUSIONS

In patients with AVSD of various morphologies closure of the left AV valve cleft significantly improves outcome without affecting the need for reoperation. Risk factors for early and late death (multivariate analysis) were a pulmonary/aortic pressure ratio >0.7 and the occurrence of any complication after surgery. The concept of an early surgical AVSD correction before an increase in pulmonary vascular resistance and AV valve deformations occur would represent a better surgical option than a late correction as done in our series. Early correction allows for reduction of early mortality, superior long-term survival rates and a high freedom from subsequent valve degeneration.

Modification of the radial procedure in a patient with partial atrioventricular septal defect

We successfully cured atrial fibrillation while preserving internodal conduction in a patient with a partial atrioventricular septal defect. Because the anterior and middle internodal tracts are interrupted by the defect, the lower right atrial incision of either the maze or the radial procedure may interrupt the remaining posterior tract, resulting in internodal conduction block. We deleted the posterior septal incision from the radial procedure and replaced it with a right-side left atriotomy. The patient resumed normal sinus rhythm with significant contraction of the right and left atria. The preserved internodal pathway through the posterior interatrial septum was confirmed by electrophysiologic study.

Partial atrioventricular canal defect in a dog

A case of a partial atrial canal defect is described in a nine-month-old female English setter. The patient had a large ostium primum atrial septal defect and a concurrent malformation of the mitral valve. Electrocardiographic and radiographic findings were suggestive of marked enlargement of the right heart and pulmonary overcirculation. Definitive diagnosis and assessment of the haemodynamic consequences were made using echocardiography. The magnitude of the left-to-right intracardiac shunt was estimated by measuring the pulmonary to systemic flow ratio (Qp/Qs) from Doppler-derived pulmonary and aortic blood flow. The results of this report suggest that dogs with a partial atrioventricular canal defect and concurrent mild mitral regurgitation may exhibit no clinical signs during the first years of life, even in cases with a Qp/Qs ratio of greater than 2.

Surgical results of double-orifice left atrioventricular valve associated with atrioventricular septal defects

BACKGROUND

Double-orifice left atrioventricular valve (LAVV) is a rare but surgically important anomaly, which is regarded as a risk factor for surgical correction of atrioventricular septal defects (AVSDs).

METHODS

Of 209 consecutive patients with AVSDs, double-orifice LAVV was identified in 19 patients (9.1%, including 7 infants). Preoperative LAVV function, surgical procedures and results, incidence of postoperative LAVV dysfunction and reoperations were reviewed and compared between patients with this valve malformation (group I, n = 19) and those without it (group II, n = 190).

RESULTS

There were no operative or late deaths in group I. Preoperative LAVV function was similar in both groups. The cleft was totally closed in 77.2% of group II and 47.1% of group I (p < 0.01). In partial AVSDs, freedom from postoperative LAVV insufficiency was 77.0% in group II versus 30.5% in group I at 5 years (p = 0.009) and freedom from reoperation was 89.9% in group II versus 58.3% in group I at 5 years (p = 0.012); however, there was no difference in complete AVSDs. None of the infants in group I underwent total cleft closure and 4 of them showed more than moderate LAVV insufficiency postoperatively.

CONCLUSIONS

Double-orifice LAVV is a significant predictor for postoperative LAVV incompetence and reoperation in partial AVSDs, but not in complete AVSDs. Surgical procedures for the cleft should be individualized with careful intraoperative evaluation of the structure and function of this abnormal valve, especially in partial AVSDs and infants.

Advances in congenital heart surgery

Congenital heart surgery is a young and constantly evolving field. Since the first patent ductus arteriosus ligation by Robert Gross of Boston in 1938, a greater understanding of the anatomy and pathophysiology of congenital heart disease, improved diagnostics, and the advent of cardiopulmonary bypass and deep hypothermic circulatory arrest have allowed the open repair of many lesions. Further advances in preoperative, intraoperative, and postoperative patient management have resulted in greatly improved survivals for even the most complex congenital defects. By looking forward through continual technical innovation and back with the critical evaluation of established techniques, we continue to advance the care of the patient with congenital heart disease.

Direct closure of ostium primum defect in the repair of atrioventricular septal defect

BACKGROUND

Patch closure is generally performed for atrial septation of an atrioventricular septal defect. We recently developed a new surgical technique for repairing atrioventricular septal defects that avoids the use of any patch material for closing the atrial septal defect. We report our experience with this procedure.

METHODS

Seven patients (complete type: 5, partial type: 2) underwent this new operation. The diameters of the atrial septal defects were measured by transesophageal echocardiography. The preoperative electrocardiograms were compared with those taken after the operations.

RESULTS

Diameters of the atrial defects ranged from 3 to 10 mm. Electrocardiograms before and after the operations did not change. No significant atrioventricular valve regurgitation and no residual shunts were detected by postoperative echocardiography.

CONCLUSIONS

This method simplifies the repair of atrioventricular septal defects. In the short-term results, no arrhythmia and no valve regurgitation was seen.