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Mavroudis C, Ong CS, Vricella LA, Cameron DE. Historical Accounts of Congenital Heart Surgery. World J Pediatr Congenit Heart Surg 2023; 14:626-641. [PMID: 37737603 DOI: 10.1177/21501351231186415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
We present historical accounts of congenital heart surgery since the early 1900s, as our specialty evolved from individual heroic efforts into an established and sophisticated surgical specialty with consistent and excellent results. We highlight colleagues and intrepid pioneers who have strived to solve seemingly insurmountable problems during this remarkable journey and celebrate continued success into the 21st century with surgical advances that have resulted in innovative operations, database inquiries, quality measures, new techniques of medical illustration, and the establishment of the Congenital Heart Surgeons' Society, which has become the leading organization dedicated to congenital heart surgery in North America.
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Affiliation(s)
- Constantine Mavroudis
- Department of Surgery, Johns Hopkins University School of Medicine, Peyton Manning Children's Hospital, Indianapolis, IN, USA
| | - Chin Siang Ong
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Luca A Vricella
- Department of Surgery, University of Chicago School of Medicine, Chicago, IL, USA
| | - Duke E Cameron
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Common Atrioventricular Canal. CONGENIT HEART DIS 2022. [DOI: 10.1016/b978-1-56053-368-9.00011-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Alhawri KA, Mcmahon CJ, Alrih MM, Alzein Y, Khan AA, Mohammed SK, Alalwi KS, Walsh KP, Kenny DP, McGuinness JG, Nolke L, Redmond JM. Atrioventricular septal defect and tetralogy of Fallot - A single tertiary center experience: A retrospective review. Ann Pediatr Cardiol 2019; 12:103-109. [PMID: 31143034 PMCID: PMC6521653 DOI: 10.4103/apc.apc_87_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Complete atrioventricular septal defect (CAVSD) in association with tetralogy of Fallot is a rare and complex disease that makes its repair more difficult than repair of either lesion alone. We reviewed retrospectively our experience in managing this lesion. Patients and Methods: Between February 2006 and May 2017, 16 patients who underwent repair of CAVSD/tetralogy of Fallot (TOF) were reviewed retrospectively. Fifteen patients had trisomy 21. Five patients underwent primary repair while eleven patients went for staged repair in the form of right ventricular outflow tract (RVOT) stenting (n = 9) or systemic to pulmonary (S-P) surgical shunt (n = 2). RVOT stenting has replaced surgical shunt since 2012 in our center. Early presentation with cyanosis was the main determinant factor for staged versus primary repair. Results: The median age at first palliation was 46 days (range 15–99 days). The median age at total repair for both groups was 6 months (range 3–18 months); the median age for the palliated patients was 6.5 months (range 5–18 months) while the median age for primary repaired patients was 5 months (range 3–11 months). The median weight at final repair was 6.9 kg (3.7–8.2 kg). The pulmonary valve was preserved in five patients (31%), four of them had no prior palliation. Chylothorax occurred in 50% of the patients. One late mortality occurred after final repair due to sepsis. Conclusion: CAVSD/TOF can be repaired with low mortality and morbidity. The use of RVOT stent has replaced the surgical (S-P) shunt with acceptable results in our center.
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Affiliation(s)
- Khaled A Alhawri
- Department of Pediatric Cardiothoracic Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland
| | - Colin J Mcmahon
- Department of Pediatric Cardiothoracic Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland
| | - Mohammed M Alrih
- Department of Pediatric Cardiothoracic Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland
| | - Yamin Alzein
- Department of Pediatric Cardiothoracic Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland
| | - Asad A Khan
- Department of Pediatric Cardiothoracic Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland
| | - Suhaib K Mohammed
- Department of Pediatric Cardiothoracic Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland
| | - Khaled S Alalwi
- Department of Pediatric Cardiothoracic Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland
| | - Kevin P Walsh
- Department of Pediatric Cardiothoracic Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland
| | - Damien P Kenny
- Department of Pediatric Cardiothoracic Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland
| | - Jonathon G McGuinness
- Department of Pediatric Cardiothoracic Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland
| | - Lars Nolke
- Department of Pediatric Cardiothoracic Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland
| | - John M Redmond
- Department of Pediatric Cardiothoracic Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland
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Long-Term Outcome of Patients With Complete Atrioventricular Septal Defect Combined With the Tetralogy of Fallot: Staged Repair Is Not Inferior to Primary Repair. Ann Thorac Surg 2016; 103:876-880. [PMID: 27692233 DOI: 10.1016/j.athoracsur.2016.07.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 07/08/2016] [Accepted: 07/11/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Primary repair is the preferred strategy for surgical treatment of complete atrioventricular septal defect combined with the tetralogy of Fallot. However, a staged approach may be preferable for very small or cyanotic infants. The long-term outcomes of infants undergoing staged vs primary repair were compared. METHODS Data from 47 patients with complete atrioventricular septal defect combined with the tetralogy of Fallot who were operated on at our institution between 1974 and 2013 were reviewed. The study end points were all-cause death and reoperation. The patients were classified into two groups: staged repair (SR) and primary repair (PR). The indications for staged repair were cyanosis and young age. RESULTS There were 22 SR and 25 PR patients. The SR patients were younger at the time of the initial operation (p = 0.001), and were more frequently cyanotic (21 SR vs 5 PR patients, p = 0.003). The 10-year survival after repair of the SR and PR patients was 78% ± 11% and 83% ± 8%, respectively (p = 0.8). No risk factors for death were identified. The 10-year freedom from reoperation for atrioventricular valve regurgitation of SR and PR patients after repair was 73% ± 12% and 71% ± 10%, respectively (p = 0.5). At least moderate atrioventricular valve regurgitation before repair was the only risk factor for reoperation (p = 0.01). CONCLUSIONS Cyanotic and very young children with complete atrioventricular septal defect combined with the tetralogy of Fallot who require urgent treatment have long-term outcomes after staged repair similar to those of patients who undergo primary repair. Preoperative atrioventricular valve regurgitation is associated with increased risk for reoperation over the long-term.
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Tetralogy of Fallot with atrioventricular septal defect: surgical strategies for repair and midterm outcome of pulmonary valve-sparing approach. Pediatr Cardiol 2013; 34:861-71. [PMID: 23104595 DOI: 10.1007/s00246-012-0558-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 10/04/2012] [Indexed: 01/25/2023]
Abstract
Repair for tetralogy of Fallot (TOF) with complete atrioventricular septal defect (CAVSD) has been reported with good early and intermediate outcomes. Morbidity, however, remains significantly high. To date, repair of CAVSD/TOF using a pulmonary valve-sparing technique (PVS) and freedom from valve reoperation are not well defined. A study was undertaken to investigate outcomes. This study was conducted in as a retrospective investigation. Between January 1988 and December 2008, 13 consecutive patients with CAVSD/TOF were identified, and their records were reviewed retrospectively. Of these 13 patients, 9 had Rastelli type C CAVSD. Trisomy 21 was present in 9 cases (69 %; 7 with type C). Five patients had received a systemic-to-pulmonary shunt (SPS) before complete repair at a mean age 1.7 ± 0.6 months. All the patients survived until complete repair. At complete CAVSD/TOF repair, AVSD was corrected with a two-patch technique in all patients. For eight patients (61.5 %), PVS was used. The remaining five patients had transannular patch (TAP) repair. The mean age at complete repair was 6.3 ± 2.4 months. At complete repair, the mean cardiopulmonary bypass time was 173.5 ± 30.6 min, and the cross-clamp time was 134.7 ± 28.8 min. There was one hospitalization and no late deaths. The median follow-up period was 9.2 years [interquartile range (IQR), 4.7-13.3 years]. The actuarial survival was 90.0 ± 9.5 % at 1 year, 90 ± 9.5 % at 5 years, and 90 ± 9.5 % at 8 years. Of the 12 survivors, 6 had some reintervention during the follow-up period. Within the first 11 years after complete repair, two patients underwent left atrioventricular (AV) valve repair, and one patient had right AV valve repair. Two patients had residual VSD closure. Four patients underwent the first right ventricular outflow tract (RVOT) reintervention for critical insufficiency or stenosis at a mean interval of 6 ± 21) months. One patient had a second RVOT reoperation. Findings showed that CAVSD/TOF with PVS was related to significantly higher freedom from RVOT reintervention (100 % at 1, 5, and 8 years compared with 80 ± 17.9 % at 1 year, 60 ± 21.9 % at 5 years, and 40 ± 21.9 % at 8 years for CAVSD/TOF using TAP; P < 0.05). No patient who underwent PVS had left ventricular outflow tract obstruction requiring reoperation. Overall freedom from any reintervention was 90.9 ± 8.6 % at 1 year, 71.6 ± 14.0 % at 5 years, and 53.7 ± 8.7 % at 8 years in this group of patients. Correction of TOF with CAVSD can be performed at low risk with favorable intermediate-term survival and satisfactory freedom from reoperation. Use of TAP can be avoided in almost two thirds of patients and may influence freedom from early RVOT reintervention.
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Shuhaiber JH, Robinson B, Gauvreau K, Breitbart R, Mayer JE, Del Nido PJ, Pigula F. Outcome after repair of atrioventricular septal defect with tetralogy of Fallot. J Thorac Cardiovasc Surg 2011; 143:338-43. [PMID: 21855095 DOI: 10.1016/j.jtcvs.2011.05.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 04/04/2011] [Accepted: 05/05/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND Long-term outcomes of repair of tetralogy of Fallot associated with complete atrioventricular septal defect are seldom reported. We report our survival and reintervention outcomes over a 29-year time period. METHODS Between March 1979 and April 2008, 61 patients with the combined cardiac defect of atrioventricular septal defect and tetralogy of Fallot were surgically managed. Trisomy 21 was present in 49 (80%) patients. Primary repair was performed in 36 patients at a median age of 9 months (range, 1 month to 16 years), whereas 25 patients had initial palliation by systemic-pulmonary shunt at a median age of 21 months (range, 0 days to 36 years). Thirty-one (51%) patients had a transannular patch. Fifty-three patients required right ventriculotomy for relief of the right ventricular outflow tract obstruction. Four patients had a right ventricle-pulmonary artery conduit with a homograft. Relationships between patient characteristics and outcome variables were examined using Kaplan-Meier survival curves; comparisons were performed using the log-rank test. RESULTS Median follow-up was 4.7 years. A total of 12 patients died during the course of follow-up: 4 (7%)deaths within 30 days of surgery and 8 late deaths (range, 4 months to 9.9 years after repair). Since 2000, there have been no early deaths and 1 late death, 5 months after the operation. The estimated survival at 5 years after definitive repair was 82% (95% confidence interval, 69%, 90%). Time to death was not associated with any patient or surgical variables examined. Overall, 30% of the survivors required a reoperation. The type of reoperations was on the mitral valve (4 repairs, 4 replacements) and 7 pulmonary valve replacements. We did not find an effect of era on mortality (P = .23 for comparison of 1979-1989, 1990-1999, and 2000-2008). The percentage of patients with primary repair did not change during the different quartiles. The estimated freedom from reoperation at 5 years was 80% (65%, 90%). Time to reoperation was shorter for patients with a conduit (P = .01). CONCLUSIONS Excellent long-term survival was achieved after repair of tetralogy of Fallot associated with complete atrioventricular septal defect. Palliation and primary repair resulted in comparable outcomes; as such, primary repair is favored. The choice of right ventricular outflow tract reconstruction affects the need for reoperation.
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Affiliation(s)
- Jeffrey H Shuhaiber
- Department of Cardiovascular Surgery, Children's Hospital Boston, Boston, Mass., USA.
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Tchervenkov CI, Bernier PL, Duca DD, Hill S, Ota N, Samoukovic G, Al-Habib H, Korkola S. Repair of atrioventricular canal with double-outlet right ventricle, transposition, or truncus arteriosus. World J Pediatr Congenit Heart Surg 2010; 1:119-26. [PMID: 23804732 DOI: 10.1177/2150135110362093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atrioventricular canal and conotruncal anomalies are a heterogeneous group of lesions presenting unique challenges for surgical repair. These are the establishment of unobstructed pathways from left ventricle (LV) to aorta and from right ventricle (RV) to pulmonary artery, closure of the inlet ventricular septal defect (VSD) and atrial septal defect (ASD) ostium primum, and the avoidance of significant left and right atrioventricular valve (AV) regurgitation. Repair of complete atrioventricular canal (CAVC) with tetralogy of Fallot (TOF) has been most commonly achieved, either using a single-patch or a 2-patch technique. In patients with CAVC with double-outlet right ventricle (DORV) with subaortic VSD extension, the 2-patch repair is not unlike that of CAVC with TOF. However, biventricular repair is most challenging in patients with CAVC and complete origin of the aorta from the RV, as in CAVC with DORV and noncommitted VSD and those with CAVC with transposition of the great arteries (TGA) and LVOTO. The technique of VSD translocation allows anatomic biventricular repair for these particularly challenging patients. The arterial switch operation with CAVC repair can be used for patients with CAVC with DORV with subpulmonary VSD extension and CAVC with TGA without left ventricular outflow tract obstruction. Biventricular repair is achievable in most patients with balanced complete atrioventricular canal and conotruncal anomaly. The extreme heterogeneity of CAVC with conotruncal anomalies requires a highly individual approach that is tailored to the specific constellation of lesions in each patient.
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Affiliation(s)
- Christo I Tchervenkov
- Montreal Children's Hospital of the McGill University Health Center, Montreal, Québec, Canada
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Brancaccio G, Michielon G, Filippelli S, Perri G, Di Carlo D, Iorio FS, Oricchio G, Iacobelli R, Amodeo A, Di Donato RM. Transannular patching is a valid alternative for tetralogy of Fallot and complete atrioventricular septal defect repair. J Thorac Cardiovasc Surg 2009; 137:919-23. [DOI: 10.1016/j.jtcvs.2008.09.055] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 04/06/2008] [Accepted: 09/30/2008] [Indexed: 10/21/2022]
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Surgical correction for patients with tetralogy of Fallot and common atrioventricular junction. Cardiol Young 2008; 18 Suppl 3:29-38. [PMID: 19094377 DOI: 10.1017/s1047951108003272] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hoohenkerk GJF, Schoof PH, Bruggemans EF, Rijlaarsdam M, Hazekamp MG. 28 years' experience with transatrial-transpulmonary repair of atrioventricular septal defect with tetralogy of Fallot. Ann Thorac Surg 2008; 85:1686-9. [PMID: 18442566 DOI: 10.1016/j.athoracsur.2007.11.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Revised: 11/09/2007] [Accepted: 11/09/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND The outcome of surgical correction of atrioventricular septal defect and tetralogy of Fallot has improved in recent years but is still reported to be associated with high mortality. Controversy exists about the need of a right ventriculotomy or a right ventricular to pulmonary artery conduit. The purpose of this study was to evaluate our results of atrioventricular septal defect and tetralogy of Fallot repair by transatrial-transpulmonary approaches. METHODS Between 1979 and 2007, 20 consecutive patients underwent correction of atrioventricular septal defect and tetralogy of Fallot. Five patients had undergone prior palliative shunts. In all patients, a transatrial-transpulmonary approach was used and repair was accomplished without a conduit. The two-patch technique was used to correct the atrioventricular septal defect. Clinical data were obtained by retrospective review of inpatient and outpatient clinical charts. RESULTS There was no in-hospital mortality and one late, noncardiac death. Six patients required eight reoperations, six for left atrioventricular valve insufficiency (repair: n = 4; replacement: n = 2), one for residual ventricular septal defect, and one for pulmonary artery branch obstruction. Follow-up was complete for all patients (median, 17 years; range, 1.5 to 28 years). All 19 survivors were in good clinical condition at last control, without medication, and in New York Heart Association class I (n = 18) or II (n = 1). Transesophageal echocardiography revealed good right ventricular function, low right ventricular outflow tract gradients (mean, 9 +/- 7.4 mm Hg), and trace pulmonary valve insufficiency (n = 11). CONCLUSIONS Atrioventricular septal defect and tetralogy of Fallot can be repaired with low mortality by the transatrial-transpulmonary approach without the use of a conduit.
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Affiliation(s)
- Gerard J F Hoohenkerk
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands.
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Tchervenkov CI, Hill S, Del Duca D, Korkola S. Surgical repair of atrioventricular septal defect with common atrioventricular junction when associated with tetralogy of Fallot or double outlet right ventricle. Cardiol Young 2006; 16 Suppl 3:59-64. [PMID: 17378042 DOI: 10.1017/s1047951106000771] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The association of atrioventricular septal defect with common atrioventricular junction and malformations of the ventricular outflow tracts presents a significant challenge for the surgeon. In the most common of these, the association with tetralogy of Fallot, several surgical techniques have been described, and shown to deliver excellent results.1–10On the other hand, in the setting of more extreme malformations, such as double-outlet right ventricle, discordant ventriculo-arterial connections, or common arterial trunk, albeit rare lesions, the combination presents a more formidable surgical challenge, as evidenced by the few reports of successful repair of these lesions. This challenge is both physiological, when dealing with a very sick neonate or infant, as well as anatomical in terms of the complexity of the malformation and the ability to achieve a successful biventricular repair. Our goal in this review is to discuss the surgical treatment in the setting of tetralogy of Fallot and double outlet right ventricle, with emphasis on biventricular repair.
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Affiliation(s)
- Christo I Tchervenkov
- Division of Cardiovascular Surgery, Montreal Children's Hospital of the McGill University Health Center, McGill University, Montreal, Quibec, Canada.
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Okamura T, Nagase Y, Matsumoto Y, Park IS, Mitsui F, Shibairi M. Complete atrioventricular canal and tetralogy of Fallot with pulmonary atresia. Ann Thorac Surg 2004; 78:e69-71. [PMID: 15464457 DOI: 10.1016/j.athoracsur.2003.12.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2003] [Indexed: 10/26/2022]
Abstract
Our patient was diagnosed with complete atrioventricular canal and Tetralogy of Fallot with pulmonary atresia at the age of 1 month. Then he underwent right and left Blalock-Taussig shunts at the ages of 2 months and 5 years, respectively. His cyanosis had increased at 20 years of age. Cardiac catheterization showed occlusion of the left Blalock-Taussig shunt and absence of the left pulmonary artery. Lung perfusion scintigram showed late phase perfusion in the left lung. Chest computed tomographic scan demonstrated the left pulmonary artery. We describe the operative technique of total correction.
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Affiliation(s)
- Toru Okamura
- Department of Cardiovascular Surgery, Matsudo City Hospital, Chiba, Japan.
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Prifti E, Bonacchi M, Bernabei M, Leacche M, Bartolozzi F, Murzi B, Battaglia F, Nadia NS, Vanini V. Repair of Complete Atrioventricular Septal Defect with Tetralogy of Fallot:. J Card Surg 2004; 19:175-83. [PMID: 15016061 DOI: 10.1111/j.0886-0440.2004.04031.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of this report is to describe the rationale of our surgical approach, to explore the best management for complete atrioventricular septal defect associated with the tetralogy of Fallot (CAVSD-TOF), and to present our outcome in relation to the previously reported series. MATERIALS AND METHODS Between January 1990 and January 2002, 17 consecutive children with CAVSD-TOF underwent complete correction. Nine patients (53%) underwent previous palliation. Mean age at repair was 2.9 +/- 1.9 years. Mean gradient across the right ventricular outflow tract was 63 +/- 16 mmHg. All children underwent closure of septal defect with a one-patch technique, employing autologous pericardial patch. Maximal tissue was preserved for LAVV reconstruction by making these incisions along the RV aspect of the ventricular septal crest. LAVV annuloplasty was performed in 10 (59%) patients. Six patients (35%) required a transannular patch. RESULTS Three (17.6%) hospital deaths occurred in this series. Causes of death included progressive heart failure in two patients and multiple organ failure in the other patient. Two patients required mediastinal exploration due to significant bleeding. Dysrhythmias were identified in 4 of 11 patients undergoing a right ventriculotomy versus none of the patients undergoing a transatrial transpulmonary approach (p = ns). The mean intensive care unit stay was 3.2 +/- 2.4 days. Two patients required late reoperation due to severe LAVV regurgitation at 8.5 and 21 months, respectively, after the intracardiac complete repair. The mean follow-up time was 36 +/- 34 months. All patients survived and are in NYHA functional class I or II. The LAVV regurgitation grade at follow-up was significantly lower than soon after operation, 1.1 +/- 0.4 versus 1.7 +/- 0.5 (p = 0.002). At follow-up, the mean gradient across the right ventricular outflow tract was 17 +/- 6 mmHg, significantly lower than preoperatively (p < 0.001). CONCLUSIONS Complete repair in patients with CAVSD-TOF seems to offer acceptable early and mid-term outcome in terms of mortality, morbidity, and reoperation rate. Palliation prior to complete repair may be reserved in specific cases presenting small pulmonary arteries or severely cyanotic neonates. The RVOT should be managed in the same fashion as for isolated TOF; however, a transatrial transpulmonary approach is our approach of choice.
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Affiliation(s)
- Edvin Prifti
- Department of Pediatric Cardiac Surgery, G. Pasquinucci Hospital, Massa, Italy
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Okada Y, Tatsuno K, Kikuchi T, Takahashi Y, Shimokawa T. Complete atrioventricular septal defect associated with tetralogy of fallot: surgical indications and results. JAPANESE CIRCULATION JOURNAL 1999; 63:889-92. [PMID: 10598897 DOI: 10.1253/jcj.63.889] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Complete atrioventricular septal defect (AVSD) associated with tetralogy of Fallot is a rare condition that still has problems in the postoperative period. The authors report their surgical experiences over the past 10 years. Nine children underwent total correction. The defect was repaired by the 2-patch technique and the ATrioventricular valve was reconstructed by suturing the cleft and annuloplasty. A transannular right ventricular outflow patch was used in 5 patients. All patients had Down syndrome and a free-floating superior bridging lEAflet. One patient died from cardiac failure. Although there was no reoperation or death in the late postoperative periods, mild mitral regurgitation occurred in 4 patients and there was moderate or severe pulmonary regurgitation in 2 patients. All survivors currently have no critical symptoms in their daily lives. With the standard of patient selection used, the optimal body weight was around 8 kg and PA index was 200 or more. Right ventriculotomy provided a better view for complete closure of the ventricular septal defect (VSD). In order to avoid re-regurgitation of the atrioventricular valve, the 2-patch technique is the most suitable procedure for total repair.
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Affiliation(s)
- Y Okada
- Department of Surgery, Sakakibara Heart Institute, Tokyo, Japan.
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Najm HK, Van Arsdell GS, Watzka S, Hornberger L, Coles JG, Williams WG. Primary repair is superior to initial palliation in children with atrioventricular septal defect and tetralogy of Fallot. J Thorac Cardiovasc Surg 1998; 116:905-13. [PMID: 9832680 DOI: 10.1016/s0022-5223(98)70040-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective was to explore the best management algorithm for atrioventricular septal defect in conjunction with tetralogy of Fallot. METHODS We reviewed the cases of 38 children referred to our division (March 1981-August 1997) who had atrioventricular septal defect associated with tetralogy of Fallot; 32 (84%) had Down syndrome. Twenty-one received initial palliation with a systemic-to-pulmonary artery shunt; of these, 2 (9.5%) died before complete repair. Thirty-one children underwent complete repair; 14 of these (45%) had undergone initial palliation (mean age at shunt 20 +/- 24 months). Right ventricular outflow obstruction was relieved by a transannular patch in 22 (71%); 14 (64% of 22) had a monocuspid valve inserted. Four required an infundibular patch. RESULTS Two children (6.4%) died early after repair; 1 had undergone previous palliation. Patients with palliation underwent repair at an older age (78 vs 36 months), required longer ventilatory support (8 vs 4 days) and inotropic support (8 vs 4 days), and had longer intensive care stays (11 vs 6 days) and hospital stays (24 vs 15 days). Eleven children (35%) underwent reoperation, 7 (58%) for right ventricular outflow reconstruction and pulmonary arterioplasty. Reoperation was more frequent in the palliation group than in the primary operation group (64% vs 12%). The single late death was related to a reoperation in the palliation group. CONCLUSIONS Atrioventricular septal defect with tetralogy of Fallot can be repaired with a low mortality rate. Initial palliation with a shunt resulted in a more complex postoperative course and a higher reoperative rate. Primary repair is superior to initial palliation with later repair.
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Affiliation(s)
- H K Najm
- Division of Cardiovascular Surgery, Department of Surgery, Hospital for Sick Children and the Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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O'Blenes SB, Ross DB, Nanton MA, Murphy DA. Atrioventricular septal defect with tetralogy of Fallot: results of surgical correction. Ann Thorac Surg 1998; 66:2078-82; discussion 2082-4. [PMID: 9930496 DOI: 10.1016/s0003-4975(98)00975-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The outcome of surgical correction of complete atrioventricular septal defect with tetralogy of Fallot has improved in recent years. Controversy exists about the optimal approach to this complex lesion. Our experience over the past 8 years with a single technique is reviewed. The important anatomic features of this lesion are discussed in relation to our method of repair. METHODS Between 1988 and 1996, 11 consecutive patients underwent correction of complete atrioventricular septal defect with tetralogy of Fallot. Nine patients had undergone prior palliative shunts. The two-patch technique for atrioventricular septal defect was used. The ventricular septal defect was closed through a right ventriculotomy in each case. The commissure between the superior and inferior bridging leaflets of the left portion of the common atrioventricular valve was closed in each patient. Management of the right ventricular outflow tract was individualized. RESULTS There was one mortality in the early postoperative period. One patient required reoperation for closure of a dehiscent left atrioventricular valve cleft. All survivors are currently in New York Heart Association functional class I or II at follow-up ranging from 2 to 101 months. CONCLUSIONS Atrioventricular septal defect with tetralogy of Fallot can be corrected with low mortality using the two-patch technique and closure of the ventricular septal defect through a combined approach using a right ventriculotomy and right atriotomy. Routine closure of the commissure of the left portion of the atrioventricular valve results in a low incidence of regurgitation. A good functional result can be achieved in most patients at intermediate-term follow-up.
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Affiliation(s)
- S B O'Blenes
- Division of Cardiovascular Surgery, The IWK Grace Health Centre, Halifax, Nova Scotia, Canada
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McElhinney DB, Reddy VM, Silverman NH, Brook MM, Hanley FL. Atrioventricular septal defect with common valvar orifice and tetralogy of Fallot revisited: making a case for primary repair in infancy. Cardiol Young 1998; 8:455-61. [PMID: 9855099 DOI: 10.1017/s1047951100007113] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Atrioventricular septal defect with common valvar orifice and tetralogy of Fallot is a rare combination of congenital cardiac anomalies. Approaches to this lesion have tended to emphasize either staged repair or complete repair beyond infancy. Between July 1992 and August 1997, nine patients underwent repair of complete atrioventricular septal defect with tetralogy of Fallot. One patient, aged 9.6 years at the time of repair, had previously undergone construction of a modified Blalock-Taussig shunt. Primary complete repair was performed in the other 8 patients at ages ranging from 2.5 to 16 months (median 4.6 months), and all but one were infants. All patients had a Rastelli type C defect, a single ventricular septal defect with inlet and outlet components, and malalignment of the muscular outlet septum with subpulmonary stenosis. A single patch technique, with closure of the zone of apposition ('cleft') in the left atrioventricular valve, was used in all eight patients undergoing primary repair, while a double patch was employed in the previously palliated older patient. In all cases of repair using a single patch, the anterosuperior bridging leaflet was divided obliquely to the right, following the malaligned outlet septum, in order to avoid subaortic obstruction. Repair of the right ventricular outflow tract included infundibular myectomy in eight, pulmonary valvotomy in four, infundibular or transannular patching in three and one, respectively, and reconstruction with a valved allograft conduit in two patients. There was no early mortality or significant morbidity. At a median follow-up of 45 months, there had been one death related to non-cardiac causes and no reinterventions. Left atrioventricular valvar regurgitation was moderate or mild in two patients, and right atrioventricular valvar regurgitation was mild in one patient. No patient had more than mild pulmonary regurgitation or a gradient across the right ventricular outflow tract in excess of 18 mm Hg. Our results demonstrate that primary repair of atrioventricular septal defect with tetralogy of Fallot can be performed with excellent early and mid-term results in young infants. Although it has been suggested that a technique utilizing oblique division of the anterosuperior bridging leaflet may lead to high rates of atrioventricular valvar regurgitation, medium-term atrioventricular valvar function in the present cohort of patients has been excellent.
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Affiliation(s)
- D B McElhinney
- Division of Cardiothoracic Surgery, University of California, San Francisco, 94143-0118, USA
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Bertolini A, Dalmonte P, Bava GL, Calza G, Lerzo F, Zannini L, Pongiglione G, Moretti R. Surgical management of complete atrioventricular canal associated with tetralogy of Fallot. CARDIOVASCULAR SURGERY (LONDON, ENGLAND) 1996; 4:299-302. [PMID: 8782923 DOI: 10.1016/0967-2109(95)00122-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Between 1984 and 1993, 12 children with an atrioventricular canal and tetralogy of Fallot underwent surgical repair. The mean(s.d.) age at operation was 58(18) months, and the mean(s.d.) body weight 15(4) kg. Nine patients underwent 11 palliative procedures. The ventricular septal defect was closed through a combined (right atrial and right ventricular) approach in nine cases, and through a right atrial approach in three, using a prosthetic patch with a wide anterior extension, secured with a running suture. The 'ostium primum' defect was closed with a separate prosthetic patch in 11 cases (double-patch technique). Right ventricular outflow obstruction was relieved by a composite infundibular patch (seven cases) or a transanular patch (five). There were four hospital deaths (33%). These were caused by low cardiac output in three cases and infection in one (three deaths occurred in patients with a transanular patch). One patient has so far died during follow-up. Assessment at 50(36) months by echo-Doppler showed moderate-to-severe 'mitral' regurgitation in three cases, and moderate 'tricuspid' regurgitation with right ventricular dysfunction in one case. Two patients have required further surgery.
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Affiliation(s)
- A Bertolini
- Department of Cardiovascular Surgery, Giannina Gaslini Institute, Children's Hospital, Genoa, Italy
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Chiu IS, Hung CR, Wang JK, Wu MH, Chu SH. Surgical treatment of complete atrioventricular septal defect associated with tetralogy of Fallot. Int J Cardiol 1995; 48:225-30. [PMID: 7782135 DOI: 10.1016/0167-5273(94)02243-c] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The combination of complete atrioventricular septal defect (AVSD) and tetralogy of Fallot (TF) was reported to occur in less than 2% of patients undergoing repair of TF. From September 1981 to November 1989, five consecutive patients with such combination underwent total correction at National Taiwan University Hospital. Their age ranged from 3.8 years to 6.3 years. Two cases were associated with Down's syndrome. All interventricular communications were repaired by combined transatrial and transventricular approach and a separate pericardial patch was used to repair the interatrial communication. The transannular patch (TAP) was not used in one case; of the four cases with TAP, a pericardial monocusp was mounted in one of them. There was one hospital mortality, and one late death. Both were related to intractable right heart failure. We conclude that total repair of this anomaly could be accomplished after 3 years of age provided there is thorough awareness of anatomical features and avoidance of right heart failure.
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Affiliation(s)
- I S Chiu
- Department of Surgery, National Taiwan University Hospital, Taipei
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Malm T, Karl TR, Mee RB. Transatrial-transpulmonary repair of atrioventricular septal defect with right ventricular outflow tract obstruction. J Card Surg 1993; 8:622-7. [PMID: 8286866 DOI: 10.1111/j.1540-8191.1993.tb00421.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Twenty patients had a repair of an atrioventricular septal defect with tetralogy of Fallot (n = 13) or double outlet right ventricle (n = 7). Mean age was 3.5 years. Surgical technique included transatrial-transpulmonary resection of right ventricular outflow tract obstruction and transatrial two patch repair of the atrioventricular septal defect. Ten patients required a transannular patch and one patient had a right ventricle-pulmonary artery conduit placed. There was no hospital mortality, and mean hospital stay was 15 days. One patient had late sudden death of unknown cause. Six patients have required reoperation because of residual ventricular septal defect (VSD), mitral incompetence, residual right ventricular outflow tract obstruction, and/or conduit stenosis. No patient was reoperated on because of left ventricular outflow tract obstruction. Fifteen patients are asymptomatic, one has exertional dyspnea, and two have intermittent occasional bronchospasm. The transatrial-transpulmonary two patch repair and extensive relief of right ventricular outflow tract obstruction have given good immediate results. Reoperation rate has been high mainly due to residual VSD and mitral incompetence.
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Affiliation(s)
- T Malm
- Victorian Paediatric Cardiac Surgical Unit, Royal Children's Hospital, Melbourne, Australia
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Abstract
Advances in medical and surgical management of congenital heart disease in the last three decades have resulted in a great many survivors to adulthood. Proper care requires intimate knowledge of the basic malformations and their surgical anatomy and results. Tetralogy of Fallot, the most common cyanotic malformation in adults, represents a spectrum from mild right ventricular outflow tract obstruction to complete pulmonary atresia. Evaluation of surgical residua and sequelae includes imaging of aortic-to-pulmonary arterial palliative shunts, detection of residual ventricular septal defect patch leaks or right ventricular outflow tract obstruction, definition of extracardiac conduit patency, and quantitation of ventricular function and valvular regurgitation. Refined echocardiographic imaging and hemodynamic definition is a mainstay in precise segmental anatomical and hemodynamic assessment. Transesophageal echocardiography is particularly important for intraoperative evaluation of surgical results.
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Affiliation(s)
- J S Child
- Division of Cardiology, UCLA Adult Congenital Heart Disease Center, University of California, Los Angeles, School of Medicine, 90024
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