Surgical repair of complete atrioventricular septal canal defects with absent posterior leaflet

Echocardiographic assessment of obstructive lesions in atrioventricular septal defects

OBJECTIVES

We sought to determine the accuracy of transthoracic echocardiography (TTE) in identifying risk factors in patients with an atrioventricular septal defect (AVSD).

BACKGROUND

Atrioventricular septal defect is a common lesion, and many decisions about it are based on echocardiography alone. The identification of associated left-sided inflow and outflow obstructive lesions is important, as they are responsible for mortality and morbidity.

METHODS

Between 1983 to 1998, 549 patients with AVSD underwent repair. The TTE findings were correlated with surgery, angiocardiography, autopsy or postoperative TTE. Papillary muscle measurements were made in those with either a left ventricular outflow tract (LVOT) or left ventricular inflow abnormality and compared with those measurements from control subjects. Measurements of the LVOT were made in patients with an identified LVOT abnormality.

RESULTS

There were 63 missed lesions, decreasing over time. Double-orifice left atrioventricular valve (DOLAVV) and nonobstructive chordae in the LVOT were more often missed. Reoperation was performed to address a missed lesion in 2 of 68 patients. Two of 55 patients died of reasons related to a missed lesion. In 67% of patients, DOLAVV was missed. Abnormal papillary muscle angles were seen with either a LVOT abnormality or DOLAVV. High insertion of the anterolateral papillary muscle was a risk factor for death or residual LVOT obstruction. Abnormal LVOT measurements were found in patients with tunnel obstruction and those with an acquired subaortic ridge.

CONCLUSIONS

Transthoracic echocardiography provides accurate preoperative information on AVSD.

Commissuroplasty: a method of valve repair for mitral and tricuspid endocarditis

BACKGROUND

We describe our experience with a technique of cusp commissuroplasty to reconstruct atrioventricular valves damaged by endocarditis of the commissure and adjacent cusps.

METHODS

We operated on 3 patients with mitral endocarditis and one patient with previous tricuspid endocarditis. Infected leaflet tissue was excised from each side of the commissure, leaving a defect between one quarter and one third of the valve area. Using the technique of valve commissuroplasty, leaflet remnants were reapposed at the cut edges to obliterate the commissure. The residual D-shaped defect between the apposed leaflets and annulus was either closed directly or patched with pericardium, depending on the size of the defect.

RESULTS

Constructing unicommissural mitral and bicuspid tricuspid valves restored leaflet continuity. One patient was lost to follow-up. Postoperative echocardiography performed at a mean interval of 14.7 months showed competent and nonobstructed valves. There was no recurrent endocarditis at a mean follow-up time of 15.7 months.

CONCLUSIONS

The technique of cusp commissuroplasty can be used to reconstruct atrioventricular valves that have been damaged by endocarditis of the commissure and adjacent cusps.