Anatomically sound, simplified approach to repair of "complete" atrioventricular septal defect

A 27-Year Experience with Atrioventricular Septal Defect Correction

This single-center study investigated long-term outcomes after surgical correction of atrioventricular septal defect (AVSD).A total of 248 patients underwent biventricular repair for AVSD between 1995 and 2022. A total of 208 (83.9%) patients had complete (cAVSD), 29 (11.7%) partial (pAVSD), and 11 (4.4%) transitional AVSD (tAVSD). Associated cardiovascular anomalies were present in 88 (35.5%) cases and 61 (24.6%) patients were born prematurely. Median age at repair was 7.1 for cAVSD, 23.7 for pAVSD, and 13 months for tAVSD.Overall survival or reoperation incidence did not differ significantly between AVSD types and improved significantly over surgical eras. Survival of the entire cohort was 88.3% at 10, 83.8% at 15, and 79.6% at 25 years. Prematurity (hazard ratio [HR]: 2.43, p = 0.029), low weight (<4 kg) (HR: 3.05, p = 0.028), and partial cleft closure (HR: 2.43, p = 0.037) were independent risk factors for mortality. Forty-eight patients (19.4%) underwent a total of 64 reoperations over the study period. The main indication for reoperation was left atrioventricular valve regurgitation (LAVVR) with 55/64 procedures. However, 36% of procedures were performed to address several lesions, with left ventricular outflow tract obstruction being the second most common indication. Freedom from reoperation was 78.2, 75.8, and 72.5% at 10, 15, and 25 years, respectively. The incidence of reoperation increased significantly in association with early postoperative LAVVR ≥ I-II° (HR: 2.6, 95% confidence interval [CI]: 1.4-4.7, p = 0.002) and presence of residual cardiac defects (HR: 2.0, 95% CI: 1.1-3.6, p = 0.018).While LAVVR is the main indication for reoperation, a significant proportion of procedures address additional pathologies. Premature patients and those with associated cardiovascular anomalies should receive special attention during postoperative follow-up.

A Case of Successful Biventricular Repair of the Transposition of the Great Arteries with a Coronary Anomaly Associated with an Atrioventricular Septal Defect

The transposition of the great arteries (TGA) associated with a complete atrioventricular septal defect is a rare and serious congenital cardiac anomaly. In this report, we describe the successful biventricular repair of a TGA with a complete atrioventricular septal defect in an infant. Due to the low body weight of the patient and a complex coronary pattern anomaly, an arterial switch operation was executed, with the Mee procedure and pulmonary arterial banding as initial palliative measures when the infant was 22 days old and weighed 2.5 kg. Subsequently, atrioventricular septal defect repair using the modified one-patch method was performed when the patient was 1.3 years old and weighed 8.8 kg. Remarkably, the postoperative course of the patient demonstrated no notable incidents. To our knowledge, this is the first time a two-stage strategy was applied to repair these complex defects, presenting a promising approach for managing similar cases in future medical practice.

The V-shaped double-layer patch technique for complete atrioventricular septal defect: A novel surgical technique

OBJECTIVE

Several surgical techniques for repair of a complete atrioventricular septal defect have been developed. However, the postoperative complications with these methods may lead to reoperation during follow-up. The aim of this report is to share our experience with a modified surgical technique for complete atrioventricular septal defect that has anatomic advantages postoperatively and could reduce the reoperation rate.

METHODS

Twenty-nine patients who underwent repair of complete atrioventricular septal defect using a V-shaped double-layer patch between April 2011 and September 2019 were retrospectively investigated.

RESULTS

There were no deaths (0%) and only 1 reoperation (3.4%) in the series. The aortic crossclamp and cardiopulmonary bypass times were 62.7 ± 16.0 minutes and 113.9 ± 25.9 minutes, respectively. The median follow-up duration was 5.1 years. To date, no significant residual ventricular septal defects have been detected and no left ventricular outflow tract obstruction has been seen on echocardiography in any patient. During follow-up, the left atrioventricular valve status was assessed as no incompetence in 9 patients (31.0%), trivial in 18 patients (62.1%), and mild in 2 patients (6.9%).

CONCLUSIONS

The V-shaped double-layer patch technique is a valuable surgical option for patients with complete atrioventricular septal defects. The midterm results in our series document excellent performance of this technique, which augments the area of the anterior valve of the left atrioventricular valve to make it closer to a normal mitral valve and may also reduce the need for reoperation.

Modified single-patch repair for atrioventricular septal defects results in good functional outcomes in the absence of deep ventricular septal defects

OBJECTIVES

We compared 2-patch repair (TP) with modified single-patch repair (MSP) for complete atrioventricular septal defects and evaluated their effect on the left atrioventricular valve (LAVV) competence. We also identified risk factors for unfavorable functional outcomes.

METHODS

This retrospective study included 118 patients with complete atrioventricular septal defects who underwent intracardiac repair from 1998 to 2020 (MSP: 69; TP: 49). The median follow-up period was 10.4 years. The functional outcome of freedom from moderate or greater LAVV regurgitation (LAVVR) was estimated using the Kaplan-Meier method.

RESULTS

The hospital mortality was 1.7% (2/118) and late mortality was 0.8% (1/118). Eight patients required LAVV-related reoperation (MSP: 4; TP: 4) and none required left ventricular outflow tract-related reoperation. In the MSP group without LAVV anomaly, the receiver operating characteristic curve analysis revealed that the ventricular septal defect (VSD) depth was strongly associated with moderate or greater postoperative LAVVR, with the best cutoff at 10.9 mm. When stratified according to the combination of intracardiac repair type and VSD depth, the MSP-deep VSD (VSD depth >11 mm) group showed the worst LAVV competence among the 4 groups (P = .002). According to multivariate analysis, weight <4.0 kg, LAVV anomaly, and moderate or greater preoperative LAVVR were independent risk factors for moderate or greater postoperative LAVVR, whereas MSP was not a risk factor.

CONCLUSIONS

Postoperative LAVVR remains an obstacle to improved functional outcomes. MSP provides LAVV competence similar to TP unless deep VSD is present. The surgical approach should be selected on the basis of anatomical variations, specifically VSD depth.

The effect of surgical technique, age, and Trisomy 21 on early outcome of surgical management of complete atrioventricular canal defect

BACKGROUND

The optimal timing, surgical technique, and the influence of Trisomy 21 on the outcome of surgical repair of Complete Atrioventricular Canal Defect remains uncertain. We reviewed our experience in the repair of CAVC to identify the influence of these factors on operative outcomes.

METHODS

A prospective study included 70 patients, who underwent repair of CAVC at our institute between July, 2016 and October, 2019. Primary endpoint was mortality and the secondary endpoint was a degree of left atrioventricular valve regurgitation.

RESULTS

No significant difference was noted between patients operated on, at the first 6 months of age versus later, regarding mortality or LAVV regurgitation. Surgical repair by modified single-patch technique showed a significant reduction in bypass time (71.13 ± 13.507 min versus 99.19 ± 27.092 min, p-value = 0.001). Compared to closure of cleft only, posterior annuloplasty used for repair of LAVV resulted in significant reduction in the occurrence of post-operative valve regurgitation during the early period (LAVV 2 + 43 versus 7 %, p-value = 0.03) and at 6 months of follow-up (LAVV 2 + 35.4 versus 0 %, p-value = 0.01), respectively.

CONCLUSIONS

Early intervention, in the first 6 months in patients with CAVC by surgical repair gives comparable acceptable results to later repair; Trisomy 21 was not found to be a risk factor for early intervention. Repair of common AV valve by cleft closure with posterior LAVV annuloplasty showed better results with a significant decrease in post-operative LAVV regurgitation and early mortality in comparison to the closure of cleft only.

Long-Term Outcome Up To 40 Years after Single Patch Repair of Complete Atrioventricular Septal Defect in Infancy or Childhood

Objectives  Patients with repaired complete atrioventricular septal defect (CAVSD) represent an increasing portion of grown-ups with congenital heart disease. For repair of CAVSD, the single-patch technique has been employed first. This technique requires division of the bridging leaflets, thus, among other issues, long-term function of the atrioventricular valves is of particular concern.

Methods  Between 1978 and 2001, 100 consecutive patients with isolated CAVSD underwent single-patch repair in our institution. Hospital mortality was 11%. Primary endpoints were clinical status, atrioventricular valve function, and freedom from reoperation in long term. Follow-up was obtained contacting the patient and/or caregiver, and the referring cardiologist.

Results  Eighty-three patients were eligible for long-term follow-up (21.0 ± 8.7, mean ± standard deviation [21.5; 2.1–40.0, median; min–max] years after surgical repair). Actual long-term mortality was 3.4%. Quality of life (QoL; self- or caregiver-reported in patients with Down syndrome) was excellent or good in 81%, mild congestive heart failure was present in 16%, moderate in 3.6% as estimated by New York Heart Association classification. Echocardiography revealed normal systolic left ventricular function in all cases. Regurgitation of the right atrioventricular valve was mild in 48%, mild–moderate in 3.6%, and moderate in 1.2%. The left atrioventricular valve was mildly stenotic in 15% and mild to moderately stenotic in 2%; regurgitation was mild in 54%, mild to moderate in 13%, and moderate in 15% of patients. Freedom from left atrioventricular-valve-related reoperation was 95.3, 92.7, and 89.3% after 5, 10, and 30 years, respectively. Permanent pacemaker therapy, as an immediate result of CAVSD repair ( n  = 7) or as a result of late-onset sick sinus syndrome ( n  = 5), required up to six reoperations in single patients. Freedom from pacemaker-related reoperation was 91.4, 84.4, and 51.5% after 5, 10, and 30 years, respectively.

Conclusion  Up to 40 years after single-patch repair of CAVSD, clinical status and functional results are promising, particularly, in terms of atrioventricular valve function. Permanent pacemaker therapy results in a life-long need for surgical reinterventions.

Correlation of ventricular septal defect height and outcomes after complete atrioventricular septal defect repair

 

OBJECTIVES

There are limited data available on the height of the ventricular component of the septal deficiency (VSD) in patients undergoing complete atrioventricular septal defect (CAVSD) repair. VSD height may influence optimal choice of repair strategy with potential consequences for long-term outcomes. We aimed to measure VSD height using 2-dimensional echocardiography and review its association with postoperative outcomes.

METHODS

We retrospectively reviewed the preoperative echocardiograms of 45 consecutive patients who underwent CAVSD repair between May 2010 and December 2015 at a single centre. VSD height and left ventricular length on the four-chamber view were measured. Demographic details and early and late outcomes including reoperation and long-term survival were studied.

RESULTS

Twenty patients underwent modified single-patch repair and 25 patients underwent double-patch repair of CAVSD. VSD height in the modified single-patch group ranged from 4.2 to 11.7 mm and in the double-patch group ranged from 5.1 to 14.9 mm. Nine patients had a deep ‘scoop’ with a VSD height of >10 mm, (7 double patch, 2 modified single patch). VSD height did not correlate with a specific Rastelli classification. There was no significant difference in the VSD height (P = 0.51) or the VSD height-to-left ventricular length ratio (P = 0.43) between the 2 repair groups. There was no 30-day mortality. Eight patients required reoperation; however, VSD height was not a significant predictor of reoperation (hazard ratio 0.95, 95% confidence interval 0.69–1.33; P = 0.08).

CONCLUSIONS

There was no correlation between VSD height and risk of reoperation after CAVSD repair. A deep ventricular scoop is uncommon in CAVSD patients.

The role of abnormal subaortic morphometry as a substrate for left ventricular outflow tract obstruction following atrioventricular septal defect repair

OBJECTIVES

Although left ventricular outflow tract (LVOT) obstruction is a recognized risk after atrioventricular (AV) septal defect (AVSD) repair, quantitative assessments to define the substrate of the obstruction are lacking.

METHODS

Morphometric analyses were based on measurements from early 2-dimensional echocardiographic scans (within 3 months postoperatively) for 117 patients (82 CAVVO = common AV valve; 35 SAVVO = separate AV valve orifices), which were compared to 50 age/weight matched controls (atrial septal defect/ventricular septal defect). Late echocardiographic analyses were performed in 57 patients with AVSD (follow-up range, 1.2-10.7 years).

RESULTS

Adequate z scores (above -2.5) were observed in 109 (93%) patients with AVSD at the aortic annulus and in 89 (76%) with AVSD in the subaortic area. Compared to the control group, patients with AVSD had lower median z scores at the aortic annulus (-0.64 vs 0.60; P < 0.001) and the subaortic areas (-1.48 vs 0.59; P < 0.001), disproportionate subaortic/aortic annulus ratio <1.00 (67% vs 22%; P < 0.001), narrower annuloaortic-septal angle (94.0 vs 104.0; P < 0.001) and annuloaortic left AV valve angle (78.0 vs 90.0; P < 0.001). Compared to patients with CAVVO, those with SAVVO had narrower annuloaortic-septal angles (P = 0.022) that persisted at late analysis, with lower subaortic/aortic annular ratios (P = 0.039). In patients with CAVVO, lower early postoperative subaortic z scores were found following modified single-patch repairs (median -2.12 vs -1.02 in two-patch repairs; P = 0.004). A total of 6/117 (5%) patients (4 CAVVO, 5% and 2 SAVVO, 6%) required reoperations for LVOT obstruction (mean 6.9 years postoperatively), with no difference in morphology or types of operations.

CONCLUSIONS

Despite having adequate z scores, patients with AVSD demonstrated abnormal LVOT morphometrics early postoperatively. Besides intrinsic morphology, repair techniques may have an impact on postoperative LVOT morphometrics and requires further evaluation.

Surgical Management for Complete Atrioventricular Septal Defects: A Systematic Review and Meta-Analysis

A meta-analysis is performed for a comparison of outcomes between the modified one-patch repair (MPR) and two-patch repair (TPR) for complete atrioventricular septal defects (CAVSD). Electronic databases, including PubMed, Scopus, Embase, and Cochrane Library were searched systematically for the literature which aimed mainly at comparing the therapeutic effects for CAVSD administrated by MPR and TPR. Corresponding data sets were extracted and two reviewers independently assessed the risks of bias. Meta-analysis was performed using Revman 5.3 and Stata 12.0. Fifteen studies meeting the inclusion criteria were included, involving 2076 subjects in total. It was observed that MPR was associated with shorter cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC) times, as compared with TPR. However, no statistical differences were found in terms of size of ventricular septal defects (VSD), reoperation, mortality, implantation of permanent pacemakers, and length of ventilation, hospital and intensive care unit stay. As compared with TPR, MPR is superior in terms of ACC and CPB. However, with regard to reoperation, mortality, length of ventilation, ICU and hospital stay and permanent pacemakers implantation, no significant differences are found between these two procedures. MPR is likely to apply to younger infants with faster completion of surgery. Surgery is recommended between 3 and 6 months of age.

Modified Single-Patch versus Two-Patch Repair for Atrioventricular Septal Defect: A Systematic Review and Meta-Analysis

BACKGROUND

We performed a meta-analysis of studies to determine whether the modified single-patch technique offers benefits when compared to the two-patch repair. The postoperative outcomes examined in this study were cardiopulmonary bypass time, cross-clamp time, duration of mechanical ventilation, intensive care unit length of stay, total hospital length of stay, need for reoperation, need for reoperation for left ventricular outflow tract obstruction or left atrioventricular valve regurgitation, need for pacemaker implantation, and mortality during follow-up.

METHODS

A review was conducted to identify studies comparing a modified single-patch repair versus two-patch repair. A fixed-effects model was utilized for end points with low heterogeneity and a random-effects model for end points with significant heterogeneity. Meta-regression was also performed to determine the influence of other factors on the variables of interest.

RESULTS

A total of 964 unique manuscripts were screened, with 10 being included in the final analyses. There were a total of 724 patients, with 353 (49%) having undergone repair utilizing a modified single-patch repair. Mean age at repair for modified single-patch repair and two-patch repair was 8.81 and 9.03 months, respectively. Significant differences were noted in cardiopulmonary bypass time and cross-clamp time with mean difference of -28.53 and -22.69 minutes, respectively. In comparison to the two-patch repair, both times were decreased in modified single-patch repair. No significant difference was noted in any other variables.

CONCLUSIONS

Modified single-patch repair for atrioventricular septal defects requires less cardiopulmonary bypass and cross-clamp time but does not significantly impact the examined postoperative outcomes.

Modified-Single Patch vs Double Patch Repair of Complete Atrioventricular Septal Defects

Biventricular repair of complete atrioventricular septal defect (CAVSD) is largely achieved using the double-patch (DP) or modified single-patch (MSP) techniques in the current era; however, long-term results following MSP repair are not well defined. We aimed to compare long-term outcomes including reoperation and mortality after CAVSD repair using DP and MSP techniques, and identify the risk factors associated with adverse outcomes. A retrospective cohort study was performed including all patients who underwent CAVSD repair using DP and MSP techniques at our institution between 17 May 1990 and 14 December 2015. Demographic details, early (≤30 days) and late (>30 days) outcomes (reoperation, mortality) were studied. Competing risks analysis with cumulative incidence function was used for survival analyses. Overall, 273 consecutive patients underwent CAVSD repair (120 DP and 153 MSP) and 41 patients required reoperation during follow-up. Competing risks analysis showed no association between repair technique and reoperation (P = 1.0) or mortality (P = 0.9). Considering competing risks due to mortality, the cumulative incidence of reoperation at 5, 10, and 15 years was 14%, 17%, and 17% for DP and 12%, 13%, and 16% for MSP, respectively. Non-Down syndrome and moderate or greater left atrioventricular valve regurgitation were predictors for reoperation. Pulmonary artery banding was predictive of mortality, though strongly associated with earlier surgical era. Median follow-up duration was 8.0 years (interquartile range 3.9-20.8) for DP and 11.6 years (interquartile range 5.4-16.1) for MSP (P = 0.4). Event-free survival is similar after DP and MSP repair of CAVSD indicating either repair technique can be safely utilized.

A review of the Nunn modified single patch technique for atrioventricular septal defect repair

Atrioventricular septal defect (AVSD) is a common congenital cardiac surgical problem. Over the years, younger and smaller infants are having operations for this condition before irreversible cardio pulmonary changes occur. Traditionally a single or two patch techniques have been used to repair this defect. However, in the past two decades an innovative method of modified single patch technique popularized by Dr. Graham Nunn has gained worldwide popularity. This review discusses the origin, surgical principles, technique and outcomes of this method, popularly known as Nunn or Australian technique. Research comparing the modified single patch technique to classic single and double patch techniques has shown good preservation of atrioventricular valve function, no residual ventricular septal defect (VSDs), low incidence of left ventricular outflow obstruction, preserved conduction, easy reproducibility, and improved perioperative and long-term mortality.

Modified Single-Patch Technique Versus Two-Patch Technique for the Repair of Complete Atrioventricular Septal Defect: A Meta-Analysis

Technical selection for surgical repair of complete atrioventricular septal defect (CAVSD) still remains controversial. This meta-analysis aimed to compare the modified single-patch (MP) technique with the two-patch (TP) technique for patients with CAVSD. Relevant studies comparing the MP technique with the TP technique were identified through a literature search using MEDLINE, EMBASE, Google Scholar, Cochrane Library, and the China National Knowledge Infrastructure databases. The variables were ventricular septal defect (VSD) size, cardiopulmonary bypass (CBP) time, aortic cross-clamp (ACC) time, intensive care unit stay, hospital stay, and other outcomes involving mortality, left ventricular outflow tract obstruction, atrioventricular valve regurgitation, residual septal shunt, atrioventricular block, and reoperation. A random-effect/fixed-effect model was used to summarize the estimates of mean difference/odds ratio with 95% confidence interval. Subgroup analysis stratified by region was performed. Fifteen publications involving 1034 patients were included. This meta-analysis demonstrated that (1) VSD size in the MP group was significantly smaller; (2) CBP time, ACC time, and hospital stay in the MP group experienced improvement; (3) Other postoperative outcomes showed no significant differences between two groups; and (4) The trends in China and other countries were close. The MP and TP techniques had comparable outcomes; however, the MP technique was performed with significantly shorter CBP and ACC times in patients with smaller VSDs. Given this limitation of data, the results of comparison of the two techniques in patients with larger VSDs remain unknown. Further studies are needed.

Complete Atrioventricular Canal Defect: Towards a More Physiological Repair

We describe a more physiological technique of complete atrioventricular septal defect repair which restores normal heart anatomy with the offset between the insertions of the mitral and tricuspid valves. This technique overcomes the drawbacks of the previous approaches, and may improve surgical outcomes, particularly in small infants with high ventricular septal defect component or dextroposed aorta.

Surgical repair of complete atrioventricular defect (Nunn technique)

Two procedures have been traditionally used for the surgical repair of complete atrioventricular canal. The single-patch technique includes the division of valve leaflets, and the use of one patch to close the ventricular and the atrial septal defects, whereas the double-patch technique uses two separate patches, without the division of the bridging leaflets. Between 1997 and 2007, another technique emerged, the modified single-patch technique, or the 'Australian' technique, whereby the ventricular septal defect (VSD) is closed by the direct apposition of the bridging leaflets against the crest of the defect. Because of the absence of the ventricular septal patch, concerns have been raised about the possible left ventricular outflow tract obstruction (LVOTO), or atrioventricular valve (AVV) distortion, especially in case of a deep VSD, or if the defect extends superiorly. The results of the modified single-patch technique in terms of mortality, immediate and long-term AVV function and LVOTO have been similar to the standard techniques in most reports. This article will describe in detail the operative technique and review the relevant literature.

Biventricular repair for common atrioventricular canal defect with parachute left atrioventricular valve

OBJECTIVES

Parachute left atrioventricular (AV) valve can complicate repair of common atrioventricular canal (CAVC), and single-ventricle palliation is sometimes preferred. The goal of this study is to review our single institutional experience in biventricular repair in this patient group.

METHODS

The demographic, procedural and outcome data were obtained for all children who underwent biventricular repair for complete CAVC with parachute [single left ventricular (LV) papillary muscle] or forme fruste parachute left AV valve (closely spaced LV papillary muscles) from 2001 to 2012. Primary outcomes were survival, freedom from left AV valve stenosis (defined as an inflow gradient ≥7 mmHg and post-capillary pulmonary hypertension) and freedom from left AV valve replacement.

RESULTS

A total of 24 patients were included (21 parachutes, 3 forme frustes). There was 1 early death (4.2%). At discharge, no patient had more-than-mild regurgitation and 1 had stenosis. During a median follow-up of 3.7 years (IQR 4 months to 5 years), there were 2 late deaths (8.3%), 6 patients (25%) presented significant left AV valve stenosis and 2 patients (8.3%) required valve replacement. Freedom from stenosis was 95 ± 4.9% at 1 year, 83.1 ± 8.9% at 3 years, 64.7 ± 13.5% at 5 years and 51.7 ± 15.8% at 10 years. Complete cleft closure was not associated with a significantly different freedom from left AV valve reoperation (log-rank test, P = 0.89) or significant stenosis (P = 0.47).

CONCLUSION

Biventricular repair in parachute left AV valve and CAVC is feasible with acceptable mortality and freedom from stenosis. The burden of reoperation remains significant in this patient group.

Modified single patch: are we still worried about subaortic stenosis?

BACKGROUND

When the modified single-patch technique for atrioventricular septal defect (AVSD) repair was introduced by Dr Benson Wilcox, there was concern that these patients might be at risk for late subaortic stenosis and left ventricular outflow tract obstruction (LVOTO). This review evaluated our modified single-patch population for LVOTO in the postoperative period.

METHODS

Between January 2000 and 2013, 77 infants underwent AVSD repair with a modified single-patch technique. Median age was 4.2 months, and median weight was 5 kg. Eight patients had a prior repair of coarctation of the aorta via left thoracotomy in the newborn period.

RESULTS

The median hospital stay was 10 days. No patient required a pacemaker. The mean and median follow-up times were 4.6 and 3.7 years, respectively. Only 2 patients (2.5%) required reoperation for LVOTO; both had prior repair of coarctation of the aorta (2 of 8 vs 0 of 69, p = 0.01). A discrete fibrous subaortic membrane developed in the first patient that required resection at 3 and 7 years after repair. The other patient had LVOTO from accessory chordae of the left atrioventricular valve and required mitral valve replacement 5 months after repair. One early death occurred at 4 months postoperatively due to liver failure related to hyperalimentation.

CONCLUSIONS

At intermediate term follow-up, LVOTO does not appear to be a significant postoperative issue after modified single-patch repair of AVSD. Coarctation of the aorta was the most significant predictor of late LVOTO after repair of AVSD with the modified single-patch technique.

A Novel Technique for Repair of Complete Atrioventricular Canal Defect

Background:

Two-patch, single-patch, and modified single-patch repairs are accepted techniques for repair of complete atrioventricular (AV) canal defects. We propose a novel, alternative technique: the central patch technique.

Methods:

For the central patch technique, the superior and inferior bridging leaflets are attached with simple sutures to the right and left of their coaptation point. Both bridging leaflets are incised along a line above the ventricular crest, similar to a traditional single-patch technique. An oval pericardial patch is sewn to the central defect created in the AV valve tissue. Interrupted, horizontal mattress sutures are placed along the ventricular crest, through the midline of the central patch and through the edge of the atrial septal defect (ASD) patch. Tying the sutures simultaneously closes the ventricular septal defect (VSD) and secures the ASD patch to the ventricular crest. Repair of the left AV valve and ASD closure are performed in the routine fashion.

Results:

Five patients underwent the central patch technique repair of complete AV canal defect. Weight was 4.8 to 6.3 kg; age was four to eight months. Cardiopulmonary bypass and myocardial times averaged 137 minutes and 109 minutes, respectively. No patient had more than mild left AV valve regurgitation or trivial residual VSD at completion of repair. No patient developed left ventricular outflow tract obstruction.

Conclusion:

The central patch technique is applicable to all forms of complete AV canal defect. Subjectively, it offers technical advantages compared to standard techniques and may result in a shorter learning curve for junior congenital heart surgeons. Results are preliminary but are consistent with standard techniques.

Comparison of two surgical techniques for complete atrioventricular septal defect repair using two- and three-dimensional echocardiography

Different surgical techniques for complete atrioventricular septal defect (CAVSD) repair have been described, with the double-patch technique being most frequently employed. More recently a newer technique using a modified single-patch repair has been advocated. We hypothesized that the modified single-patch technique would result in an increased incidence of the two major post-repair comorbidities, namely, distortion of the left AV valve (LAVV) leaflets and narrowing of the left-ventricular outflow tract (LVOT). We studied 14 patients with CAVSD who underwent either traditional double-patch technique [group 1 (n = 7)] or modified single-patch technique [group 2 (n = 7)]. Preoperative and immediate postoperative two-dimensional (2D) echocardiograms, as well as follow-up 2D and three-dimensional (3D) studies, were reviewed. For group 1, the median age at repair was 4.1 months with a median duration from surgical repair and last echocardiogram of 44 months. For group 2, the median age at repair was 3 months with a median duration from surgical repair and last echocardiogram of 28 months. The two groups had similar demographics and ventricular septal defect size before surgery. For the LAVV, no significant difference was observed with respect to LAVV annulus size, tenting height, and the size of the vena contracta. Furthermore, there was no significant difference in the 2D echocardiographic areas and volumes of the LVOT between pre-repair and immediate post-repair studies for both groups. At the last evaluation, although there had been growth of the LVOT in both groups, no significant difference between areas and volumes were observed. Areas of the LVOT measured by 3D echocardiography on the final study showed no significant statistical difference between both groups. There was good correlation of the areas measured by 2D and 3D echocardiography within each group. In this small group, modified single-patch technique does not appear to tether the LAVV or promote an increase in regurgitation. In the short term, LVOT growth is unaffected, and the repair does not promote LVOT obstruction. 3D echocardiography is useful for area measurements of the LVOT and showed good correlation with areas measured by assumption of the LVOT shape as determined using 2D techniques.

Reoperation for left ventricular outflow tract obstruction after repair of atrioventricular septal

Left ventricular outflow tract obstruction (LVOTO) is an important source of morbidity and mortality after repair of atrioventricular septal defect (AVSD). The intrinsic anatomy of the left ventricular outflow tract in AVSD is complex and predisposes to the development of LVOTO. LVOTO after repair of AVSD usually involves multiple levels and sources of obstruction, and surgical intervention must address each component of the obstruction. This includes fibromuscular obstruction, septal hypertrophy, and valve related sources of obstruction. Special attention is also directed to the anterolateral muscle bundle of the left ventricle, a well defined but under recognized feature of the left ventricular outflow tract in AVSD. It is present in all patients with AVSD, and resection of a hypertrophic anterolateral muscle bundle of the left ventricle should be incorporated in all operations for LVOTO after repair of AVSD. LVOTO after repair of AVSD has several unique features that must be taken into consideration to maximize outcome after surgical intervention. These include anatomic factors, technical aspects of surgical intervention, and proper selection of the operation used for relief of LVOTO.

Modified single-patch compared with two-patch repair of complete atrioventricular septal defect

BACKGROUND

We compared the outcomes of modified single-patch and two-patch surgical repair of complete atrioventricular septal defect (CAVSD) on left ventricular outflow tract (LVOT) diameter and on left atrioventricular valve (LAVV) coaptation.

METHODS

We reviewed retrospectively postoperative 2-dimensional echocardiograms of all CAVSD patients who underwent modified single-patch or two-patch repair between 2005 and 2011. We measured the leaflet coaptation length of the LAVV in the apical four-chamber view. The LVOT was measured in the long axis view.

RESULTS

Fifty-one patients underwent CAVSD repair at a median age of 4 months (range, 1 to 9 months) (single-patch, n=29; two-patch, n=22). The images from 46 echocardiograms were adequate for analysis. Modified single-patch repair required significantly shorter bypass time (102.0±33.6 vs 152.9±39.5 minutes, p<0.001) and ischemic time (69.0±21.7 vs 106.9±29.7 minutes, p<0.001) than did two-patch repair. The indexed coaptation length of the septal and lateral leaflets was not different between single-patch and two-patch (3.1±2.3 vs 4.1±3.1 mm/m2, p=0.25; 2.3±2.3 vs 3.3±3.0 mm/m2, p=0.21). Indexed LVOT diameter was not different in the two groups (26.1±5.2 vs 28.5±7.1 mm/m2, p=0.22). There was no hospital or late death during the median follow-up time of 35 months (range, 1 to 69 months). Five patients underwent reoperation after single-patch repair (3 with residual ventricular septal defect [VSD] and LAVV regurgitation, 1 with residual VSD, 1 with pacemaker implantation). After the two-patch repair, 1 patient required reoperation for a residual VSD and right atrioventricular valve regurgitation (p=0.22).

CONCLUSIONS

The modified single-patch repair was performed with significantly shorter bypass time and myocardial ischemic time. The postoperative LVOT diameter and LAVV leaflet coaptation length were not significantly different between techniques.

Mitral valve operations at a high-volume pediatric heart center: Evolving techniques and improved survival with mitral valve repair versus replacement

Mitral valve disease is quite variable and can occur as an isolated defect or in association with other complex left sided lesions. These lesions are often best described with detailed pre-operative imaging studies to define the valve anatomy and to access associated left heart disease. Depending on the type of mitral valve disease, various surgical repair techniques have led to improved survival in the recent era. We describe lesion specific approach to mitral valve repair and results.

Early outcomes and prognostic factors for left atrioventricular valve reoperation after primary atrioventricular septal defect repair

This study aimed to identify early outcomes of and prognostic factors for left atrioventricular valve (LAVV) reoperation after primary atrioventricular septal defect (AVSD) repair. A retrospective cohort study was performed using the Pediatric Cardiac Care Consortium database, which included 370 patients with previously repaired AVSDs who subsequently underwent LAVV reoperation between 1982 and 2007. Of these patients, 243 underwent LAVV repair, and 127 underwent LAVV replacement. Median time to first reoperation after primary repair was 0.67 years in the repair subgroup and 0.18 years in the replacement subgroup. Thirty-day survival was significantly poorer in the replacement subgroup compared with the repair subgroup (P = 0.0002). In multivariable analysis, independent predictors of earlier time to valve replacement included presence of Down syndrome and postoperative left atrioventricular valve stenosis. Independent predictors of in-hospital death after valve replacement included presence of Down syndrome (hazard ratio [HR] 2.34, 95% CI 1.19-4.58) and prosthetic valve size-to-weight ratio >3 mm/kg (HR 3.02, 95% CI 1.52-6.01). The identification of a subgroup of previously repaired AVSD patients at high risk for early postoperative death after LAVV replacement suggests that for these patients, a low threshold for detailed hemodynamic monitoring and/or reintervention for hemodynamic aberrations is warranted.

Surgical management of complete atrioventricular septal defect: associations with surgical technique, age, and trisomy 21

OBJECTIVES

We sought to evaluate the contemporary results after repair of a complete atrioventricular septal defect and to determine the factors associated with suboptimal outcomes.

METHODS

The demographic, procedural, and outcome data were obtained within 1 and 6 months after repair of a complete atrioventricular septal defect in 120 children in a multicenter observational study from June 2004 to 2006.

RESULTS

The median age at surgery was 3.7 months (range, 9 days to 1.1 years). The type of surgical repair was a single patch (18%), double patch (72%), and a single atrial septal defect patch with primary ventricular septal defect closure (10%). The incidence of residual septal defects and the degree of left atrioventricular valve regurgitation (LAVVR) did not differ by repair type. The median interval of intensive care stay were 4 days, ventilation use 2 days, and total hospitalization 8 days. All were independent of the presence of trisomy 21 (80% of the cohort). The in-hospital mortality rate was 2.5% (3/120). The overall 6-month mortality rate was 4% (5/120). The presence of associated anomalies and younger age at surgery were independently associated with a longer hospital stay. The age at repair was not associated with residual ventricular septal defect or moderate or greater LAVVR at 6 months. Moderate or greater LAVVR occurred in 22% at 6 months, and the strongest predictor for this was moderate or greater LAVVR at 1 month (odds ratio, 6.9; 95% confidence interval, 2.2-21.7; P < .001).

CONCLUSIONS

The outcomes after repair of complete atrioventricular septal defect did not differ by repair type or the presence of trisomy 21. An earlier age at surgery was associated with increased resource use but had no association with the incidence of residual ventricular septal defect or significant LAVVR.

Individualized Approach to Repair of Complete Atrioventricular Canal: Selective Use of the Traditional Single-Patch Technique Versus the Australian Technique

The traditional single-patch technique for repair of complete atrioventricular (AV) canal requires surgical division of the superior and inferior common leaflets. In the neonate and young infant, subsequent resuspension of very delicate AV valve tissue on the pericardial patch can be problematic. Selective application of the modified single-patch technique as described by Nunn (Australian technique) minimizes manipulation of the AV valve leaflet tissue. Previous reports have documented that since the late 1980s, the traditional single-patch approach with leaflet resuspension is possible with a mortality of 3% or less. A review of the initial 33 patients managed with the Australian technique was undertaken. The ventricular septal defect was moderate or large in 29 patients (88%). In the balanced canal subgroup, there was no early mortality; 1 patient underwent reoperative mitral repair for cleft dehiscence 1 year postoperatively, and 1 patient with heterotaxy required pacemaker implantation. In the unbalanced canal subgroup, 2 patients died perioperatively (22%). There have been no late deaths or new left ventricular outflow tract obstruction in either subgroup. Selective application of the single-patch technique currently allows excellent results for surgical repair in the neonatal period or early infancy. Even during the learning phase of the Australian technique, satisfactory results were achieved.