Results with the two-patch technique for repair of complete atrioventricular septal defect

From May, 1982, to September, 1983, 9 patients underwent repair of complete AV septal defect. They ranged in age from 11 months to 48 months and in weight from 5.3 kg to 16.5 kg. Seven patients were 24 months old or less. Previous operations included pulmonary artery banding in 1 patient and ligation of a patent ductus arteriosus with repair of coarctation in another. All patients had large left-to-right shunts (mean pulmonary to systemic flow ratio, 3.1), and the 7 young infants had marked pulmonary hypertension. Mitral regurgitation was absent in 2 patients, mild in 3, moderate in 2, and severe in 2. One patient had the right ventricular dominant form of complete AV septal defect. In all instances, repair was done using separate ventricular and atrial patches. Leaflet tissue was not divided, and a trileaflet mitral valve was left in each patient. Eight patients survived operation and are well 3 to 17 months after repair. The single operative death occurred in the patient with right ventricular dominance. Only 1 patient has mild residual heart failure 4 months after operation. Clinically, mitral regurgitation is absent in 4 patients and, at most, mild in the other 4. No patient has a conduction disturbance. Repair of complete AV septal defect is facilitated by using separate patches for the ventricular and atrial components of the defect. Less distortion is created, and a more accurate reconstruction of a competent trileaflet mitral valve can be done.     

Surgical treatment of complete atrioventricular septal defect with the two-patch technique: early-to-mid follow-up

We report our results on surgical treatment of complete atrioventricular septal defects using the two-patch technique. Forty patients with complete atrioventricular septal defects were operated on in the period from November 1995 to January 2004 and retrospectively analyzed. The age at the time of surgery ranged from 4 months to 20 years (average=18.8+/-37 months). Their weights ranged from 3 to 39 kg (average=7.6+/-5.8 kg). Associated tetralogy of Fallot was present in 20% of the cases (8 patients). Monitoring was complete until January 2007, corresponding to a follow-up ranging from 36 to 135 months (average=74+/-33.7 months). The surgical mortality rate was 2.5% and the hospital mortality rate was 5%. A third patient died from a brain abscess two years after surgery. Over the long-term, two patients needed further operations: one was submitted to mitral plasty due to severe residual mitral insufficiency, one year later; the other underwent a resection of a sub-aortic membrane after three years. Differences were evaluated using the Student-t or Mann-Whitney tests. Surgical treatment of complete atrioventricular septal defect using the two-patch technique results in low morbidity and mortality in early-to-mid term follow-up.     

Results of primary two-patch repair of complete atrioventricular septal defect.

OBJECTIVE: The policy of primary repair of complete atrioventricular septal defect (CAVSD), using a two-patch technique, was evaluated with special attention to the risk of implantation of a prosthetic atrioventricular (AV) valve. METHODS: From 1986 to 1999, all 97 patients who underwent primary repair for CAVSD were included in a retrospective analysis. Seventy-five patients (75%) had Down's syndrome. Preoperative echocardiographic AV valve regurgitation was absent or limited in 85 (88%), moderate in seven (7%) and severe in five (5%). Fifty-six patients (58%) were on diuretics, six (6%) on artificial ventilation and four (4%) were on inotropic support. The mean age at operation was 10.2 months (SD, 16.4), with a mean weight of 5.9 kg (SD, 3.7). RESULTS: Early mortality comprised three patients (4%), and late mortality two patients. Follow up was complete and comprised 402 patient-years (mean, 4.5 years; SD, 3.2). The cumulative survival at 10 years was 93% (95% CI, 89-97%). Multivariate analysis with regard to mortality revealed no associations with any of the analyzed factors. Eight patients were reoperated, all for regurgitant left AV valve. The reoperation-free survival at 10 years was 83% (95% CI, 75-91%). Multivariate analysis with regard to reoperation showed being on preoperative diuretics to be a decreasing risk factor (Odd's Ratio (OR), 0.13; 95% CI, 0.00-0. 99; P=0.005) and significant postoperative left AV valve regurgitation to be an increasing risk factor (OR, 9.90; 95% CI, 1. 90-53.0; P=0.001). Only one prosthetic valve was implanted (annual linearized risk of 0.002/patient-year). At the latest follow up of the surviving patients, left AV valve regurgitation was absent or limited in 83 (90%) and moderate in nine (10%). Right AV valve regurgitation was absent or limited in all 92 (100%) patients. All surviving patients are thriving well, seven (8%) of whom are on diuretics. CONCLUSIONS: Primary repair of CAVSD with a two-patch technique, including cleft closure of the left AV valve, has good clinical and functional results without problems for the right-sided AV valve. The need for prosthetic valve implantation for the left AV valve is minimal.     

Ventricular septal defect and aortic regurgitation

We have reviewed our experience of 29 patients with the association of ventricular septal defect and aortic regurgitation, 27 of whom have been treated surgically. Our present approach to the surgical management is outlined and the embryology and pathological anatomy are reviewed. The most common cause of aortic regurgitation was a prolapsed aortic valve cusp, which occurred in 19 patients. Aneurysmal dilatation of an aortic sinus accounted for the regurgitation in three patients, and two patients had both abnormalities. In two patients no cause for the aortic regurgitation was found. Those patients with aortic cusp prolapse commonly had large ventricular septal defects, of which nearly a third were supracristal. Because of cusp prolapse into the ventricular septal defect, and sometimes into the right ventricular outflow tract, the findings at cardiac catheterization often suggested erroneously that the ventricular septal defect was small and that infundibular obstruction was present. Characteristic angiographic features have been demonstrated, in particular the deformed and prolapsed aortic cusp. The various techniques of surgical correction which were used are described, the majority of patients having had a patch closure of the ventricular septal defect and repair of the aortic valve. Some residual aortic regurgitation was usual, but it was improved or minimized in 18 of the 23 survivors, and the more recent results have been particularly encouraging. Closure of the ventricular septal defect alone relieved heart failure in a 3-year-old child. There were four operative deaths (15% mortality) in patients with severe aortic regurgitation, three of whom were in heart failure before operation. The medical course was commonly of slowly increasing severity of the aortic regurgitation with progression to heart failure. However, the individual course was unpredictable and three children developed heart failure within a year of the onset of their aortic regurgitation. Infective endocarditis occurred in a quarter of the patients and usually followed the development of the aortic regurgitation. Despite the difficulties of surgical management it is felt that the unpredictable prognosis, high operative risk once cardiac failure has supervened, and the hazard of infective endocarditis make early operation desirable.     

Ventricular septal defect following myocardial infarction.

Review of the literature since 1970 revealed more than 200 patients who had a ventricular septal defect following myocardial infarction and underwnet operation. Pathogenesis and diagnosis are discussed. The primary therapy is operative repair, which is considered from the standpoint of approach, timing, technique, concomitant coronary artery bypass, mortality, and long-term survival. Operative mortality in those patients operated on less than 3 weeks following perforation remains high (40%) but when it is possible to wait 3 weeks, there is a marked decrease in mortality (6%). Several general principles have evolved for the care of these patients. (1) Operation should be deferred until 3 weeks after infarction if possible. (2) The intraaortic balloon allows preoperative evaluation of the patient with clinical hemodynamic deterioration in the early postinfarction period. (3) The incision should be placed through the infarct. (4) Associated coronary artery or mitral valve disease should be repaired as well.     

Ventricular septal defect associated with aortic regurgitation

The effectiveness of aortic valvuloplasty and the indications for aortic valve replacement were examined in 76 patients with ventricular septal defect associated with aortic regurgitation. Results of this study indicate aortic regurgitation is associated with rapid deterioration and that aortic valvuloplasty should be performed as soon as aortic regurgitation is detected. The data also suggest that aortoplasty is indicated if aortic valvuloplasty alone is inadequate for coaptation of the aortic cusps with thickening.     

Double patch technique for repairing postinfarction ventricular septal defect

We report 2 cases in which the double patch technique was used to repair an anterior postinfarction ventricular septal defect. To do this, we modified infarct exclusion as follows: In addition to a conventional patch excluding the infarcted muscle, another small patch is used to directly close the septal defect. Gelatin-resorcin-formal glue is applied between the double patches, which prevent the glue from being washed away and enhance it to polymerize stably, thereby rapidly stabilizing the infarcted myocardium with the endocardial patch. Echocardiography immediately after operation showed the infarcted septum had completely adhered to the endocardial patch. Both patients demonstrated satisfactory postoperative hemodynamics. Although 1 patient did well, the other died 6 months postoperatively due to complications of pneumonia and gastrointestinal bleeding secondary to colon carcinoma. This double patch technique appears useful, although further experience is needed to verify its safety and efficacy.     

Ventricular septal defect associated with left ventricular outlfow tract obstruction below the defect

Muscular subaortic stenosis associated with ventricular septal defect (VSD) is a rare but important anomaly. Two types of left ventricular outflow tract (LVOT) obstruction should be distinguished on the basis of morphologic as well as hemodynamic differences, depending on whether the stenosis is localized above (Type I) or below (Type II) the defect. The five cases presented are all in the latter category. In the first two cases the correct diagnosis was not made until after repair of the VSD. Two patients had previously undergone banding of the pulmonary artery (PAB). Marked carotid shudder and a vertical QRS axis in the frontal plane were presented in all cases. For the diagnosis to be established by catheterization, the catheter tip must be maneuvered into the apical part of the left ventricular cavity in order to detect the stenosis on the withdrawal curve. It is difficult to visualize the stenosis by angiography. The surgical approach through the VSD via a right atriotomy is highly recommended for Type II subaortic stenosis.     

Alternative technique for repair of sinus venosus atrial septal defect

A technique is described for closure of a sinus venosus atrial septal defect using a single patch held in place by sutures placed from outside the right atrium and underneath the superior vena cava. The superior vena cava does not require enlargement and potential damage to the artery to the sinoatrial node is avoided.     

Ventricular septal defect and aortic insufficiency. Surgical treatment.

Twenty-five patients with ventricular septal defect (VSD) associated with aortic insufficiency (AI) have been since 1964. Of these patients, one died suddenly without operation; in 2 patients, AI developed in the late postoperative period following VSD closure; and in 3 others, AI developed shortly after VSD closure. The remaining 19 patients are discussed in detail. The VSD was subpulmonic in 13 (68 per cent) and subcristal in 6 (32 per cent). Primary suture of the VSD was undertaken in 13 patients and patch closure in 6. Seven patients had aortic valvuloplasty and 2 had aortic valve replacement. There were no surgical deaths, and the long-term follow-up shows that VSD closure alone has been sufficient to arrest progression of AI in patients with mild insufficiency, particularly in those with subpulmonic VSD. Valvuloplasty, when necessary, was more effective when done at an early age.     

Surgical closure of sinus venosus atrial septal defect using a single patch--transcaval repair technique

Abstract Objective: We would like to share our experience of surgical repair of sinus venosus atrial septal defect (ASD) using a simple “transcaval repair technique.” Method: Between January 2007 and October 2010, 48 consecutive patients of sinus venosus ASD underwent surgical repair using transcaval repair technique at our institute. Their ages ranged from 5 to 15 years and male to female ratio was 1.6:1. The principles of the technique were longitudinal incision over the lateral aspect of superior vena cava (SVC) at the entry point of anomalous right pulmonary veins, use of a single autologous untreated pericardial patch, and finally closure of the caval incision in such a way that the patch gets sandwiched between two caval lips. Results: All 48 patients came off cardiopulmonary bypass in sinus rhythm. The average pressure gradient across the patch was 3 mmHg. Immediate postoperative electrocardiograms and echocardiograms showed all patients were in sinus rhythm with no residual shunt and no pulmonary or systemic venous obstruction respectively, except in one patient who required SVC augmentation. The follow‐up was done at three months (100%), one year, and two years. All patients were asymptomatic and their electrocardiograms and transthoracic echocardiograms revealed sinus rhythm, no residual shunt, and no obstruction to systemic or pulmonary venous drainage, respectively. There was no early or late mortality. Conclusion: We conclude that this technique is safe and simple for the repair of selected cases of sinus venosus atrial septal defect with partial anomalous pulmonary venous connection and it preserves the sinoatrial node function after surgery. (J Card Surg 2011;26:429‐434)     

Ventricular septal defect with right pulmonary agenesis and left bronchial stenosis

We report a case of ventricular septal defect (VSD) with right pulmonary agenesis and left bronchial stenosis. Delivery of a male infant was uneventful. Birth weight was 3,050g. At 12 days of age, he presented himself with tachypnea and wheezing. Dextrocardia was noted on a chest X-ray. Computed tomography (CT) of the chest showed right pulmonary agenesis and severe narrowing of the left main bronchus. An echocardiogram showed VSD, patent ductus arteriosus (PDA) and pulmonary hypertension (PH). At 22 days of age, he was put on ventilator. At 1 month of age, pulmonary artery banding and division of PDA were performed through median sternotomy. At 5 months of age, weighing 5.0 kg, the VSD was closed with a Dacron patch through median sternotomy. At 6 months of age, tracheostomy was necessitated. At 1-year-old, he became free from ventilator.     

Simplified single patch technique for the repair of atrioventricular septal defect.

OBJECTIVE: Because of the complexity of traditional 1- and 2-patch techniques for the repair of complete atrioventricular septal defect, we modified our repair technique to avoid the use of any ventricular septal patch material. We report our prospective experience with this simplified 1-patch technique. METHOD: Forty-seven consecutive patients between May 1995 and August 1998 underwent repair with the use of this technique without modification. Repair was done in all patients by direct suturing of the common atrioventricular valve leaflets to the crest of the ventricular septum. No division of valve leaflets was necessary. A single pericardial patch was used to close the defect in the atrial septal component. Follow-up included electrocardiography and echocardiographic assessment of ventricular function, atrioventricular valve function, and adequacy of the left ventricular outflow tract. RESULTS: There were 2 deaths (4%), only 1 cardiac related, in the series. There were 17 male patients and 30 female patients. Mean age at repair was 5.6 months (median, 3.4 months). Associated lesions were repaired in 19 patients (40%). Mean follow-up was 1.85 years (median, 1.9 years). There was no heart block. There were no significant residual ventricular septal defects detected and no left ventricular outflow tract obstruction seen on echocardiography in any patient to date. Mitral valve status after operation was assessed as no incompetence in 13 patients (28%), minimal in 19 patients (40%), mild in 12 patients (26%), and moderate in 3 patients (6%). CONCLUSION: The repair of complete atrioventricular septal defect by direct suturing of the atrioventricular valve leaflets to the crest of the ventricular septum with a single-patch technique greatly simplifies the repair and does not lead to left ventricular outflow tract obstruction nor interfere with valve function.