Abstract
Despite improved survival, surgical treatment of atrioventricular septal defect (AVSD) remains challenging. The optimal technique for primary left atrioventricular valve (LAVV) repair and prediction of suitability for biventricular approach in unbalanced AVSD are still controversial. We evaluated the ability of our recently developed echocardiographic left atrioventricular valve reduction index (LAVRI) in predicting LAVV reoperation rate and surgical strategy for unbalanced AVSD. Retrospective echocardiographic analysis was available in 352 of 790 patients with AVSD treated in our institution and included modified atrioventricular valve index (mAVVI), ventricular cavity ratio (VCR), and right ventricle/left ventricle (RV/LV) inflow angle. LAVRI estimates LAVV area after complete cleft closure and was analyzed with regard to surgical strategy in primary LAVV repair and unbalanced AVSD. Of the entire cohort, 284/352 (80.68%) patients underwent biventricular repair and 68/352 (19.31%) patients underwent univentricular palliation. LAVV reoperation was performed in 25/284 (8.80%) patients after surgical correction of AVSD. LAVRI was significantly lower in patients requiring LAVV reoperation (1.92 cm2/m2 [IQR 1.31] vs. 2.89 cm2/m2 [IQR 1.37], p = 0.002) and significantly differed between patients receiving complete and no/partial cleft closure (2.89 cm2/m2 [IQR 1.35] vs. 2.07 cm2/m2 [IQR 1.69]; p = 0.002). Of 82 patients diagnosed with unbalanced AVSD, 14 were suitable for biventricular repair (17.07%). mAVVI, LAVRI, VCR, and RV/LV inflow angle accurately distinguished between balanced and unbalanced AVSD and predicted surgical strategy (all p < 0.001). LAVRI may predict surgical strategy in primary LAVV repair, LAVV reoperation risk, and suitability for biventricular approach in unbalanced AVSD anatomy.
Highlights
Due to advances in surgical techniques, postoperative management, and pre- and intraoperative echocardiographic imaging, survival rates after surgical correction of atrioventricular septal defect (AVSD) significantly increased over the past decades [1,2,3]
We evaluated the ability of left atrioventricular valve reduction index (LAVRI) in devising surgical strategy in primary left atrioventricular valve (LAVV) repair and predicting the LAVV reoperation risk
Of 284 patients who received biventricular repair (BVR), primary LAVV repair was performed with complete cleft closure in 247 patients and partial cleft closure in 28 patients
Summary
Due to advances in surgical techniques, postoperative management, and pre- and intraoperative echocardiographic imaging, survival rates after surgical correction of atrioventricular septal defect (AVSD) significantly increased over the past decades [1,2,3]. The preoperative evaluation of atrioventricular valve anatomy seems indispensable for devising the optimal surgical strategy of primary LAVV repair and predicting the risk for LAVV reoperation. Another challenge concerning AVSD repair is the surgical management of unbalanced AVSD due to uncertainties in decision-making between biventricular repair (BVR) and univentricular palliation (UVP) in borderline AVSD anatomy. Compared to patients with balanced AVSD, in patients with unbalanced anatomy, BVR is associated with a higher mortality rate and a more complicated postoperative course including numerous re-interventions [7,8,9,10,11]. Various echocardiographic indices have been introduced to facilitate decision-making, so far no universal recommendations exist to unequivocally select the optimal therapeutic approach in case of ventricular imbalance
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