Repair Of Atrioventricular Septal Defect Research Articles

Development of Left Atrioventricular Valve Regurgitation After Correction of Atrioventricular Septal Defect

Left-sided atrioventricular valve regurgitation is the main indication for reoperation in patients after repair of both partial and complete atrioventricular septal defect. Until now, the timing for reoperation is difficult. We sought to determine the outcome of severe residual left-sided atrioventricular valve regurgitation, either medically treated or reoperation. In this regard risk factors were determined for severe residual left-sided atrioventricular valve regurgitation and reoperation, and the most appropriate strategy for patients with postoperative severe left-sided atrioventricular valve regurgitation was identified. Retrospective review of clinical, operative, and echocardiographic data was performed. From 1990 until 2001 164 patients underwent correction of their atrioventricular septal defect. Five patients died in the immediate postoperative period, and 2 patients were lost to follow-up. During follow-up (median, 66 months; range, 9 months to 12 years), 30 patients (19%) had severe left-sided atrioventricular valve regurgitation. Sixteen patients had severe left-sided atrioventricular valve regurgitation in the immediate postoperative period; 4 of them showed spontaneous regression to near-normal valve function during follow-up. Fourteen patients exhibited left-sided atrioventricular valve regurgitation during follow-up; 8 of them remained stable with medication only. Fifteen of the 30 patients with severe left-sided atrioventricular valve regurgitation underwent reoperation. A significant risk factor for the development of severe left-sided atrioventricular valve regurgitation and reoperation was the presence of preoperative severe left-sided atrioventricular valve regurgitation. Severe left-sided atrioventricular valve regurgitation develops in a significant number of patients after correction of atrioventricular septal defect, and preoperative severe left-sided atrioventricular valve regurgitation is an important risk factor. Although reoperation usually results in good valve function, spontaneous regression after the immediate postoperative period is possible and should be given a fair chance.

Outcome after primary repair of atrioventricular septal defects with regard to anatomy and timing of repair

Objectives: Repair of atrioventricular septal defects (AVSD) remains a challenging procedure due to the complex three-dimensional malformation and variable anatomy. Timing of repair is discussed controversially because of the delicate AV-valve tissue in young infants.

Outcome after primary repair of atrioventricular septal defects with regard to anatomy and timing of repair

Outcome after primary repair of atrioventricular septal defects with regard to anatomy and timing of repair

Avantages et risques de la chirurgie cardiaque dans la trisomie 21

Down’s syndrome is the most frequent chromosomic anomaly. Fifty percent are associated with a congenital heart disease. Life expectancy and quality of life are increasing since 15 years with improving surgical techniques. Patients and methods. – This study presents 73 patients with Down’s syndrome who underwent a surgical repair of congenital heart disease between 1992 and 2002. Among them, 37 (50.6%) had a complete atrio–ventricular septal defect (AVSD) and 36 an other anomaly. Results. – Five children died in the post operative period: all had an AVSD. Two late deaths occurred due to extra cardiac causes during the follow up. Two children who underwent a repair of AVSD had to be reoperated. The majority of the children are doing well, without any cardiac symptom. Thirty-eight percent of patients with AVSD repair have a middle mitral or tricuspid regurgitation and three had a massive mitral or tricuspid regurgitation. One child presents neurological sequelae related to surgery. Conclusion. – Congenital heart diseases in Down’s syndrome can be repaired with a limited risk of death. Final results are good for many children with significant improvement of the quality of life and life expectancy.

Better surgical prognosis for patients with complete atrioventricular septal defect and Down's syndrome

Background Several studies have shown that Down's syndrome is not a risk factor for biventricular repair of complete atrioventricular septal defects. However, few data are available about the comprehensive outcome of all the cardiac surgical procedures in patients with trisomy 21, including palliative surgery. Methods This is a retrospective study of 206 consecutive patients who underwent cardiac surgery from January 1992 to January 2002. Data about mortality and morbidity were analyzed and the impact of Down's syndrome was evaluated. Results Overall mortality was 7.7%. Actuarial survival was 94% among patients with Down's syndrome versus 86% of the group with normal karyotype ( p = 0.12). The presence of unbalanced ventricles was the only independent risk factor affecting survival at multivariate analysis ( p < 0.0001). The need for a Norwood type surgery was more frequent among non-Down patients (12.0% vs 1.5%, p = 0.02) as was the prevalence of pulmonary artery banding operations (22.9% vs 9.3%, p = 0.04). Cumulative mortality after palliation was higher in non-Down patients (44% vs 2.9%, p = 0.0001). Freedom from reoperation was lower in the group with normal chromosomes in respect to patients with Down's syndrome (81.4% vs 94.6%, p = 0.04), due to the higher prevalence of anomalies of the mitral valve (4.9% vs 1.8%, p = 0.03) or left ventricular outflow tract (7.3% vs 0%, p = 0.01). Conclusions Down patients showed a decreased risk for biventricular repair and lower mortality and morbidity in cases of complex cardiac malformations requiring complex palliative operations.

Left atrioventricular valve regurgitation after repair of incomplete atrioventricular septal defect

Background Excellent surgical results have been reported for repair of incomplete atrioventricular septal defect; however, left atrioventricular valve regurgitation (ltAVVR) is a major cause of late morbidity. We reviewed our entire experience with incomplete atrioventricular septal defect in order to investigate long-term results of ltAVVR after repair and determine the factors influencing the progression of ltAVVR in late follow-up. Methods Between 1983 and 2002, 61 patients underwent surgical repair of incomplete atrioventricular septal defect, including 7 patients with intermediate forms. The age of operation ranged from 1 month to 62 years old (median 5.3 years old). Thirteen patients were less than 2 years old, including 7 infants, while there were 15 adult patients. All patients underwent patch closure of the ostium primum defect. Before 1995, the cleft was left open in 7 patients and partial closure of the cleft was done in 41 patients, whereas complete closure of the cleft was performed in 9 patients since 1996. Preoperative and postoperative ltAVVR at hospital discharge and late follow-up were graded 0–IV by echographic evaluation. Results There was 1 early death and 4 late deaths with a 91% 10-year actuarial survival rate. Preoperative ltAVVR grade was I in 25 patients, II in 31 patients, III in 4 patients, and IV in 1 patient. Postoperatively, ltAVVR deteriorated in 3 patients. Left AVVR decreased in 21 patients, whereas in 37 patients it remained the same at hospital discharge. Consequently, ltAVVR remained grade II in 18 patients, grade III in 2, and there was no patient with grade IV. During the long-term follow-up, 24 patients were noted to have increased ltAVVR, including grade III in 8 patients and grade IV in 4. Reoperations for ltAVVR were required in 5 patients (8.3% of hospital survivors); valve replacement in 3 patients and valve repair in 2. Actuarial freedom from reoperation for ltAVVR was 91% at 10 years, whereas actuarial freedom from postoperative ltAVVR grade III or more was 89% at 5 years and 78% at 10 years. Multivariate analysis indicated that postoperative ltAVVR grade II or more at hospital discharge ( p = 0.0032, odds ratio = 7.41, 95%CI: 1.95–28.10) was the only independent variable related to late ltAVVR, whereas age at operation, preoperative grade of ltAVVR, and the method of cleft repair were not significant risk factors. Conclusions Left AVVR is still a significant risk in long-term follow-up. Because the postoperative grade of ltAVVR is the only independent risk factor for late ltAVVR, more efforts should be focused on left atrioventricular valve repair so as to minimize residual regurgitation, even mild regurgitation.

Repair of complete atrioventricular septal defects in patients weighing less than 5 kg

Background The aim of this study was to evaluate the impact of weight less than 5 kg at operation on mortality and morbidity in patients with atrioventricular septal defect (AVSDc) undergoing total correction. Methods Between January 1990 and December 2002, 190 consecutive patients with AVSDc underwent total biventricular correction. They were divided into two groups: group I (n = 64 patients weighing < 5 kg) and group II (n = 126 patients weighing > 5 kg). Associated major cardiac malformations were found in 49 (25.8%) patients. Associated left atrioventricular valve (LAVV) malformations were found in 35 (18.4%) patients. The mean follow-up time was 4.1 ± 2.9 years (range 2 months–10.7 years). Results The in-hospital mortality in group I was 7.8% (5 patients) versus 8.7% (11 patients) in group II ( p = 0.95). Major associated cardiac malformations ( p < 0.001) and pulmonary hypertension ( p = 0.006) were found to be strong predictors for poor postoperative survival. At discharge the mean LAVVR grade in group I was 1.45 ± 1.2 versus 1.2 ± 1 in group II ( p = 0.13). The actuarial overall survival rates at 1, 3, 5, and 7 years were 96.5%, 92.5%, 91.5%, and 89% respectively and the actuarial overall reoperation free survival rates at 1, 3, 5, and 7 years were 95%, 87%, 84%, and 73%. Twenty-three patients underwent reoperation due to severe left atrioventricular valve regurgitation (LAVVR). Strong predictors for overall reoperation free survival were the operation year before 1995 ( p < 0.001), postoperative LAVVR greater than or equal to 2 ( p = 0.006), major associated cardiac malformations ( p = 0.00034), associated LAVV malformations ( p = 0.0044), and non or partial LAVV cleft closure ( p = 0.012). The actuarial survival rates between patients weighing less than 5 kg versus patients weighing more than 5 kg were similar ( p = 0.51); instead the overall reoperation free survival was significantly lower in patients weighing less than 5 kg ( p = 0.022) according to the log-rank test. Weight less than 5 kg ( p = 0.023, β = −0.6) was one of the predictors for reoperation due to severe LAVVR in this series. Conclusions We may conclude that in the current era repair of AVSDc can be carried out successfully in patients less than 5 kg, however, weight less than 5 kg at initial complete repair seems to be a predictor for late reoperation due to LAVVR. Suture separation at the cleft site or between the leaflets of the newly created mitral valve and the patch remain the main causes of postoperative LAVVR in patients weighing less than 5 kg.

Total repair of atrioventricular septal defect with tetralogy of Fallot or Fallot's type double outlet right ventricle

To summarize the experience in total repair of atrioventricular septal defect with tetralogy of Fallot or Fallot's type double outlet right ventricle. Ten patients with atrioventricular septal defect associated with tetralogy of Fallot or Fallot's type double outlet right ventricle underwent repair between June 2000 and September 2002. Atrioventricular septal defect was repaired with a 2-patch technique. The ventricular patch material was dacron artificial vascular patch, autologous pericardium was used to close the ostium of atrial septal defect after repair of the atrioventricular valve. Closure of ventricular septal defect (VSD) necessitated a combined right atrial and right ventricular approach. Each patient underwent an extensive infundibulectomy performed through the right ventriculotomy. If the pulmonary valve was more than 1 mm or 2 mm in diameter, smaller than the normal size, a transannular pericardial patch was used. If abnormal coronary arteries existed in the surface of right ventricular outflow, a homograft was used to connect the right ventricle with pulmonary artery. There was one death (10%) six months after repair. Two patients were not able to be extubated from ventilator because of residual VSD. After repairing the residual VSD, one patient was extubated from ventilator. The other still wasn't able to be extubated from ventilator due to right diaphragm paralysis. After folding right diaphragm, the patient got stable recovery. Atrioventricular septal defect with tetralogy of Fallot or Fallot's type double outlet right ventricle can be corrected with low mortality. Residual VSD can severely affect recovery. Long-term results need to be followed up.

Atrioventricular septal defects: effect of bridging leaflet division on early valve function

Background Bridging leaflet division may facilitate repair of atrioventricular septal defects (AVSD). However, the consequences of bridging leaflet division on early valve function and mortality are not well defined. Methods Records of children undergoing AVSD repair between January 1995 and January 2002 were reviewed. Multivariable analysis defined risk factors for moderate or greater atrioventricular valve regurgitation (AVVR) and death/reoperation within 1 year of repair. Results A total of 209 children (median age 5 months, median weight 5 kg) had defects whose repair included the possibility of bridging leaflet division. Bridging leaflets divided were both (n = 119, 58%), one (n = 30, 15%), or none (n = 55, 27%). Freedom from AVVR (moderate or greater) is 84%, 80%, and 78% at 1, 6, and 12 months. Risk factors include technical factors: number of bridging leaflets divided, longer cross-clamp time, and right-sided annuloplasty. Other risk factors include preoperative AVVR (moderate or greater), double-orifice or parachute left AV valve, and younger age. Freedom from death/reoperation for AVVR is 96%, 92%, and 90% at 1, 6, and 12 months. Risk factors are preoperative AVVR (moderate or greater) and parachute left AV valve. Findings at reoperation (n = 15, 7.2%) were cleft dehiscence or tear along cleft closure (n = 10), dehiscence of divided leaflet from septation patch (n = 1), or other (n = 4). Operative mortality (n = 6, 2.9%) included failed reoperations for AVVR (n = 4), dehiscence of divided leaflet from septation patch (n = 1), and sepsis (n = 1). Conclusions Division of bridging leaflets is a risk factor for AVVR (moderate or greater) during the first year after repair. Preservation of bridging leaflet integrity may improve valve competency, decrease the need for future reoperation, and eliminate some causes of operative mortality.

Repair of Atrioventricular Septal Defect (AVSD) associated with Tetralogy of Fallot (TOF)

Repair of Atrioventricular Septal Defect (AVSD) associated with Tetralogy of Fallot (TOF)

Echocardiographic Predictors for the Development of Subaortic Stenosis After Repair of Atrioventricular Septal Defect

Echocardiographic Predictors for the Development of Subaortic Stenosis After Repair of Atrioventricular Septal Defect

Repair of partial atrioventricular septal defect through a minimal right vertical infra-axillary thoracotomy.

To report a new minimally invasive and cosmetic approach for partial atrioventricular septal defect (PAVSD) repair. From November 1997 to January 2000, six patients with a mean age of 19.2 +/- 7.7 years underwent minimal right vertical infra-axillary thoracotomy for PAVSD repair. Left atrioventricular (AV) valve regurgitation was assessed on the beating heart before and after valvuloplasty. Commissuroplasty of the left AV valve and atrial septum repair were done in all patients. There were no operative or late mortality, and no morbidity directly related to the thoracotomy approach. The average length of the incision was 8.3 +/- 131 cm. The arrest times averaged 32.8 +/- 8.3 minutes, and the cardiopulmonary bypass times averaged 66.0 +/- 9.0 minutes. One patient had a mild to moderate left AV valve regurgitation postoperatively. All patients were free of symptoms during the follow-up. The minimal right vertical infra-axillary thoracotomy is a safer, more cosmetic and less invasive approach than median sternotomy for the repair of PAVSD.

Complete atrioventricular septal defect repair: Simplified single patch technique

Background: There has been a rekindling of interest in alternatives to conventional two patch technique for the repair of complete atrioventricular septal defect in infancy in the recent past. We applied the simplified single patch technique to 15 consecutive infants and herein report our intermediate term results. Methods: Between March 1998 and September 2001, fifteen patients underwent repair of complete atrioventricular septal defect with this technique (mean age 6 months, mean weight 5.4 kg). Downs syndrome was present in 11 patients. Repair was done in all patients by direct suturing of the common atrioventricular valve leaflets to the crest of the ventricular septum irrespective of the size of the ventricular septal component. The cleft in the anterior mitral leaflet was closed in all patients. The atrial septal component was closed by a pericardial patch. Results: There was no mortality. There were no pulmonary arterial hypertensive crises or heart block. The mean follow up was 13.2 months. One patient underwent mitral valve replacement after one year due to severe mitral regurgitation. The remaining fourteen patients had no significant mitral regurgitation, residual ventricular septal defect or left ventricular outflow tract obstruction on echocardiography. Conclusion: Simplified single patch technique is an easily reproducible method for surgical repair of complete atrioventricular septal defect. It is less time consuming and minimises ischaemic time. Atrioventricular valve function is preserved and there is no incidence of obstruction to left ventricular outflow tract. The intermediate term results are encouraging.

Echocardiographic predictors for the development of subaortic stenosis after repair of atrioventricular septal defect

Echocardiographic predictors for the development of subaortic stenosis after repair of atrioventricular septal defect

Left atrioventricular valve function following repair of atrioventricular septal defects: A 22-year experience

Left atrioventricular valve function following repair of atrioventricular septal defects: A 22-year experience

Complete atrioventricular septal defect, Down syndrome, and surgical outcome: risk factors

Background This study was conducted to evaluate surgical outcome and to identify risk factors for hospital mortality and reoperation after repair of complete atrioventricular septal defect. Methods A total of 147 consecutive children underwent repair between January 1986 and December 1998. Of those, 106 had Down syndrome, 37% had normal chromosomes, and 4 had other syndromes; 108 underwent primary repair, 19 had prior pulmonary artery banding, and 20 had additional tetralogy of Fallot. The median weight at primary repair was 4.5 kg. A two-patch technique was used in 88%. Results The 30-day mortality was 15% (70% confidence interval [CI] 12% to 19%). A double orifice atrioventricular valve was found to be a significant risk factor ( p = 0.002), with 6 of 11 patients dying. If double orifice atrioventricular valve patients are excluded, the mortality rate falls to 12% (70% CI 9% to 15%). No difference in mortality was found between Down syndrome and chromosomally normal children but the latter more commonly required reoperation. Chromosomally normal children frequently have a dysplastic common atrioventricular valve (24% versus 3% in Down children, p < 0.001). In a multivariate Cox model including both variables, the presence of a dysplastic atrioventricular valve was a significant risk factor for reoperation. After controlling for the presence of a dysplastic atrioventricular valve, Down syndrome retained a significant protective effect but the upper limit of the confidence interval was close to 1. Conclusions The presence of a double orifice atrioventricular valve emerged as an unforeseen risk factor for death.

Effect of cardiopulmonary bypass on urea cycle intermediates and nitric oxide levels after congenital heart surgery

Objective To test the hypothesis that cardiopulmonary bypass used for repair of ventricular septal defects and atrioventricular septal defects would decrease availability of urea cycle intermediates including arginine and subsequent nitric oxide availability. Study design Consecutive infants (n = 26) undergoing cardiopulmonary bypass for repair of an unrestrictive ventricular septal defect or atrioventricular septal defect were studied. Blood samples were collected immediately before surgery, immediately after surgery, and 12 hours, 24 hours, and 48 hours after surgery. Urea cycle intermediates, including citrulline, arginine, and ornithine, were measured by amino acid analysis. Nitric oxide metabolites were measured by means of the modified Griess reaction. Results Cardiopulmonary bypass caused a significant decrease in the urea cycle intermediates arginine, citrulline, and ornithine at all postoperative time points compared with preoperative levels. The ratio of ornithine to citrulline, a marker of urea cycle function, was elevated at all postoperative time points compared with preoperative values, indicating decreased urea cycle function. Nitric oxide metabolites were significantly decreased at all postoperative time points except for 48 hours, compared with preoperative levels. Conclusions Cardiopulmonary bypass significantly decreases availability of arginine, citrulline, and nitric oxide metabolites in the postoperative period. Decreased availability of nitric oxide precursors may contribute to the increased risk of postoperative pulmonary hypertension. (J Pediatr 2003;142:26-30)

Two-patch repair of complete atrioventricular septal defect using a small ventricular patch

Since 1992, 19 patients with an atrioventricular septal defect have undergone surgical treatment using a novel annuloplasty technique in which a small ventricular patch was used to reduce the anterior-posterior dimension of the atrioventricular orifice. All patients recovered uneventfully and needed no reoperation for the residual regurgitation or shunt. The results showed that the new annuloplasty technique was promising, although a long-term result is yet to be seen.

Mortality and volume of cases in paediatric cardiac surgery: retrospective study based on routinely collected data

Objectives: To determine whether mortality between 1991 and 1995 in hospitals in England carrying out surgery for congenital heart disease in children was associated with the annual volume of cases...

Correction of Complete Atrioventricular Canal

Correction of Complete Atrioventricular Canal