Double-patch Technique Research Articles

VSD-closure using double-patch technique in cases of VSD with severe pulmonary artery hypertension (PAH)—Our experience

VSD-closure using double-patch technique in cases of VSD with severe pulmonary artery hypertension (PAH)—Our experience

Surgery for post-infarction ventricular septal defect (VSD): double patch and glue technique for early repair

Repair of post-infarction ventricular septal defect (VSD) remains a challenging procedure with a high risk of VSD recurrence. In order to reduce this risk, a double patch and glue technique was introduced in the department in 1986. This surgical technique is hereunder presented. Since 1971, ninety-three patients have been operated on early (≪15 days) after the occurrence of a post-infarction VSD. This retrospective study allows to compare the results of this double patch and glue technique to those obtained with the conventional one, in terms of hospital death and VSD recurrence. The double patch and glue technique avoids recurrence of VSD and plays a part in reducing hospital mortality.

A new double patch technique for early repair of postinfarct posterior ventricular septal rupture: Avoiding ventriculotomies

Our new double patch technique for repairing posteroinferior ventricular septal ruptures (VSRs) offers placement of patches in both the left and right ventricle, avoids ventriculotomies and gives good access and complete control of both AV-valves during implantation. We have treated two patients with this technique. Both survived with unremarkable status upon leaving the hospital.

Double-patch technique for postinfarction ventricular septal perforation

A modified infarct-exclusion technique for postinfarction ventricular septal perforation is presented. The perforation is closed directly by a small patch next to the conventional patch, and biological glue is applied between the patches to induce stable polymerization. The patch stuck to the infarcted septum, and no residual shunt was observed in any patient because the wide adhesion prevents excessive pressure on the suture line. Seven of 9 patients in whom this method was used had good results. This technique appears suited for repair of ventricular septal perforations, especially those with extensive fresh infarction.

Early and long term outcome of the arterial switch operation for transposition of the great arteries: predictors and functional evaluation

The aims of this report were to study the early and late outcome in terms of mortality, freedom from reoperation, predictors for late pulmonary stenosis (PAS) and insufficiency of the neo-aortic valve (AVI) in patients with transposition of the great arteries (TGA) undergoing arterial switch operation (ASO). Between January 1990 and December 2001, 134 patients with TGA underwent ASO. The patients were divided in Group I (n=88)-TGA with intact ventricular septum and Group II (n=46)-TGA with ventricular septal defect (VSD). The pulmonary artery was reconstructed employing the direct anastomosis technique (PT-I) in 21 (15.7%) patients, the double-patch technique (PT-II) in 41 (30.6%), single pantaloon patch (partial circumference) (PT-III) in 46 (34%) and single pantaloon patch (total circumference) (PT-IV) in 35 (26%) patients. The mean follow-up was 3.4+/-1.3 years. The hospital mortality was 17 (12.7%) patients. The mortality in Group I was significantly lower than Group II (P=0.002). The overall actuarial survival at 1, 3 and 5 years follow-up resulted to be 98, 93, and 91.5%, resulting to be significantly higher in Group I (P=0.032). The multivariate analysis revealed the complex TGA (P=0.007), VSD (P=0.032), coronary anomalies (P=0.004), aortic coarctation or hypoplastic aortic arch (P=0.021), left ventricular outflow tract obstruction (LVOTO) or moderate PAS (P=0.041) as strong predictors for poor free-reoperation cumulative survival. A strong inverse correlation was found between the mean trans-pulmonary gradient at follow-up and the age at the operation (r=-0.41, P<0.0001). The univariate analysis revealed the PT-I technique (P=0.002), prior moderate PAS (P=0.0001), and age <1 month (P=0.018) as strong predictors for moderate-to-severe PAS. The neo-AVI incidence was significantly higher in Group II (P=0.011). Predictors for neo-AVI were male sex (P=0.003), preoperative neo-AV Z-score >1 (P<0.001), prior or concomitant operation for aortic coarctation or hypoplastic aortic arch (P=0.001), LV retraining (P=0.003). ASO remains the procedure of choice for the treatment of various forms of TGA with acceptable early and later outcome in terms of overall survival and free reoperation. Strong predictors for poor overall free-reoperation survival are complex TGA, VSD, coronary anomalies, aortic coarctation and LVOTO or moderate PAS. The pulmonary artery reconstruction using a single 'pantaloon patch' seems to offer less residual stenosis. Patients with a VSD and a significant mismatch between the neo-aortic root and distal aorta are at a higher risk for developing postoperative neo-AVI.

Total anomalous pulmonary venous connection: long-term appraisal with evolving technical solutions.

To evaluate late outcome of non-isomeric total anomalous pulmonary venous connection (TAPVC) repair, controlling for anatomic subtypes and surgical technique. Between 1983 and 2001, 89 patients (median age 54 days) underwent repair for supracardiac (38), cardiac (26), infracardiac (16) or mixed (nine) TAPVC. Ten patients (11.2%) presented associated anomalies other than PDA. Twenty-eight patients (31.5%) were emergencies, due to obstructed drainage. Supracardiac and infracardiac TAPVC repair included the double-patch technique with left atrial enlargement in 29 patients and side-to-side anastomosis between the pulmonary venous (PV) confluence and the left atrium in 29 patients. Coronary sinus unroofing was preferred for cardiac TAPVC repair. Total follow-up was 727.16 patient-years (mean 8.55 years, 98.8% complete). Early mortality was 7.86% (7/89). Ten patients (11.2%) underwent reintervention, including reoperation (eight), balloon dilation (one) and intraoperative stents placement (one), for anastomotic (four) or diffuse PV stenosis (six), with four late deaths. Kaplan-Meier survival is 87.3+/-0.036 SE% at 18.07 years with no difference according to anatomic type or surgical technique. Freedom from PV reintervention for operative survivors is 86.7+/-0.052 SE% at 18.07 years. Cox proportional hazard indicates associated anomalies (P=0.008) and reoperation for intrinsic PV stenosis (P=0.034) as independent predictors of mortality. According to logistic analysis, preoperative obstruction predicts higher risk of reintervention for intrinsic PV stenosis (P=0.022), while the double-patch technique increased the risk of late arrhythmias (P=0.005). Side-to-side anastomosis provides excellent results for TAPVC repair while left atrial enlargement procedures appear to be associated with higher risk of late arrhythmias. Although early and aggressive reintervention for recurrent PV obstruction is mandatory, intrinsic PV stenosis remains a predictor of adverse outcome.

Enlargement of the aortic annulus using a double-patch technique: a safe and effective method

We have tested a new method to enlarge the aortic annulus using a double-patch technique after the Manouguian principle. Our study included 14 patients who had no operative mortality and no complications; long-term follow-up was 13 years. The method prevented mitral insufficiency and operative bleeding at the aortic root.

Predisposing factors of valve regurgitation in complete atrioventricular septal defect

Objectives. We sought to determine the intrinsic risk factors of valve regurgitation in complete atrioventricular septal defect.Background. Progression of regurgitation varies in each case, although the structure of the common atrioventricular valve itself is a predisposing factor.Methods. In 90 consecutive patients undergoing surgical repair, we evaluated the preoperative and postoperative regurgitation, valve morphology, age at surgery and associated anomalies. A regurgitation jet with a high velocity reaching the deep left atrial wall by echocardiography was estimated as marked regurgitation.Results. None of the 40 patients with Rastelli type C and an undivided inferior bridging leaflet had preoperative regurgitation in the first year of life, and 12% of them (95% confidence intervals [CI]: 0% to 28%) showed regurgitation at the age of 2. Of the remaining 50 with Rastelli type A and/or a divided inferior leaflet, regurgitation was determined in 21% (95% CI: 6% to 35%) of those 1 year old and in 49% (95% CI: 29% to 69%) of those 2 years old (p < 0.01). All patients underwent corrective surgery using the double-patch technique, with the “cleft” being sutured adequately. Irrespective of the valve morphology, regurgitation remained in 52% (12 of 23) of those with preoperative regurgitation, whereas regurgitation developed postoperatively in 28% (16 of 58) of those without regurgitation (p < 0.001).Conclusions. Those with Rastelli type C and an undivided inferior leaflet had a lesser degree of progression of preoperative regurgitation. However, regurgitation was likely to exist even after adequate repair once regurgitation had already advanced. Therefore, early primary repair before progression of the regurgitation may be the key to maintaining better competence of the atrioventricular valve.

Late Hypotony After Cataract Extraction Due to a Scleral Fistula: A Technique for Surgical Correction

The authors report the use of a surgical procedure for the correction of a scleral fistula in a patient with late hypotony after cataract surgery. Trephination of necrotic tissue lining the scleral fistula with a double scleral patch technique was performed. Four months later, the patient's vision had improved to 20/40, with improvement of the macular folds and an intraocular pressure of 10 mm Hg. The authors conclude that the use of a double-patching technique is effective in the repair of scleral fistulas. The technique allows one to avoid more risky repair procedures that involve a greater area of tissue excision.

Correction of complete atrioventricular septal defects with the double-patch technique and cleft closure

Controversy continues to surround determining which is the most beneficial method of complete atrioventricular septal defect repair, eg, one- versus two-patch repair, closure of mitral cleft, and the necessity of annuloplasty. Between January 1988 and November 1995, 120 patients with complete atrioventricular septal defect underwent total correction at the German Heart Institute Berlin. Sixty-nine of the patients were infants and 51 were children or adolescents. Eleven patients had previously undergone pulmonary artery banding. One hundred three patients had Down's syndrome. In all 120 patients complete atrioventricular septal defect repair was performed using the two-patch technique. The mitral cleft was closed with interrupted sutures in 119 cases. Thirty-four patients required aggressive treatment of postoperative pulmonary hypertensive crises (including nitric oxide inhalation). There were 12 hospital deaths (10%). Mortality was highest in patients with persistently high postoperative pulmonary arterial pressure (pulmonary artery pressure/systemic artery pressure > 0.6) (7 of 17 patients died; 41%). Associated atrioventricular valve anomalies, especially dysplastic valve tissue and severe preoperative cardiopulmonary instability necessitating catecholamine support and artificial ventilation, represented other risk factors. There were six late deaths (5%); cumulative mortality was 15%. Four patients suffered a complete heart block and sick sinus node syndrome necessitating pacemaker implantation 1 to 6 months after operation. During the follow-up period (3 to 80 months after operation), 7 patients (6.8% of survivors) were successfully reoperated on after significant mitral valve incompetence due to an open "cleft" (suture failure) developed. Correcting complete atrioventricular septal defect using the two-patch technique, routine cleft closure, and atrial septal incision led to a low incidence of residual mitral valve incompetence. Mortality was primarily influenced by severe cardiopulmonary instability and additional atrioventricular valve anomalies preoperatively and the persistence of high pulmonary arterial hypertension postoperatively.

Surgical management of complete atrioventricular canal associated with tetralogy of Fallot

Between 1984 and 1993, 12 children with an atrioventricular canal and tetralogy of Fallot underwent surgical repair. The mean(s.d.) age at operation was 58(18) months, and the mean (s.d.) body weight 15 (4) kg. Nine patients underwent 11 palliative procedures. The ventricular septal defect was closed through a combined (right atrial and right ventricular) approach in nine cases, and through a right atrial approach in three, using a prosthetic patch with a wide anterior extension, secured with a running suture. The ‘ostium primum’ defect was closed with a separate prosthetic patch in 11 cases (double-patch technique). Right ventricular outflow obstruction was relieved by a composite infundibular patch (seven cases) or a transanular patch (five). There were four hospital deaths (33%). These were caused by low cardiac output in three cases and infection in one (three deaths occurred in patients with a transanular patch). One patient has so far died during follow-up. Assessment at 50(36) months by echo-Doppler showed moderate-to-severe ‘mitral’ regurgitation in three cases, and moderate ‘ricuspid’ regurgitation with right ventricular dysfunction in one case. Two patients have required further surgery.

Surgical Management of Complete Atrioventricular Canal Associated with Tetralogy of Fallot

Between 1984 and 1993, 12 children with an atrioventricular canal and tetralogy of Fallot underwent surgical repair. The mean(s.d.) age at operation was 58(18) months, and the mean(s.d.) body weight 15(4) kg. Nine patients underwent 11 palliative procedures. The ventricular septal defect was closed through a combined (right atrial and right ventricular) approach in nine cases, and through a right atrial approach in three, using a prosthetic patch with a wide anterior extension, secured with a running suture. The ‘ostium primum’ defect was closed with a separate prosthetic patch in 11 cases (double-patch technique). Right ventricular outflow obstruction was relieved by a composite infundibular patch (seven cases) or a transanular patch (five). There were four hospital deaths (33%). These were caused by low cardiac output in three cases and infection in one (three deaths occurred in patients with a transanular patch). One patient has so far died during follow-up. Assessment at 50(36) months by echo-Doppler showed moderate-to-severe ‘mitral’ regurgitation in three cases, and moderate ‘tricuspid’ regurgitation with right ventricular dysfunction in one case. Two patients have required further surgery. Copyright © 1996 The International Society for Cardiovascular Surgery.

Total anomalous pulmonary venous connection: Surgical repair with a double-patch technique

A double-patch technique has been used to repair total anomalous pulmonary venous connection in 35 patients (mean age, 4.9 months; mean weight, 4.2 kg). In all patients with supracardiac or subdiaphragmatic type of total anomalous pulmonary venous connection, repair has been accomplished by enlarging the “new” left atrium. There were three early deaths (3 of 35 = 8.6%) and no late deaths in a mean follow-up of 30 months (3 to 71 months). We propose this double-patch technique as an alternative surgical option for total anomalous pulmonary venous connection.

Successful Immediate Repair of Acquired Ventricular Septal Defect and Survival in Patients with Acute Myocardial Infarction Shock Using a New Double Patch Technique

Despite excessive mortality early following ventricular septal defect (VSD) due to acute myocardial infarction, immediate operation within the initial honrs and early repair within a few days following perforation has generally been too hazardous. Recognizing the need for an improved therapeutic approach, this report describes successful immediate VSD repair within a few hours of rupture and longterm survival using a new double patch technique and infarctectomy in three consecutive patients with cardiogenic shock, in the first day (two patients) and sixth day (third patient) of acute anterior infarction. Closure was achieved in two of the patients six and seven hours after rupture. VSD diagnosis and quantification of left-to-right shunt ratios (6.0, 5.1 and 2.8/1) were carried out at bedside right heart catheterization. In addition, left heart catheterization including ventricular angiography and selective coronary arteriography, was performed preoperatively. Closure of the muscular VSD was achieved by sandwiching both sides of the septum with two large Teflon patches sutured together to completely enclose the infarcted septal area. Catheterization two weeks postoperation demonstrated objectively intact ventricular septum by oxygen series, cardiogreen dye curves, hydrogen electrode and angiography. AD patients recovered fully without difficulty and are living (9 to 14 months). Thus are demonstrated the feasibility and safety of immediate repair of VSD, ie within a few hours of rupture due to acute myocardial infarction, with reversal of refractory pump failure.