Left Atrioventricular Valve Incompetence Research Articles

Left atrioventricular valve repair technique in partial atrioventricular septal defects

Background. The aim of our study was to evaluate the effect of chordal transfer around the cleft on left atrioventricular valve competence in the late postoperative period.Methods. Forty-four adult patients underwent surgical correction of partial atrioventricular septal defect between 1983 and 1997. Fenestration was found in 8 patients (18.2%) and cleft, in 35 (79.5%). There was no chordal support of the free edges of the left superior and left inferior leaflets around the cleft in 18 patients. Two chordae were mobilized from the left lateral leaflet and reimplanted into the tip of the left superior and left inferior leaflets around the cleft.Results. At 5 years postoperatively, left atrioventricular valve insufficiency was severe in 5 patients and moderate in 11 patients who had had cleft closure alone. In contrast, severe valvular insufficiency was present in only 1 patient in the group with chordal transfer (p < 0.05). Reoperation was done in 5 patients with isolated cleft closure. Left AV valve replacement was performed in 1 patient.Conclusions. Chordal transfer plus cleft closure with interrupted sutures significantly reduces early and late left atrioventricular valve incompetence and also decreases the rate of reoperation.

Results of left atrioventricular valve reconstruction after previous correction of atrioventricular septal defects.

The objective of this study was to determine causes of severe left atrioventricular (AV) incompetence and the factors leading to the success of valve repair later after correction of atrioventricular septal defects (AVSD). A total of 28 patients aged 5 months to 38 years (mean age 6.7 years) were operated for significant (grade II-III) left AV valve incompetence (LAVVI), two months to twenty-five years (median 1.5 years) after correction of complete (11 patients) or partial atrioventricular septal defects. Fourteen patients had initially undergone surgery during infancy. At reoperation a completely open or partially sutured cleft was found in 16 patients combined with dysplastic valve tissue in four cases, with a fibrotic valve in three cases, with posterior leaflet prolapse in two cases, with a double orifice valve in three cases, and a parachute valve in two cases. Partial or complete reopening of a previously sutured cleft caused by suture dehiscence was found in 12 cases combined with a fibrotic valve in five cases, with a dysplastic valve in one case and with severe deformity of valve in one case. A combination of these anomalies was observed in seven patients in both groups. Left atrioventricular valve repair including cleft closure combined with annuloplasty and other surgical procedures resulted in the disappearance or significant diminishing of LAVI in 18 patients (64%). Severe SAVI persisted in six patients, five of them exhibiting a combination of several additional left AV valve anomalies (fibrotic or dysplastic valve, parachute valve). Five of these six patients underwent successful left AV valve replacement with a mechanical prosthesis 7 days to 2 years after reoperation. The presence of additional left AV valve anomalies was the single statistically significant factor for recurrent major LAVVI after reoperation (P = 0.0106). There were two postoperative deaths in patients with mild LAVVI after surgery, and no late deaths. An open cleft is the major factor of late severe SAVVI after correction of AVSD. Although suturing the cleft in conjunction with performing annuloplasty improved valvular function in most of the cases, the presence of severe left AV valve anomalies increased the risk of recurrent LAVVI and the need for valve replacement, thus playing a major role in determining the outcome of valve reconstruction in patients after reoperation.

Ten-year experience with surgical treatment of partial atrioventricular septal defect: Risk factors in the early postoperative period

Partial atrioventricular septal defects are electively repaired with good results. However, recent reports suggest that such repair is potentially a high-risk surgical procedure. Our aim was to determine the risk factors of adverse outcome early after surgical treatment of atrioventricular septal defects in our hospital. A retrospective study was done in 100 consecutive patients from 2 months to 50.6 years old (median 3.6 years) who underwent surgical correction between January 1984 and December 1993. An intermediate form of the lesion was noted in 31% of cases. Congestive heart failure occurred in 50% of cases. Preoperative left atrioventricular valve incompetence (moderate to severe) was present in 63% of patients. Severe abnormalities of left subvalvular apparatus were noted in 28% of patients. The cleft of the left atrioventricular valve was closed in 76% of cases. The study was done to determine risk factors associated with hospital mortality (13%), postoperative residual left atrioventricular valve incompetence (23%), and early reoperation (14%) within the first 30 postoperative days. Univariate analysis showed that age at the date of operation and cleft closure were not related to an early adverse outcome. A stepwise logistic regression with variables selected by univariate analysis identified infections and severe abnormalities of left subvalvular apparatus as predictive factors of early death (odds ratios, 28.07 and 6.18, respectively), preoperative left atrioventricular valve regurgitation as a predictive factor of residual postoperative left atrioventricular valve regurgitation (odds ratio, 5.34), and severe abnormalities of left subvalvular apparatus as a predictive factor of early reoperation (odds ratio, 5.27). These results emphasize the importance of the severity of the morphologic features of the left subvalvular apparatus, the occurrence of early postoperative infections, and the presence of residual left atrioventricular valve regurgitation as risk factors in the early period after surgical correction of partial atrioventricular septal defects. (J T horac C ardiovasc S urg 1996;112:14-20)

Left atrioventricular valve incompetence after repair of common atrioventricular canal defects

Reoperation rate for residual atrioventricular (AV) valve regurgitation after repair of common atrioventricular canal defect (AVCD) is currently between 5% and 10%. This retrospective analysis evaluates the impact of AV valve anatomy, age at repair, and surgical technique on postoperative AV valve incompetence. Between January 1982 and July 1994, 205 patients with common AVCD underwent surgical repair at our institution. A complete form with common atrioventricular orifice (CCAVCD) was present in 81 patients. One hundred twenty-four had separate AV valves and orifices; 22 of these had a restrictive ventricular septal defect component. Preoperative moderate to severe AV valve regurgitation (AVVR) was present in 74 (36%), with a lower incidence in the CCAVCD group (20/81, 25%) versus the transitional (8/22, 36%) or the partial forms (46/102, 45%) (p = 0.02). The incidence was 12.5% (3/24) for CCAVCD patients less than 4 months of age (p = 0.02). Repair of the left AV valve was performed according to the trifoliate approach in most cases (142/205, 70%). Follow-up was 98% complete. By Kaplan-Meier analysis, survival at 12.3 years was 97.8% +/- 1% in partial AVCD, 95.4% +/- 4% in transitional AVCD, and 73.2% +/- 5% in CCAVCD (median follow-up, 60 months). Freedom from reoperation at 12.3 years was 93.5% +/- 2% for partial AVCD, 76.9 +/- 9% for the transitional form, and 68.3% +/- 5% for CCAVCD: Postoperative moderate to severe AVVR occurred in 42 patients (21%), with lower incidence for CCAVCD (10/81, 12.5%) versus transitional AVCD (8/22, 36%) and partial AVCD (24/102, 24%) (p = 0.02). Postoperative moderate AVVR was found in only 1 patient with CCAVCD less than 4 months of age (p < 0.01). Nine patients (5%) underwent reoperation for residual postoperative AVVR Valve repair was performed in all with no operative death. By Cox proportional risk multivariate analysis, preoperative AVVR and double orifice "mitral" valve were associated with increased risk of postoperative left AVVR (p < 0.01), whereas a bifoliate approach appeared to reduce the risk of this event in partial AVCD (p = 0.03). Postoperative AVVR is related to the type of anatomy of the AV valve, to the age at repair, and to the surgical technique employed. Residual AVVR can still be corrected with conservative techniques at low mortality rates. Early repair of common AVCD is associated with a lower incidence of preoperative and postoperative AVVR in CCAVCD and seems to prevent progression of annular dilation and preoperative AVVR in partial AVCD.

Left Atrioventricular Valve Incompetence After Repair of Common Atrioventricular Canal Defects

Left Atrioventricular Valve Incompetence After Repair of Common Atrioventricular Canal Defects

Management of the left atrioventricular valve in the repair of complete atrioventricular septal defects

Left atrioventricular valve regurgitation in atrioventricular canal defects is usually due to malalignment of the edges of the cleft or to annular dilatation. Intraoperative assessment and correction of left atrioventricular valve incompetence is critical for successful outcome in the surgical management of complete atrioventricular canal defects. Although some have elected not to suture the cleft in the setting of minimal incompetence, we have found that this often results in significant left atrioventricular valve insufficiency, necessitating reoperation. From January 1982 through December 1990, 105 patients with complete atrioventricular canal underwent definitive repair. Repair was performed with a single pericardial patch technique in 86 patients (82%). Intraoperative assessment of left atrioventricular valve competence was performed in all cases. Ninety-six patients (91%) required suturing of the cleft and 63 (60%) required annuloplasty to establish satisfactory competence of the left atrioventricular valve. The overall early mortality rate was 10.5% (11/105 patients). From 1986 to 1990, the early mortality rate decreased to 7.7% (6/78 patients). In a mean follow-up of 39 months (range 1 to 106 months), late survival was 96% (90/94 operative or early survivors). Reoperation was performed on eleven (11.5%) patients; six (6.3%) for failure of the atrioventricular valve repair, three for patch dehiscence, and two for residual ventricular septal defects. These data demonstrate that routine approximation of the cleft and aggressive use of left atrioventricular valve annuloplasty is safe and results in an excellent outcome with a low incidence of reoperation for failure of left atrioventricular valve repair.

Actuarial survival, freedom from reoperation, and other events after repair of atrioventricular septal defects

Repair of an atrioventricular septal defect was performed in 134 patients from 1973 to 1985. Interventricular communication was present in 54 (40%) and none was present in 80 (60%). There were 12 hospital deaths (9%; 70% confidence limits 6%-12%). Earlier date of operation (p = 0.03) and younger age at repair (p = 0.005) were incremental risk factors for hospital death after repair of partial atrioventricular septal defect. Smaller size (p = 0.003) and longer cross-clamp time (p = 0.002) were risk factors for hospital death in those patients with complete atrioventricular septal defect. Higher preoperative pulmonary vascular resistance was a risk factor for death in both groups (p = 0.007). The 10 year actuarial survival rate was 82% overall. Increasing preoperative severity of left atrioventricular valve incompetence was not a risk factor for early (p = 0.001) or late (p = 0.002) death. The 10 year actuarial freedom from reoperation after repair of partial atrioventricular defects was 85%, and it was 68% for complete atrioventricular defects (p = 0.06). We conclude that the intermediate term results after repair of atrioventricular septal defects are good. Incompetence of the left atrioventricular valve has apparently been neutralized as a risk factor for hospital death in this series. However, the durability of the repair has been disappointing. A policy of earlier repair has been adopted and should improve hospital mortality and permit better preservation of the atrioventricular valve structures with resultant improved late term functional status.

Congenitally corrected transposition in adults with left atrioventricular valve incompetence.

Congenitally corrected transposition of the great vessels (CCT) is usually detected in childhood owing to the presence of associated cardiac malformations. If such malformations are absent, the patient may remain asymptomatic until adulthood; such persons usually present with left atrioventricular valve incompetence and conduction disturbances. The chest radiograph may be the first clue to the diagnosis, demonstrating the typical cardiovascular silhouette produced by the convex left ascending aorta. The authors examined seven cases of CCT manifested in adulthood and found that in four of them the diagnosis was not apparent from the plain image because the ascending aorta instead followed a concave course. Hallmarks of this phenomenon are discussed, and two radiological signs are presented: the double mediastinal stripe and the straight left lower cardiac border.