Surgical repair of complete atrioventricular septal defect

Asian Cardiovascular and Thoracic Annals http://aan.sagepub.com/

Surgical Repair of Complete Atrioventricular Septal Defect Mohammed Jalal Uddin, Stojanovic Velimir, Abdul Latif Salama, Babu Othman, Lulu Othman, Enamul Haque and Hani Shuhaiber Asian Cardiovascular and Thoracic Annals 1998 6: 37 DOI: 10.1177/021849239800600108 The online version of this article can be found at: http://aan.sagepub.com/content/6/1/37

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Uddin ORIGINAL

CONTRIBUTION

COMPLETE ATRIOVENTRICULAR SEPTAL DEFECT

SURGICAL REPAIR OF COMPLETE ATRIOVENTRICULAR SEPTAL DEFECT Mohammed Jalal Uddin, PhD, Stojanovic Velimir, MD, Abdul Latif Salama, MD, Babu Othman, DM, Lulu Abushaban, MRCP, Enamul Haque, MRCP1, Hani Shuhaiber, FRCS Department of Cardiac Surgery and Cardiology Chest Diseases Hospital, Safat, Kuwait 1 Department of Paediatrics Adan Hospital, Adan, Kuwait

ABSTRACT Between January 1988 and March 1996, 40 patients underwent repair of complete atrioventricular septal defect with a two-patch technique and routine atrioventricular valve cleft closure. The mean age of the patients was 10.8 ± 6.9 months and the mean weight was 6.6 ± 2.6 kg. Twenty-three had Down’s syndrome and 13 had coexisting cardiac anomalies. Preoperative angiography and echocardiography revealed mild atrioventricular valve regurgitation in 22 patients, moderate regurgitation in 16, and severe regurgitation in the other 2. The mortality was 12.5% (4 early and 1 late deaths). The major cause of death was pulmonary hypertensive crisis. Reoperation was necessary in 3 patients; 2 had atrioventricular valve annuloplasty and one had prosthetic valve replacement. All 3 survived reoperation. Echocardiography at a mean of 32 ± 20 months postoperatively showed mild left atrioventricular valve regurgitation in 32 patients and moderate regurgitation in 3. Management of postoperative pulmonary hypertensive crisis and repair of complete atrioventricular septal defect before the development of high pulmonary vascular resistance may reduce the mortality of this surgical procedure. (Asian Cardiovasc Thorac Ann 1998;6:37–40)

INTRODUCTION

report describes our experience in the surgical management of AVSD.

Surgical repair is considered to be the definitive treatment for atrioventricular septal defect (AVSD). Early experience showed that the surgical procedure was complicated by postoperative left atrioventricular (AV) valve dysfunction, conduction disturbance, and postoperative pulmonary hypertensive crisis.1–3 Better understanding of the pathoanatomic features of this disease, careful timing of the surgery, advances in surgical technique, and improvements in the preoperative and postoperative management have reduced the postoperative morbidity and mortality.4–7 This

MATERIALS AND METHODS Between January 1988 and March 1996, 40 patients with complete AVSD underwent surgery in our center. The clinical records, cardiac catheterization results, echocardiographic reports, and operative notes were reviewed retrospectively. The characteristics of the patients are shown in Table 1. The patients were classified according to Rastelli and colleagues.3 The criteria of Carpentier5 and Becker and Anderson6 were used to define AVSD in this study. Five patients underwent palliative pulmonary artery banding before total repair because of significant ventricular imbalance, prematurity, multiple ventricular septal defects, and the preference of the cardiologists. One patient underwent repair of coarctation of the aorta and another had a Blalock-Taussig shunt before total repair because of combined AVSD and tetralogy of Fallot. Patients who had

For reprint information contact: Mohammed Jalal Uddin, PhD P.O. Box 4082 Safat 13041, Kuwait Tel: 965 481 1615 Fax: 965 484 5280

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COMPLETE ATRIOVENTRICULAR SEPTAL DEFECT pulmonary artery resistance above 8 Woods units·m–2 were operated if they were still reactive to an oxygen test. Preoperative echocardiography with or without cardiac catheterization showed mild, moderate, and severe AV valve regurgitation in 22, 16, and 2 patients, respectively. Additional anomalies coexisting with AVSD were patent ductus arteriosus in 9, and double-outlet right ventricle in 2 patients.

closed at the base with a couple of stitches to ensure valve competence. The extension of these stitches was limited by the theoretical size of the valve in relation to the age of the patient. Valve size was measured with Hegar dilators after each stitch. A left atrial catheter was used in all patients. A pulmonary artery catheter was used only when the preoperative pulmonary arterial pressure was very high. Pulmonary hypertensive crisis was defined as a sudden increase of pulmonary artery pressure to at least 70% of the systemic value, accompanied by a decrease in systemic pressure, a decrease in oxygen tension, and an increase in CO2 tension relative to the physiological levels.

Cardiopulmonary bypass was instituted with systemic hypothermia at 20° to 25°C. Cold crystalloid cardioplegic solution was infused into the aortic root at the rate of 20 to 30 mL per kg of body weight and topical cooling with ice was included for additional myocardial protection. A careful assessment of the intracardiac anatomy was made with special reference to the AV valve. The surgical technique was consistent throughout the series and comprised standard repair without division of the AV valve leaflet tissue as described by Kirklin and Pacifico.7

RESULTS There were 5 deaths (4 early and 1 late) among the 40 patients who underwent AVSD repair. The causes of death are shown in Table 2. The major cause of death was postoperative pulmonary hypertensive crisis. The 36 patients who survived the early stage of their initial repair were followed up for a mean of 32 ± 20 months. One of these patients died 50 months postoperatively. A permanent pacemaker was implanted in this patient during the initial repair. Three patients needed reoperation (Table 3). Two of these had left AV valve annuloplasty and one had left AV valve replacement. All 3 survived the second procedure.

The patch used to repair the ventricular septal defect was constructed from soft knitted Dacron velour or Gore-Tex (WL Gore, Flagstaff, AZ, USA) and fashioned into a halfmoon shape. The ventricular septal defect patch was sutured to the right side of the crest of the ventricular septum. After the septal position of the ventricular septal defect patch was secured, an autologous pericardial patch was employed to close the atrial septal defect. A sandwich technique was used to suture the AV valve to the ventricular and atrial patches. The cleft of the left AV valve septal leaflet was

Postoperative left AV valve function was assessed in all patients from a combination of clinical and echocardiographic criteria. Left AV valve regurgitation was graded as mild if the left atrial and ventricular dimensions were normal, moderate if left atrial and ventricular dilatation was present, and severe if there was symptomatic regurgitation necessitating medical therapy. Preoperative and postoperative assessments of the left AV valve were compared in the 35 surviving patients (Figure 1). Postoperatively, 32 (91.4%) patients had mild regurgitation and 3 (8.5%) had moderate regurgitation. Of the 16 patients with moderate-tosevere left AV valve regurgitation preoperatively, 13 were left with mild regurgitation (12 after the initial repair and 1 following a second repair). The remaining 3 patients were left with moderate AV valve regurgitation (1 after the initial

Table 1. Characteristics of 40 Patients Operated for DoublePatch Closure of Complete Atrioventricular Septal Defect Male : female Mean age at operation (months) Mean weight at operation (kg) Down’s syndrome Coexisting cardiac anomalies Rastelli classification Class A Class B Class C

18 : 22 10.8 ± 6.9 6.6 ± 2.6 23 patients (57.5%) 13 patients (32.5%) 26 patients 2 patients 12 patients

Table 2. Mortality Birth Age (months)

12 12 18 10 12

Coexisting

Atrioventricular

Weight

Down’s

Cardiac

Valve

Sex

(kg)

Syndrome

Anomaly

Regurgitation

PA/Sys

Cause of Death

Male Male Male Male Male

4.5 4.0 5.6 5.4 3.9

Yes Yes Yes Yes Yes

None None DORV None None

Mild Moderate Moderate Mild Mild

0.95 0.89 0.94 0.96 0.83

Pulmonary hypertensive crisis Pulmonary hypertensive crisis Myocardial dysfunction Pulmonary hypertensive crisis Unknown

DORV = double-outlet right ventricle, PA/Sys = pulmonary artery pressure/systemic pressure.

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COMPLETE ATRIOVENTRICULAR SEPTAL DEFECT Table 3. Reoperations Atrioventricular Valve Regurgitation

Type of Reoperation

Type of First Operation

Interval Between Repairs

Annuloplasty

Double-patch repair Cleft closure Chordal shortening Double-patch repair Cleft closure Annuloplasty Double-patch repair Cleft closure Annuloplasty

10 days

Severe

Moderate

15 days

Moderate

Moderate

6 years

Severe

Normal

Annuloplasty

Atrioventricular Valve Replacement

PREOPERATIVE ATRIOVENTRICULAR VALVE REGURGITATION

19 Mild

POSTOPERATIVE LEFT ATRIOVENTRICULAR VALVE REGURGITATION AT LATEST FOLLOW-UP

19

32 Mild

2 (1 Valve Repair)

3 Moderate

1 (1 Valve Replacement)

2 Severe

1 (1 Valve Repair)

0 Severe

Figure 1. Evaluation of the left atrioventricular valve before and after complete repair in 35 survivors.

placement and the other needed annuloplasty after the initial repair. Of the 35 surviving patients, 91.4% had mild AV valve regurgitation and 8.6% had moderate regurgitation at follow-up. No significant relationship was observed between the degree of preoperative AV valve regurgitation and the postoperative findings.

Some patients develop partial or complete heart block following AVSD repair. One of our patients developed complete heart block following the first repair and he needed a permanent pacemaker. Suturing of the patch to the base of the left AV valve in the area where the bundle of His runs has reduced this complication. Although Midgley and colleagues14 reported significantly higher mortality in complete AVSD repair following pulmonary artery banding, Frid and colleagues15 showed good results in a two-stage operation, which was compatible with our experience.

repair and 2 after the second repair). All of the 19 patients who had mild AV valve regurgitation preoperatively showed no worsening of this problem postoperatively.

DISCUSSION Surgical mortality of AVSD repair has decreased significantly over the last 20 years from 50% in early reports to a range of 3% to 6% recently, due to improvements in surgical techniques, myocardial preservation, and improvements in postoperative management.8–12 In spite of this improvement, failure to achieve a competent left AV valve and pulmonary hypertensive crisis remain the most significant risk factors for both early and late mortality following the surgical repair of the AVSD. Of the 4 early deaths in this series, 3 were due to postoperative pulmonary hypertensive crisis.

CONCLUSION We concluded from our experience that double-patch repair of an AVSD with routine suture closure of the cleft reduces the necessity of reoperation for left AV valve regurgitation. Postoperative pulmonary hypertensive crisis is the major risk factor for early postoperative death. Prompt management of postoperative pulmonary hypertensive crisis and repair of complete AVSD before the development of high pulmonary vascular resistance can reduce the mortality of

Studer and colleagues13 concluded that severe valve incompetence preoperatively was a risk factor for reoperation. In our series, 2 patients had severe AV valve regurgitation preoperatively, one of them required prosthetic valve re1998, VOL. 6, NO. 1

After Reoperation

The choice of a double patch for cleft closure rather than a single patch is debatable. Both techniques provide good early and late results and no significant differences have been observed in the incidence of mortality, reoperation, or postoperative complete heart block between these two techniques.9,14 We prefer to use the double-patch technique for AVSD closure because it produces less AV valve distortion and avoids dividing the bridging leaflet in a type C defect, which is always necessary in the single-patch technique. In the double-patch technique, the pericardial ASD patch completely eliminates hemolysis that can occur occasionally when a small jet through the left AV valve strikes the ASD patch.

12

14 Moderate

Before Reoperation

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COMPLETE ATRIOVENTRICULAR SEPTAL DEFECT this surgical procedure. The benefits of a double-patch repair of an AVSD should be considered.

7.

Kirklin J, Pacifico A. The surgical treatment of atrioventricular defect. In: Pediatric cardiac surgery. Chicago: Medical Year Book, 1985:155–70.

Presented at The 8th Scientific Session of the Saudi Heart Association, February 19, 1997, Al-Khobar, Saudi Arabia.

8.

Backer CL, Mavroulididis C, Alboliras ET, Zales VR. Repair of complete atrioventricular canal defect: result with two-patch technique. Am Thorac Surg 1995;60: 530–7.

9.

Bando K, Turrentine MW, Sun K, et al. Surgical management of complete atrioventricular septal defects. A twenty-year experience. J Thorac Cardiovasc Surg 1995;110:1543–52.

10.

Weintraub RG, Brawn WJ, Venablie AW, Mee RBB. Two-patch repair of complete atrioventricular septal defect in the first year of life. J Thorac Cardiovasc Surg 1990;99: 320–6.

11.

Pozzi M, Remig J, Fimmer R, Urban AE. Atrioventricular septal defects. Analysis of short and medium term result. J Thorac Cardiovasc Surg 1991;101:138–42.

ACKNOWLEDGMENT The authors wish to thank Suhas C Sanyal, PhD and M. Mounajjed, MD for their help in preparation of the manuscript.

REFERENCES 1.

Cooley DA. Result of surgical treatment of atrial septal defect with particular consideration of low defects including ostium primum and atrioventricular canal. Am J Cardiol 1960;6:605.

2.

Ellis FH, McGoon D, Kirklin SW. Surgical management of persistent common AV canal. Am J Cardiol 1960;6:598.

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Rastelli GC, Ongley PA, McGoon DC, et al. The direct vision intracardiac correction of congenital anomalies by controlled cross-circulation. Surgery 1955;11:29.

Kirklin JW. Atrioventricular canal defect. In: Kirklin JW, Barratt-Boyes B, editors. Cardiac surgery. 2nd ed. New York: Churchill Livingstone, 1993:694–741.

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Kirklin JK, Blackstone EH, Kirklin JW, et al. Intracardiac surgery in infants under 3 months: incremental risk factors for hospital mortality. Am J Cardiol 1981;48:500.

Studer M, Blackstone EH, Kirklin JW, et al. Determinants of early and late result of repair of atrioventricular septal (canal) defect. J Thorac Cardiovasc Surg 1982;84: 523–42.

5.

Carpentier A. Surgical anatomy and management of the mitral component of the atrioventricular canal defect. In: Anderson RH, Shinebourne ER, editors. Paediatric cardiology. London: Churchill Livingstone, 1978:477–90.

14.

Midgley FM, Galioto FM, Shapiro SR, et al. Experience with repair of complete atrioventricular canal. Ann Thorac Surg 1980;30:151–9.

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Becker AE, Anderson RH. Atrioventricular septal defect – what is a name? J Thorac Cardiovasc Surg 1982;83:461–9.

Frid C, Thoren C, Book K, Bjork V. Repair of complete atrioventricular canal. Scand J Thorac Cardiovasc Surg 1991;25:101–5.

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