Discrete subaortic stenosis and balloon dilation: the four questions revisited

[Subaortic diaphragm surgery]

Le diaphragme sous aortique se caractérise par une certaine latence clinique et une faible morbi-mortalité. La chirurgie reste le traitement de choix malgré un réel risque de récurrence à long terme. Nous rapportons 18 patients opérés entre Avril 1994 et Mars 2011 pour diaphragme sous aortique d’âge moyen de 18,1±9,7 ans avec 11 patients de sexe masculin. Le diaphragme était de nature fibreuse chez 13 patients et fibro-musculaire chez 5 patients. Tous les patients ont été opérés par résection de diaphragme associée à une myectomie, une plastie aortique, une fermeture de communication interventriculaire et une ligature de canal artériel perméable respectivement chez 3, 3, 2 et 2 patients. La Mortalité opératoire était nulle et sans aucun cas de trouble de conduction postopératoire. Le suivi a duré en moyenne 44,3±36,8 mois sans aucun décès tardif. Deux patients ont présenté une récidive de diaphragme qui a nécessité une réopération avec bonne évolution. La tendance actuelle dans la chirurgie du diaphragme se fait vers des interventions précoces et des résections plus extensives. Cependant, le risque de récidive impose une surveillance échographique systématique et rapprochée.

Surgical outcome following treatment of isolated subaortic obstruction

Surgical and nonsurgical patients with isolated subaortic stenosis (SAS) were compared to determine the important factors contributing to the timing of surgical intervention. This study reviews 49 consecutive patients (27 surgical and 22 nonsurgical) aged 1.8 to 15.9 years with isolated SAS. The preoperative peak left ventricular outflow tract (LVOT) gradient in surgical patients was significantly higher than the gradient in nonsurgical patients (59.0 +/- 30.4 vs 22.77 +/- 13.9 mm Hg, P = .0001). The progression in LVOT gradient analyzed by echo Doppler was significantly higher in the surgical group compared with the nonsurgical group (10.48 +/- 9.7 vs 1.56 +/- 6.5 mm Hg/y, P = .007). Repeat surgical intervention was required in 22% of patients in the surgical group for recurrence of SAS, and 4% needed a third surgery. The progression in the severity of aortic regurgitation (AR) was not significantly different in the surgical and nonsurgical groups. There was a significant association between the development of AR and patients undergoing surgery (P = .045). AR may not be a reliable indication for early operative intervention in isolated SAS as there was no significant difference in its progression with surgical and nonsurgical patients. Asymptomatic patients with isolated SAS may warrant surgical intervention on the basis of progression of LVOT gradient, rather than the development or progression of AR.

[Role of surgery in subaortic stenosis. Report of 56 cases]

INTRODUCTION

Subaortic stenosis is a rare congenital heart disease defined as a left ventricular outflow tract obstruction. We reviewed our surgical experience in this cardiac disease with particularly attention to the different anatomical types of the obstruction.

PATIENTS AND METHODS

From January 1987 to December 1998, 56 patients with a mean age of 12.4 years underwent surgical treatment of subaortic stenosis in our Institution. The diagnosis included: subaortic membrane in 44 cases, fibromuscular process in seven and tunnel like hypertrophy in five.

RESULTS

There were two hospital deaths (2/56 = 3.5%) and three patients presented postoperative heart block. The first postoperative echocardiographic control showed a mean fall in left ventricleaorta gradient of 78%. In a mean follow-up of 36 months, there were no deaths. All patients periodically controlled, showed an echocardiographic progression of the gradient and it was not related to the different anatomical types of the obstruction. There were no signs of aortic insufficiency progression.

CONCLUSION

We can affirm that the surgical treatment of the subaortic obstruction is simple and safe. The medium and long-term progression toward the recurrence is independent to the anatomical type and justify the need of serial echocardiographic control.