Left atrioventricular valve regurgitation after repair of incomplete atrioventricular septal defect

Repair of the complete atrioventricular septal defect-impact of postoperative moderate or more regurgitation

OBJECTIVES

To study the risk factors for mortality, moderate or more left atrioventricular valve regurgitation (LAVVR) and reoperation after the surgical repair of complete atrioventricular septal defect (cAVSD) in a single centre.

METHODS

The current study is a retrospective review of patients who underwent surgical repair of cAVSD between 2000 and 2021. Patients with unbalanced ventricles not amenable to biventricular repair, double outlet right ventricle and malpositioned great arteries were excluded. The clinical predictors of outcome for end points were analysed with univariate and multivariable Cox regression analysis or Fine-Gray modelling for competing risks. Time-dependent end points were estimated using the Kaplan-Meier curve analysis and cumulative incidence curves.

RESULTS

The median follow-up time was 2.3 years. Among 220 consecutive patients were 10 (4.6%) operative and 21 late mortalities (9.6%). A total of 26 patients were identified to have immediate postoperative moderate or more regurgitation and 10 of them ultimately died. By multivariable analysis prematurity and having more than moderate regurgitation immediately after the operation were identified as predictors of overall mortality (P = 0.003, P = 0.012). Five- and ten-year survival rates were lower for patients with immediate postoperative moderate or more LAVVR {51.9% [confidence interval (CI): 27.5-71.7%]} when compared to patients without moderate or more regurgitation [93.2% (CI: 87.1-96.4%) and 91.3% (CI: 83.6-95.5%)].

CONCLUSIONS

The patients who undergo cAVSD repair remain subjected to a heavy burden of disease related to postoperative residual LAVVR. Immediate postoperative moderate or more LAVVR contributes significantly to overall mortality. Whether a second run of bypass can decrease this observed mortality should be investigated.

Does Down syndrome influence the outcomes of congenital cardiac surgery? A systematic review and meta-analysis

BACKGROUND

Congenital cardiac surgery for individuals with Down syndrome (DS) has historically occurred at a reduced frequency. Little data are available regarding long-term post-congenital cardiac surgical outcomes. Limited sample sizes and clinical heterogeneity require a pooled analysis approach.

AIMS

To compare long-term outcomes post-congenital heart surgery between adults with and without DS.

METHODS

Databases (Medline, Embase, and PubMed) were searched utilizing terms related to DS and congenital heart disease.Studies that enrolled adults (>18 years) with operated congenital heart disease and compared long-term outcomes with respect to DS presence were included. All study designs were included, but those with limited/peri-operative follow-up, non-English texts, case studies, and literature reviews were excluded.Blinded screening, data extraction, and quality assessment were independently conducted by two reviewers. QUIPS criteria were used for risk of bias analysis. Both random- and fixed-effects models were used for meta-analysis.

RESULTS

A total of 23 studies (n = 10 466) were included. Risk of bias was frequently high due to unblinded retrospective study designs and analyses limited in adjustment for other prognostic factors.Meta-analysis demonstrated no effect of DS on long-term mortality [hazard ratio (HR) 0.86, 95% confidence interval (95% CI) 0.6-1.23], to a maximum described follow-up of 38 years. Lower cardiac reoperation risk (HR 0.6, 95% CI 0.46-0.78) for individuals with DS was found on pooled analysis. Meta-analysis was limited by between-study variation.

CONCLUSION

DS does not affect post-congenital cardiac surgical survival in adulthood. Reduced reoperation may reflect challenges in assessing functional and symptomatic status and/or concerns regarding perceived reoperation difficulties or likely benefits.

Incidentally detected atrioventricular septal defect in an adult

A 34-year-old woman, a liver transplantation donor for her son, was referred to our hospital for preoperative evaluation. She was diagnosed with an incomplete atrioventricular septal defect (AVSD). She underwent double valve repair and patch closure of the defect. Incidental discovery of an asymptomatic AVSD in an adult is rare.

Repair of Partial Atrioventricular Septal Defects in Adults: A Single Center Experience

Limited data are available on long-term outcome after repair of partial atrioventricular septal defects (pAVSD) in adults. We sought to review our experience. Between January 1, 1957 and December 31, 2016, 179 adult patients [median age (IQR) 34 (18, 72) years] underwent primary repair of pAVSD. The most common associated defects were secundum atrial septal defect (n = 38) and ventricular septal defect (VSD) (n = 7). Left atrioventricular valve (LAVV) zone of apposition (ZOA) was complete in 47 patients and LAVV regurgitation (≥moderate) was present in 73 patients. Autologous pericardium (n = 79, 45%) and polytetrafluoroethylene felt (n = 56, 32%) were mainly used for pAVSD closure.  Repair techniques for LAVV regurgitation included: ZOA suture closure (n =  142), suture annuloplasty (n = 10) and posterior band annuloplasty (n = 9). Six had LAVV replacement. There were 61 deaths over a median follow-up of 21 years (IQR 10, 38), with only 4 early deaths. In a limited subset of patients with 80 paired measurements (n = 40), median right ventricular systolic pressure declined from 43 mm Hg (IQR 35-51) to 33 mm Hg (IQR 30-44) postoperatively (P < 0.001), and this improvement was sustained over long-term follow-up (P = 0.513). A total of 34 patients underwent a reoperation (recurrent LAVV regurgitation, n = 26; left ventricular outflow-tract obstruction, n = 7; LAVV stenosis, n = 4; patch dehiscence, n = 1) with cumulative incidence of 6% and 16% at 10 and 15 years, respectively. Repair of pAVSD in adults can be done safely with low early mortality and good long-term outcomes. Postrepair reduction of pulmonary artery pressure is significant. Despite the low re-operation rates, long-term surveillance remains essential.

Double-Orifice Left Atrioventricular Valve: The Case for Preoperative Three-Dimensional Echocardiography

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Double-orifice left AV valve complicates successful repair of common AV canal.

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Two-dimensional imaging may not recognize or define double-orifice left AV valve.

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Three-dimensional echocardiography is useful for visualizing these complex valves.

Annuloplasty band implantation in adults with partial atrioventricular septal defect: a propensity-matched study

OBJECTIVES

The incidence of recurrent left atrioventricular valve (LAVV) regurgitation is generally high after repair of partial atrioventricular septal defect (AVSD). This study aimed to evaluate the effect of implanting an additional annuloplasty band into the LAVV during partial AVSD repair and to assess the late outcomes of recurrent LAVV regurgitation.

METHODS

This study enrolled 133 patients who underwent repair of partial AVSD at our institution from January 2005 to December 2015. All patients underwent repair of the ostium primum atrial septal defect and closure of the LAVV cleft; 37 patients underwent additional annuloplasty band implantation. To minimize differences in preoperative data, propensity score matching was used to identify 33 well-matched patient pairs.

RESULTS

Cardiopulmonary bypass time and aorta cross-clamp time were significantly longer in the band implantation group (P < 0.05). The 2 groups had similar durations of intensive care and hospital stay (P > 0.05). There was 1 in-hospital death in the band implantation group. During follow-up, conduction block occurred in 6 patients in each group. After follow-up of more than 10 years, freedom from late recurrent LAVV regurgitation was 91% in the band implantation group and 57% in the isolated cleft closure group (P < 0.05). In patients with preoperative severe regurgitation and moderate/mild regurgitation, the rates of freedom from recurrent LAVV regurgitation were 85% and 37%, respectively (P < 0.05).

CONCLUSIONS

In patients with moderate/severe LAVV regurgitation or severe annular dilation, additional band implantation significantly reduces the incidence of recurrent regurgitation and improves long-term outcomes.

Symptomatic partial and transitional atrioventricular septal defect repaired in infancy

Objectives

Infants with symptomatic partial and transitional atrioventricular septal defect undergoing early surgical repair are thought to be at greater risk. However, the outcome and risk profile of this cohort of patients are poorly defined. The aim of this study was to investigate the outcome of symptomatic infants undergoing early repair and to identify risk factors which may predict mortality and reoperation.

Methods

This multicentre study recruited 51 patients (24 female) in three tertiary centres between 2000 and 2015. The inclusion criteria were as follows: (1) partial and transitional atrioventricular septal defect, (2) heart failure unresponsive to treatment, (3) biventricular repair during the first year of life.

Results

Median age at definitive surgery was 179 (range 0–357) days. Sixteen patients (31%) had unfavourable anatomy of the left atrioventricular valve: dysplastic (n=7), double orifice (n=3), severely deficient valve leaflets (n=1), hypoplastic left atrioventricular orifice and/or mural leaflet (n=3), short/poorly defined chords (n=2). There were three inhospital deaths (5.9%) after primary repair. Eleven patients (22%) were reoperated at a median interval of 40 days (4 days to 5.1 years) for severe left atrioventricular valve regurgitation and/or stenosis. One patient required mechanical replacement of the left atrioventricular valve. After median follow-up of 3.8 years (0.1–11.4 years), all patients were in New York Heart Association (NYHA) class I. In multivariable analysis, unfavourable anatomy of the left atrioventricular valve was the only risk factor associated with left atrioventricular valve reoperation.

Conclusions

Although surgical repair is successful in the majority of the cases, patients with partial and transitional atrioventricular septal defect undergoing surgical repair during infancy experience significant morbidity and mortality. The reoperation rate is high with unfavourable left atrioventricular valve anatomy.

Technical Performance Score Predicts Partial/Transitional Atrioventricular Septal Defect Outcomes

BACKGROUND

Repair of partial or transitional atrioventricular septal defects (P/TAVSDs) has excellent outcomes; however, late reinterventions remain a concern. Technical performance score (TPS) measures residua after repair and has been associated with early/mid-term outcomes after congenital cardiac operation. Our study investigates TPS as a predictor of outcomes after P/TAVSD repair.

METHODS

This was a single-center retrospective review of P/TAVSD repair from July 2000 to November 2015. Intraoperative and discharge TPS were assigned based on echocardiographic criteria: class 1, no residua; class 2, minor residua; and class 3, major residua or reintervention for major residua. Intensive care unit (ICU) hospital length of stay and reintervention after discharge were analyzed with Cox regression.

RESULTS

In our cohort, 124 partial (68%) and 59 transitional (32%) AVSDs underwent repair. Median age was 1.5 years (interquartile range [IQR]: 0.6 to 3.8 years), median weight was 9.7 kg (IQR: 6.6 to 14.1 kg), and 96 (52%) were female. Twenty patients (11%) required reintervention after discharge. On multivariable modeling, patients with TPS class 3 spent more days in the ICU (hazard ratio [HR] 0.33, 95% confidence interval [CI]: 0.19 to 0.58, p < 0.001) and hospital (HR 0.33, 95% CI: 0.19 to 0.57, p < 0.001) and had shorter time to reintervention after discharge (HR 8.76, 95% CI: 1.03 to 74.7, p = 0.047).

CONCLUSIONS

Major residua, that is TPS class 3, were a predictor of in-hospital outcomes and unplanned reinterventions after discharge, with left atrioventricular valve regurgitation being the strongest predictor. Use of TPS as a tool for residual lesions may identify patients predisposed to prolonged ICU hospital stay and reinterventions after discharge, providing feedback on areas in need of improvement in technique and identification of patients who warrant closer follow-up.

Outcomes and Prognostic Factors for Adult Patients With Congenital Heart Disease Undergoing Primary or Reoperative Systemic Atrioventricular Valve Surgery

BACKGROUND

Adults with congenital heart disease (ACHD) undergoing systemic atrioventricular valve (SAVV) surgery are a complex, understudied population. We assessed midterm outcomes and prognostic factors in ACHD undergoing SAVV surgery.

METHODS

We performed retrospective evaluation of ACHD undergoing SAVV surgery from January 2005 to February 2016: 14 (33%) patients with congenital mitral valve stenosis/regurgitation, 15 (35%) with atrioventricular septal defect (AVSD), and 14 (33%) with congenitally corrected transposition of the great arteries (ccTGA) with systemic tricuspid valve regurgitation. Adverse events were defined as mortality, reoperation on SAVV, and late more-than-moderate (> moderate) SAVV regurgitation. Statistical analysis was performed using Fisher's exact test and one-way analysis of variance as well as univariate and multivariate risk factor analysis.

RESULTS

Fifteen (35%) patients had preoperative systemic ventricular dysfunction, including 13 patients with ccTGA (93%, P < .001). Twenty-three (54%) patients underwent valve repair, 20 (47%) patients underwent replacement, and 20 (47%) patients underwent an associated procedure. Replacement was higher in patients with ccTGA (86%) than the other groups ( P < 0.01). Thirty-seven patients (91% of survivors) were free of significant SAVV regurgitation at last follow-up, with patients with AVSD having greater regurgitation grades compared to the other groups ( P < 0.01). In-hospital mortality, late mortality, late > moderate SAVV regurgitation, and SAVV reoperation rates were 5% (n = 2), 2% (n = 1), 9% (n = 3), and 7% (n = 3), respectively. On multivariate analysis, predischarge SAVV regurgitation grade was the only significant predictor of adverse events (odds ratio = 8.2, 95% confidence interval: 1.1-63.8, P = .045).

CONCLUSION

Overall outcomes in this challenging population are good. The single factor associated with adverse events was predischarge SAVV regurgitation grade.

Surgical repair of partial atrioventricular defect

Long-term survival rate of patients operated for partial atrioventricular (AV) canal is lower than that of the general population, and late complications are relatively significant: between 10 and 30% of operated patients present with left AV valve regurgitation, and up to 25% have to be reoperated for valve repair or replacement, left ventricular outflow tract obstruction or residual atrial septal defect. Because the left AV valve regurgitation is the most common complication following surgery, technical details in the surgical management of the mitral valve are the most important aspects of this procedure; for example, the decision to close the cleft and to perform an annuloplasty. The presence of mitral valve anomalies in 7-28% of the cases complicates further the surgical management of these valves. This article will describe in detail the operative technique of partial AV canal repair, and review the relevant literature.

Factors associated with moderate or severe left atrioventricular valve regurgitation within 30 days of repair of incomplete atrioventricular septal defect

Introduction

Left atrioventricular valve regurgitation is the most concerning residual lesion after surgical correction of atrioventricular septal defect.

Objective

To determine factors associated with moderate or greater left atrioventricular valve regurgitation within 30 days of surgical repair of incomplete atrioventricular septal defect.

Methods

We assessed the results of 51 consecutive patients 14 years-old and younger presenting with incomplete atrioventricular septal defect that were operated on at our practice between 2002 and 2010. The following variables were considered: age, weight, absence of Down syndrome, grade of preoperative left atrioventricular valve regurgitation, abnormalities on the left atrioventricular valve and the use of annuloplasty. The median age was 4.1 years; the median weight was 13.4 Kg; 37.2% had Down syndrome. At the time of preoperative evaluation, there were 23 cases with moderate or greater left atrioventricular valve regurgitation (45.1%). Abnormalities on the left atrioventricular valve were found in 17.6%; annuloplasty was performed in 21.6%.

Results

At the time of postoperative evaluation, there were 12 cases with moderate or greater left atrioventricular valve regurgitation (23.5%). The variation between pre- and postoperative grades of left atrioventricular valve regurgitation of patients with atrioventricular valve malformation did not reach significance (P=0.26), unlike patients without such abnormalities (P=0.016). During univariate analysis, only absence of Down syndrome was statistically significant (P=0.02). However, after a multivariate analysis, none of the factors reached significance.

Conclusion

None of the factors studied was determinant of a moderate or greater left atrioventricular valve regurgitation within the first 30 days of repair of incomplete atrioventricular septal defect in the sample. Patients without abnormalities on the left atrioventricular valve benefit more of the operation.

Challenges in echocardiographic assessment of mitral regurgitation in children after repair of atrioventricular septal defect

The validity and reproducibility of echocardiographic methods used to quantify mitral regurgitation (MR) in children with congenital heart disease are unknown. We evaluated the usefulness of methods used to quantify MR in children enrolled in a multicenter trial of enalapril 6 months after surgical repair of an atrioventricular septal defect (AVSD). MR severity in this trial was assessed using body surface area (BSA)-adjusted vena contracta lateral (i-VCW(lat)) and anterior-posterior (i-VCW(ap)) dimensions and cross-sectional area (i-VCA), regurgitant volume/BSA, regurgitant fraction, and qualitative MR grade. For each method, association with left ventricular end-diastolic volume (LVEDVz) and end-diastolic dimension (LVEDDz) z-scores and interobserver agreement were assessed. In 149 children (median age 1 year), i-VCW(lat), i-VCW(ap), and i-VCA were best associated with LVEDVz (r (2) = 0.54, r (2) = 0.24, and r (2) = 0.46, respectively; p < 0.001 for all) and showed the highest interobserver agreement (intraclass correlation coefficient = 0.62, 0.73, and 0.68, respectively). Qualitative MR grade was also associated with LVEDVz (r (2) = 0.31, p < 0.001) and showed modest interobserver agreement (kappa 0.56). Regurgitant volume/BSA and regurgitant fraction were associated with LVEDVz (r (2) = 0.45 and r (2) = 0.45, p < 0.001 for both) but showed poor interobserver agreement [ICC = 0.28 (n = 91) and ICC = 0.17 (n = 76), respectively], and their values were negative in 75% of subjects. In conclusion, echocardiographic assessment of MR severity after AVSD remains challenging. Among the quantitative methods used in this trial, i-VCW and i-VCA performed the best but offered little advantage compared with qualitative MR grade. The utility of regurgitant volume and fraction was severely limited by poor interobserver agreement and frequently negative values.

Reoperations After Repair of Partial and Complete Atrioventricular Septal Defect

The most common cause of reoperation following repair of atrioventricular septal defect (AVSD) is left atrioventricular valve regurgitation. However, reoperation for subaortic obstruction is required in some, especially after initial repair of partial AVSD. Etiology of reoperation and late outcome were evaluated. Between 1962 and 2007, 146 patients (59 male) underwent reoperation at the authors' institution after prior repair of partial (n = 96) and complete (n = 50) AVSD. Median age at reoperation after repair of partial AVSD was 26 years (range, 10 months to 71 years) and 4.5 years (range, 53 days to 38 years) after repair of complete AVSD. The 3 most common indications for reoperation included left atrioventricular (AV) valve regurgitation in 105 patients, subaortic stenosis in 29, and right AV valve regurgitation in 21. The most common procedures performed included left AV valve repair in 59 (40%) patients, left AV valve replacement in 56 (38%), subaortic fibrous resection/myectomy in 24 (16%), and right AV valve surgery in 19 (13%). Freedom from subsequent reoperation at 10 years was 48% after initial repair of complete AVSD and 84% after initial repair of partial AVSD. During late follow-up, 10-year actuarial survival was 91% and 77% after initial repair of complete and partial AVSD, respectively. The most common indication for reoperation after initial repair of partial or complete AVSD is left AV valve pathology; left ventricular outflow tract obstruction was more common in partial AVSD. Although freedom from subsequent reoperations is higher after initial repair of partial AVSD, these patients have reduced long-term survival when compared with complete AVSD.

Partial and transitional atrioventricular septal defect outcomes

BACKGROUND

Surgical and perioperative improvements permit earlier repair of partial and transitional atrioventricular septal defects (AVSD). We sought to describe contemporary outcomes in a multicenter cohort.

METHODS

We studied 87 patients undergoing primary biventricular repair of partial or transitional AVSD between June 2004 and February 2006 across seven North American centers. One-month and 6-month postoperative data included weight-for-age z-scores, left atrioventricular valve regurgitation (LAVVR) grade, residual shunts, and left ventricular ejection fraction. Paired methods were used to assess 6-month change.

RESULTS

Median age at surgery was 1.8 years; median weight z-score was -0.88. Median days for ventilation were 1, intensive care 2, and hospitalization 5, all independent of age, with 1 in-hospital death. At 1 month, 27% (16 of 73) had ejection fraction less than 55%; 20% (17 of 87) had significant LAVVR; 2 had residual shunts; 1 each had subaortic stenosis and LAVV stenosis. At 6 months (n = 60), there were no interim deaths, reinterventions, or new development of subaortic or LAVV stenosis. Weight z-score improved by a median 0.4 units (p < 0.001), especially for underweight children less than 18 months old. Left atrioventricular valve regurgitation occurred in 31% (change from baseline, p = 0.13), occurring more frequently in patients repaired at 4 to 7 years (p = 0.01). Three patients had ejection fraction less than 55%, and 1 had a residual atrial shunt.

CONCLUSIONS

Surgical repair for partial/transitional AVSD is associated with low morbidity and mortality, short hospital stays, and catch-up growth, particularly in underweight children repaired between 3 and 18 months of age. Left atrioventricular valve regurgitation remains the most common residual defect, occurring more frequently in children repaired after 4 years of age.

Cleft closure and undersizing annuloplasty improve mitral repair in atrioventricular canal defects

OBJECTIVE

Reoperation rates to correct left atrioventricular valve regurgitation after primary repair of atrioventricular canal defects remain relatively high. The causes of valvular regurgitation are likely multifactorial, and simple cleft closure is often insufficient to prevent recurrence.

METHODS

To elucidate the mechanisms leading to regurgitation, we conducted hemodynamic studies using isolated native mitral valves. Anatomy of these valves was altered to mimic atrioventricular canal type valves and studied under pediatric hemodynamic conditions. The impact of subvalvular geometry, cleft closure, annular dilatation, and annular undersizing on regurgitation were investigated.

RESULTS

Papillary muscle position did not have a significant effect on regurgitation. Cleft closure had a significant impact on valvular competence, with reduction in regurgitation volume with increased cleft closure. Regurgitation volume decreased from 12.5 +/- 2.4 mL/beat for an open cleft to 4.9 +/- 1.9 mL/beat for a partially closed cleft and to 1.4 +/- 1.6 mL/beat when the cleft was completely closed. Annular dilatation had a significant impact on regurgitation even after cleft closure. A 40% increase in annular size increased regurgitation by 59% for a partially closed cleft and by 84% for a fully closed cleft. Reducing the annular size by 20% from the physiologic level decreased the regurgitation volume by 12% for a fully open cleft and by 58% for the partially closed cleft case.

CONCLUSIONS

Annular dilatation after primary repair has a potentially significant role in the recurrence of atrioventricular valve regurgitation. Reducing the annular size and restricting dilatation as an adjunct to cleft closure is a promising surgical approach in such valve anatomies.

Partial atrioventricular canal: pitfalls in technique

Partial atrioventricular (AV) canal represents approximately 25% of all AV septal defects. While often grouped with secundum ASD from the perspective of cardiopulmonary physiology, clinical presentation, and timing of surgical correction, their optimal management truly requires an understanding of their anatomic similarities to other forms of common AVC defects. By most measures, outcomes for surgical management of partial AV canal has improved over the last four decades, though some aspects of these defects continue to pose important challenges. Current experience has witnessed the reduction in early mortality and only rare complete heart block. Left AV valve dysfunction remains the most common indication for reoperation (10%) with LVOT stenosis the next most common reason (10% to 15% incidence, 5% to 10% reoperation rate). It is important to understand in this population that postoperative left AV valve problems and LVOT stenosis may be intimately linked, both from an etiologic standpoint, and with respect to their management.

Three-dimensional Echocardiography Improves the Understanding of the Mechanisms and Site of Left Atrioventricular Valve Regurgitation in Atrioventricular Septal Defect

OBJECTIVES

The purpose of this study was to determine whether 3-dimensional echocardiography (3DE) provides additional information regarding the mechanisms and sites of left atrioventricular valve regurgitation in atrioventricular septal defect compared with transesophageal 2-dimensional echocardiography (2DE).

METHODS

Eleven patients with a median age of 5.4 years (2.9-11.6 years) and a median weight of 16.8 kg (13.7-38.3 kg) with an atrioventricular septal defect underwent simultaneous transesophageal 2DE and 3DE before operation.

RESULTS

The 2DE-3DE agreement for the assessment of the superior and mural leaflet size was 72.7%. The 2DE-3DE agreement for coaptation failure, a residual or primary cleft, and commissural abnormalities as a mechanism of regurgitation were 72.7%, 63.6%, and 36.4%, respectively. For jet sites the 2DE-3DE agreement was 63.6% for a commissural and central location.

CONCLUSION

Three-dimensional echocardiography provides new and superior data regarding the mechanisms and sites of left atrioventricular valve regurgitation in atrioventricular septal defect.

The Impact of Patch Augmentation on Left Atrioventricular Valve Dynamics in Patients with Atrioventricular Septal Defects: Early and Midterm Follow-up

OBJECTIVE

Left atrioventricular valve pericardial patch may prevent valve replacement. We assessed patch annular dynamics compared with conventional repair and normal annuli.

METHODS

Transesophageal 3-dimensional echocardiography was acquired preoperatively and postoperatively in atrioventricular septal defects (n = 10, 5 patch, 5 conventional repair). Real-time 3-dimensional annular motion at midterm was compared with that of healthy children (n = 10). Parameters were: annular area, perimeter, segmental diameter, bending angle, stenosis, and regurgitation.

RESULTS

Regurgitant jet area ratio decreased in both patient groups. Conventional repair reduced annular area (P = .02). Patch repair showed an annular area larger than normal (P = .01). Control subjects had increased systolic area whereas operative groups showed a reduction. Patch repair had segmental diameters similar to normal whereas conventional repair was inhomogeneous. Annular bending angle was maintained after operation.

CONCLUSION

Patch repair in pediatrics shows durability without shrinkage or expansion. Improved stenosis and regurgitation does not change by midterm. Operation causes increased annular stiffness and diminished compliance. Neither technique establishes normal annular eccentricity.

Utilization of double-orifice valve plasty in correction of atrioventricular septal defect

BACKGROUND

Atrioventricular valve regurgitation represents the principal indication for reoperation after repair of atrioventricular septal defect. Deciding how to correct atrioventricular valve regurgitation is challenging in some cases because of the complexity of the anatomic features. This report deals with our surgical experience in using a double-orifice valve plasty technique in cases with atrioventricular septal defect.

METHODS

From August 2002 to August 2004, 8 patients underwent double-orifice valve plasty in surgical correction of atrioventricular septal defect. Anatomic types were partial (6 patients), intermediate (1 patient), and complete (1 patient). After the mitral cleft was closed, moderate to severe atrioventricular valve regurgitation was still present in these patients. Double-orifice valve plasty was used in the mitral valve in 7 patients and in the tricuspid valve in 1.

RESULTS

No hospital deaths or postoperative morbidity occurred. The follow-up ranged from 6 months to 30 months (median, 14.4 months). No or trivial atrioventricular valve regurgitation was found in 6 patients and mild atrioventricular valve regurgitation was present in 2.

CONCLUSIONS

Double-orifice valve plasty is an easy and effective additional procedure for children and for adult patients who have moderate or severe atrioventricular valve regurgitation after repair of atrioventricular septal defect.

Real-time transthoracic three-dimensional echocardiography provides additional information of left-sided AV valve morphology after AVSD repair

AIMS

The purpose of this study was to assess the feasibility of real-time 3D echocardiography (RT-3DE) data acquisition in adult patients after atrioventricular septal defect (AVSD) repair and to evaluate whether RT-3DE has additional value over 2D echocardiography, regarding morphology and function of the left-sided AV valve (LAVV).

METHODS

Twenty consecutive patients with surgically corrected partial or complete AVSD were enrolled in this study. The 3DE data sets were acquired with the Hewlett-Packard Sonos 7500 echo system (Philips Medical Systems, Andover, MA, USA). Images were reviewed off-line with assistance of TomTec Echoview 5.2 software (TomTec Inc., Munich, Germany) by experienced observers. En face reconstructions, from, respectively, the ventricular and atrial view, were made to evaluate the LAVV morphology and motion.

RESULTS

3DE reconstruction of the LAVV was feasible in 17 of 20 patients (85%). Mean time of 3DE acquisition was 9+/-6 min. The quality of the 3DE images was optimal in 35%, good in 30%, sufficient in 20% and insufficient in 15%. Identification of the LAVV structures was importantly better facilitated from a ventricular view. Accurate identification of LAVV morphology was possible in all 17 patients (85%). Relationship of the LAVV and the abnormal position of the LVOT was easier to evaluate from the 3DE reconstructions than from 2D echo.

CONCLUSION

This study demonstrate that RT-3DE is feasible in daily practice and provides new insight into the dynamic morphology of the left-sided AV valve and LVOT anatomy after AVSD repair.

Cardiac complications relating to pregnancy and recurrence of disease in the offspring of women with atrioventricular septal defects

AIMS

In most pregnancy reports, atrioventricular septal defects (AVSD) are not differentiated from more simple septal defects, thus underestimating the risks of pregnancy. To investigate the magnitude and determinants of risk during pregnancy in female patients with balanced AVSD.

METHODS AND RESULTS

Using a nation-wide registry (CONCOR), 79 female patients with balanced/isolated AVSD were identified. A total of 29 patients had 62 pregnancies, including 12 miscarriages (19%) and two elective abortions. Detailed recordings of each completed (>20 weeks gestation) pregnancy (n=48, 26 women) were obtained. Cardiovascular events complicated almost 40% of the completed pregnancies. In particular, post-partum persistence of pregnancy-related New York Heart Association (NYHA) class deterioration [23% mainly patients with residual atrial septal defects (ASD)] and deterioration of pre-existing left AV-valvular regurgitation (17%) were frequently recorded. Additional cardiac complications were arrhythmias (19%) and symptomatic heart failure (2%). Congenital heart disease (CHD) recurred in six children (12%): AVSD (n=4, three with left-sided hypoplasia), patent ductus arteriosus (n=1), and ASD (n=1). Three children died including two children with left-sided hypoplasia.

CONCLUSION

Pregnancy is not always well tolerated in women with AVSD, predominantly due to NYHA class deterioration and worsening of pre-existing AV-valvular regurgitation. Offspring mortality is high (6.3%), primarily due to recurrence of complex CHD.