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Putotto C, Masci M, Magliozzi M, Novelli A, Marino B, Digilio MC, Toscano A. Partial atrioventricular canal defect and aortic coarctation associated with variants in GDF1 and NOTCH1 genes: A case report. Birth Defects Res 2024; 116:e2382. [PMID: 38975735 DOI: 10.1002/bdr2.2382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/23/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND A peculiar subgroup of patients with partial or complete atrioventricular canal defect exhibits a spectrum of left-sided obstructions including right ventricular dominance and aortic coarctation. The association of atrioventricular canal defect with left-sided obstructions is found in several genetic syndromes; however, the molecular basis of nonsyndromic atrioventricular canal defect with aortic coarctation is still poorly understood. Although some candidate genes for nonsyndromic atrioventricular canal defect are known, a complex oligogenic inheritance determined in some cases by the co-occurrence of multiple variants has also been hypothesized. CASE REPORT We describe a nonsyndromic infant with mesocardia with viscero-atrial situs solitus, partial atrioventricular canal defect, mild right ventricular dominance, and coarctation of the aorta. Next generation sequencing genetic testing revealed variants in two genes, GDF1 and NOTCH1, previously reported in association with atrioventricular canal defect and left-sided obstructive lesions, respectively. CONCLUSION The present report could support the hypothesis that the co-occurrence of cumulative variants may be considered as genetic predisposing risk factor for specific congenital heart defects.
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Affiliation(s)
- Carolina Putotto
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Marco Masci
- Perinatal Cardiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Monia Magliozzi
- Translational Cytogenomics Research Unit, Laboratory of Medical Genetics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Antonio Novelli
- Translational Cytogenomics Research Unit, Laboratory of Medical Genetics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Bruno Marino
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Maria Cristina Digilio
- Medical Genetics, Translational Pediatrics and Clinical Genetics Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandra Toscano
- Perinatal Cardiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Common Atrioventricular Canal. CONGENIT HEART DIS 2022. [DOI: 10.1016/b978-1-56053-368-9.00011-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Preoperative Clinical and Echocardiographic Factors Associated with Surgical Timing and Outcomes in Primary Repair of Common Atrioventricular Canal Defect. Pediatr Cardiol 2019; 40:1057-1063. [PMID: 31065759 DOI: 10.1007/s00246-019-02116-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/27/2019] [Indexed: 10/26/2022]
Abstract
In complete atrioventricular canal defect (CAVC), there are limited data on preoperative clinical and echocardiographic predictors of operative timing and postoperative outcomes. A retrospective, single-center analysis of all patients who underwent primary biventricular repair of CAVC between 2006 and 2015 was performed. Associated cardiac anomalies (tetralogy of Fallot, double outlet right ventricle) and arch operation were excluded. Echocardiographic findings on first postnatal echocardiogram were correlated with surgical timing and postoperative outcomes using bivariate descriptive statistics and multivariable logistic regression. 153 subjects (40% male, 84% Down syndrome) underwent primary CAVC repair at a median age of 3.3 (IQR 2.5-4.2) months. Median postoperative length of stay (LOS) was 7 (IQR 5-15) days. Eight patients (5%) died postoperatively and 24 (16%) required reoperation within 1 year. On multivariable analysis, small aortic isthmus (z score < - 2) was associated with early primary repair at < 3 months (OR 2.75, 95% CI 1.283-5.91) and need for early reoperation (OR 3.79, 95% CI 1.27-11.34). Preoperative ventricular dysfunction was associated with higher postoperative mortality (OR 7.71, 95% CI 1.76-33.69). Other factors associated with mortality and longer postoperative LOS were prematurity (OR 5.30, 95% CI 1.24-22.47 and OR 5.50, 95% CI 2.07-14.59, respectively) and lower weight at surgery (OR 0.17, 95% CI 0.04-0.75 and OR 0.55, 95% CI 0.35-0.85, respectively). Notably, preoperative atrioventricular valve regurgitation and Down syndrome were not associated with surgical timing, postoperative outcomes or reoperation, and there were no echocardiographic characteristics associated with late reoperation beyond 1 year after repair. Key preoperative echocardiographic parameters helped predict operative timing and postoperative outcomes in infants undergoing primary CAVC repair. Aortic isthmus z score < - 2 was associated with early surgical repair and need for reoperation, while preoperative ventricular dysfunction was associated with increased mortality. These echocardiographic findings may help risk-stratified patients undergoing CAVC repair and improve preoperative counseling and surgical planning.
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Overman DM, Baffa JM, Cohen MS, Mertens L, Gremmels DB, Jegatheeswaran A, McCrindle BW, Blackstone EH, Morell VO, Caldarone C, Williams WG, Pizarro C. Unbalanced atrioventricular septal defect: definition and decision making. World J Pediatr Congenit Heart Surg 2013; 1:91-6. [PMID: 23804728 DOI: 10.1177/2150135110363024] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Unbalanced atrioventricular septal defect is an uncommon lesion with widely varying anatomic manifestations. When unbalance is severe, diagnosis and treatment is straightforward, directed toward single-ventricle palliation. Milder forms, however, pose a challenge to current diagnostic and therapeutic approaches. The transition from anatomies that are capable of sustaining biventricular physiology to those that cannot is obscure, resulting in uneven application of surgical strategy and excess mortality. Imprecise assessments of ventricular competence have dominated clinical decision making in this regard. Malalignment of the atrioventricular junction and its attendant derangement of inflow physiology is a critical factor in determining the feasibility of biventricular repair in the setting of unbalanced atrioventricular septal defect. The atrioventricular valve index accurately identifies unbalanced atrioventricular septal defect and also brings into focus a zone of transition from anatomies that can support a biventricular end state and those that cannot.
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Affiliation(s)
- David M Overman
- Division of Pediatric Cardiac Surgery, The Children's Heart Clinic, Children's Hospitals and Clinics of Minnesota, MN, USA
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Surgical Management of Neonatal Atrioventricular Septal Defect With Aortic Arch Obstruction. Ann Thorac Surg 2013; 95:2071-7. [DOI: 10.1016/j.athoracsur.2012.11.069] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 11/22/2012] [Accepted: 11/29/2012] [Indexed: 11/19/2022]
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Takahashi Y, Hanzawa Y. Modified Konno procedure: surgical management of tunnel-like left ventricular outflow tract stenosis. Gen Thorac Cardiovasc Surg 2013; 62:3-8. [PMID: 23636634 DOI: 10.1007/s11748-013-0247-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Indexed: 11/26/2022]
Abstract
Left ventricular outflow tract stenosis represents 1-2 % of all congenital anomalies. In particular, tunnel-like left ventricular stenosis which is one type of fixed left ventricular outflow stenosis requires aggressive surgery to reduce the left ventricular outflow gradient. The purpose of the modified Konno procedure is to release fixed left ventricular outflow tract stenosis while preserving the native aortic valve and its function. Although the clinical results of the modified Konno procedure are acceptable, it is necessary to precisely understand this procedure and the anatomy of the left ventricular outflow tract in order to avoid complications.
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Affiliation(s)
- Yukihiro Takahashi
- Division of Congenital Cardiovascular Surgery, Sakakibara Heart Institute, 3-6-1 Asahi-cho, Fuchushi, Tokyo, 183-0003, Japan,
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Myers PO, del Nido PJ, Marx GR, Emani S, Mayer JE, Pigula FA, Baird CW. Improving Left Ventricular Outflow Tract Obstruction Repair in Common Atrioventricular Canal Defects. Ann Thorac Surg 2012; 94:599-605; discussion 605. [DOI: 10.1016/j.athoracsur.2012.04.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 03/30/2012] [Accepted: 04/02/2012] [Indexed: 10/28/2022]
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Abstract
Congenital heart defects affect 60-85% of patients with RASopathies. We analysed the clinical and molecular characteristics of atrioventricular canal defect in patients with mutations affecting genes coding for proteins with role in the RAS/MAPK pathway. Between 2002 and 2011, 101 patients with cardiac defect and a molecularly confirmed RASopathy were collected. Congenital heart defects within the spectrum of complete or partial (including cleft mitral valve) atrioventricular canal defect were diagnosed in 8/101 (8%) patients, including seven with a PTPN11 gene mutation, and one single subject with a RAF1 gene mutation. The only recurrent mutation was the missense PTPN11 c.124 A>G change (T42A) in PTPN11. Partial atrioventricular canal defect was found in six cases, complete in one, cleft mitral valve in one. In four subjects the defect was associated with other cardiac defects, including subvalvular aortic stenosis, mitral valve anomaly, pulmonary valve stenosis and hypertrophic cardiomyopathy. Maternal segregation of PTPN11 and RAF1 gene mutations occurred in two and one patients, respectively. Congenital heart defects in the affected relatives were discordant in the families with PTPN11 mutations, and concordant in that with RAF1 mutation. In conclusion, our data confirm previous reports indicating that atrioventricular canal defect represents a relatively common feature in Noonan syndrome. Among RASopathies, atrioventricular canal defect was observed to occur with higher prevalence among subjects with PTPN11 mutations, even though this association was not significant possibly because of low statistical power. Familial segregation of atrioventricular canal defect should be considered in the genetic counselling of families with RASopathies.
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Hraška V, Walters HL. Management of Complete Atrioventricular Canal Defect With Aortic Arch Obstruction. World J Pediatr Congenit Heart Surg 2010; 1:199-205. [DOI: 10.1177/2150135110371136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with complete atrioventricular canal defect and aortic arch obstruction represent a particular challenge for management. The incidence is rare, so surgical experience is limited. A reasonable treatment option for newborns and young infants with competent atrioventricular valves is the staged approach, with the arch obstruction repaired first, followed at an appropriate interval by repair of the complete atrioventricular canal defect. If there is a significant degree of atrioventricular valve regurgitation, the primary single-stage correction of both aortic arch obstruction and the intracardiac malformation should be undertaken, irrespective of age. It remains to be seen whether this surgical strategy can be adopted for the entire spectrum of atrioventricular canal defect associated with arch obstruction.
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Affiliation(s)
- Viktor Hraška
- German Pediatric Heart Centre, Asklepios Clinic Sankt Augustin, Germany
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Cohen MS, Spray TL. Surgical management of unbalanced atrioventricular canal defect. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2005:135-44. [PMID: 15818370 DOI: 10.1053/j.pcsu.2005.02.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Approximately 10% of endocardial cushion defects exhibit unbalance at the atrioventricular inlet. When the atrioventricular valve sits more over one ventricle than the other, the contralateral ventricle is typically hypoplastic. Surgical intervention for unbalanced atrioventricular canal has a much higher morbidity and mortality than for the balanced form of the defect. With unbalanced atrioventricular canal to the right, no universal criteria are in place to choose single versus biventricular repair. In many cases, risk factors have been extrapolated from other lesions with left ventricular hypoplasia. Even if biventricular repair is successful, the reoperation rate is high for this lesion. Little data exist in the literature regarding left unbalanced atrioventricular canal. In general, right ventricular hypoplasia is better tolerated than left ventricular hypoplasia, and biventricular repair is usually possible. If cyanosis or high systemic venous pressure results, the one and one half ventricle repair (biventricular repair with bidirectional Glenn anastomosis) is an option. This article reviews the present understanding of unbalanced atrioventricular canal and discusses diagnostic and surgical strategies for this complex lesion.
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Affiliation(s)
- Meryl S Cohen
- The Cardiac Center, The Children's Hospital of Philadelphia, Division of Cardiology, Department of Pediatrics, University of Pennsylvania School of Medicine, 19104, USA
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Marino B, Digilio MC, Toscano A, Giannotti A, Dallapiccola B. Congenital heart diseases in children with Noonan syndrome: An expanded cardiac spectrum with high prevalence of atrioventricular canal. J Pediatr 1999; 135:703-6. [PMID: 10586172 DOI: 10.1016/s0022-3476(99)70088-0] [Citation(s) in RCA: 175] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To report the relative prevalence of various forms of congenital heart disease (CHD) in children with Noonan syndrome (NS) and to describe anatomic characteristics of the subgroup of patients with atrioventricular canal (AVC). STUDY DESIGN Phenotypic and cardiologic examinations were performed in 136 patients with NS and CHD evaluated at our hospital from January 1986 to December 1998. Cardiac evaluation included chest x-ray film, electrocardiogram, 2-dimensional and color Doppler echocardiography, cardiac catheterization with angiocardiography, and cardiac surgery. RESULTS The CHDs classically reported in NS, including pulmonary stenosis (39%), hypertrophic cardiomyopathy (10%), atrial septal defect (8%), and tetralogy of Fallot (4%), are well represented in our series; however, aortic coarctation (9%) and anomalies of the mitral valve (6%) may also occur in this syndrome. Moreover, AVC was diagnosed in 21 patients, representing 15% of all CHDs in our series. All patients showed a partial form of AVC, and an associated subaortic stenosis caused by additional anomalies of the mitral valve was detected in 5 of 21 (23.8%) of those patients. CONCLUSION Left-sided lesions, such as aortic coarctation and anomalies of the mitral valve, are not rare in patients with NS and CHD. Moreover, in this syndrome AVC is quite frequent, the partial form is prevalent, and subaortic stenosis caused by additional anomalies of the mitral valve may be present. This information should be taken into consideration during the cardiologic evaluation of children with NS.
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Affiliation(s)
- B Marino
- Department of Pediatric Cardiology, Bambino Gesù Hospital, Rome, Italy
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Najm HK, Williams WG, Chuaratanaphong S, Watzka SB, Coles JG, Freedom RM. Primum atrial septal defect in children: early results, risk factors, and freedom from reoperation. Ann Thorac Surg 1998; 66:829-35. [PMID: 9768938 DOI: 10.1016/s0003-4975(98)00607-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Repair of primum atrial septal defect in children usually is associated with a low operative mortality, except for a subgroup of children with congestive heart failure. To determine the early mortality and incidence of reoperation in children with primum atrial septal defect, we analyzed retrospectively the results of patients who underwent repair of this defect. METHODS Between July 1982 and December 1996, 180 children underwent repair of primum atrial septal defect. The mean age at repair was 4.6 years (median, 3.6 years; range, 1 month to 16.4 years); of the 180 children, 23 were infants less than 1 year of age. Absent or mild symptoms were present in 145 (80%), whereas 34 (20%) of children presented with severe symptoms or congestive heart failure. RESULTS Early mortality occurred in 3 (1.6%); 2 were less than 1 year of age. Follow-up ranged from 2 months to 14.5 years (mean, 6 +/- 4.2 years). Actuarial survival is 98% at 10 years with no late deaths. Age less than 1 year is a predictor of death. During follow-up, 17 (9%) of the 180 patients underwent reoperation, 5 of whom were in the infant group. Five underwent reoperation for subaortic obstruction, and 12 for left atrioventricular valve regurgitation of whom 11 were repaired; and 1 required valve replacement. Age and preoperative moderate-to-severe left atrioventricular valve regurgitation were predictors of reoperation. CONCLUSIONS Results of the repair of primum atrial septal defect during childhood are favorable. Infants have a higher risk for death and reoperation. Left atrioventricular valve insufficiency and subaortic stenosis are important late complications and can be repaired safely at reoperation.
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Affiliation(s)
- H K Najm
- Department of Surgery, The Hospital of Sick Children, University of Toronto, Faculty of Medicine, Ontario, Canada
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Suzuki K, Ho SY, Anderson RH, Becker AE, Neches WH, Devine WA, Tatsuno K, Mimori S. Morphometric analysis of atrioventricular septal defect with common valve orifice. J Am Coll Cardiol 1998; 31:217-23. [PMID: 9426043 DOI: 10.1016/s0735-1097(97)00456-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES We sought to analyze morphometric features of atrioventricular septal defect (AVSD) in autopsy specimens and to consider the developmental implications of obstruction in either ventricular outflow tract. BACKGROUND Left ventricular outlet obstruction (LVO) is more prevalent in patients with Rastelli type A morphology. When tetralogy of Fallot (ToF) complicates this malformation, there is usually a free-floating superior bridging leaflet. The reasons for these associations are uncertain. METHODS In 133 hearts with AVSD and common atrioventricular (AV) valve orifice, we measured the degrees of horizontal and anterior deviation of the great arteries from the AV valve, the diameters of the ventricular outlets and the great arteries and the degree of deficiency of the ventricular septum. RESULTS In Rastelli type A morphology, the great arteries were deviated more leftward than in type C morphology (p < 0.01). Type A hearts also had a relatively small aorta, with a long and narrow subaortic tract. The presence of obstruction in either ventricular outlet was associated with a more oblique arrangement of the great arteries, with the pulmonary trunk being more leftward than in hearts without LVO (p < 0.01). In combination with ToF, the aorta was dextroposed and the pulmonary trunk was located more posteriorly (p < 0.01). No heart with type A morphology showed ToF (p < 0.01). CONCLUSIONS The geometric arrangement of the great arteries correlated significantly with obstruction in either ventricular outflow tract and with the Rastelli subtypes. Malrotation of the developing outlet septum may be an embryologic factor producing obstruction, with horizontal deviation of the outlets also influencing the morphology of the superior bridging leaflet.
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Affiliation(s)
- K Suzuki
- Department of Pediatrics, Sakakibara Heart Institute, Tokyo, Japan.
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Van Arsdell GS, Williams WG, Boutin C, Trusler GA, Coles JG, Rebeyka IM, Freedom RM. Subaortic stenosis in the spectrum of atrioventricular septal defects. Solutions may be complex and palliative. J Thorac Cardiovasc Surg 1995; 110:1534-41; discussion 1541-2. [PMID: 7475206 DOI: 10.1016/s0022-5223(95)70077-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
UNLABELLED From July 1982 through September 1994, 19 children had operative treatment of subaortic stenosis associated with an atrioventricular septal defect. Specific diagnosis were septum primum defects in 7, Rastelli type A defects in 6, transitional defects in 4, inlet ventricular septal defect with malattached chordae in 1, and tetralogy of Fallot with Rastelli type C defect in 1. Twenty-seven operations for subaortic stenosis were performed. Surgical treatment of the outlet lesion was performed at initial atrioventricular septal defect repair in 3 children and in the remaining 16 from 1.2 to 13.1 years (mean 4.9 years, median 3.9 years) after repair. Eighteen of the 19 children had fibrous resection and myectomy for relief of obstruction. Seven children had an associated left atrioventricular valve procedure. One child received an apicoaortic conduit. Seven children (36.8%) required 8 reoperations for previously treated subaortic stenosis. Time to the second procedure was 2.8 to 7.4 years (mean 4.9 years). Follow-up is 0.4 to 14.0 years (median 5.6 years). Six-year actuarial freedom from reoperation is 66% +/- 15%. The angle between the plane of the outlet septum and the plane of the septal crest was measured in 10 normal hearts (86.4 +/- 13.7) and 10 hearts with atrioventricular septal defects (22.2 +/- 26.0; p < 0.01). The outflow tract can be effectively shortened, widened, and the angle increased toward normal by augmenting the left side of the superior bridging leaflet and performing a fibromyectomy. CONCLUSION Standard fibromyectomy for subaortic stenosis in children with atrioventricular septal defects leads to a high rate of reoperation. Leaflet augmentation and fibromyectomy may decrease the likelihood of reoperation.
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Affiliation(s)
- G S Van Arsdell
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
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DeLeon SY, Ilbawi MN, Wilson WR, Arcilla RA, Thilenius OG, Bharati S, Lev M, Idriss FS. Surgical options in subaortic stenosis associated with endocardial cushion defects. Ann Thorac Surg 1991; 52:1076-82; discussion 1082-3. [PMID: 1953127 DOI: 10.1016/0003-4975(91)91285-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Over a 15-year period, 12 patients with endocardial cushion defects undergoing correction had subaortic stenosis requiring operative intervention. Ages ranged from 4 months to 17 years (mean, 7 +/- 6 years) and subaortic gradients from 15 to 100 mm Hg (mean, 60 +/- 25 mm Hg). Subaortic stenosis was due to discrete fibromuscular tissues in 7 patients, mitral valve malattachment in 3, and tunnel outflow in 2. In 2, the subaortic stenosis was clinically significant at the time of endocardial cushion defects repair, whereas in 10 it was noted 2 to 14 years postoperatively (mean, 6.3 +/- 5 years). Surgical relief of subaortic stenosis was accomplished by resection of muscle tissues in 7, apicoaortic conduit insertion in 2, modified Konno procedure (aortic valve preserved) in 2, and lifting of malattached mitral valve from the outflow in 1. There was no early death and one late death (infected conduit). Severe mitral insufficiency developed in the patient who had the mitral valve lifted and necessitated valve replacement. Postoperative echocardiographic gradient in 9 patients ranged from 0 to 36 mm Hg (mean, 10.5 +/- 14 mm Hg). Clinically significant subaortic stenosis has not developed in any patient in 15 years of follow-up (mean, 5 +/- 4 years). We conclude that in subaortic stenosis associated with endocardial cushion defects, resection is effective for discrete obstruction, whereas a modified Konno procedure is preferable for obstruction due to tunnel outflow or mitral valve malattachment.
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Affiliation(s)
- S Y DeLeon
- Heart Institute for Children, Christ Hospital and Medical Center, Oak Lawn, Illinois
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Gallo P, Formigari R, Hokayem NJ, D'Offizi F, D'Alessandro, Francalanci P, d'Amati G, Colloridi V, Pizzuto F. Left ventricular outflow tract obstruction in atrioventricular septal defects: a pathologic and morphometric evaluation. Clin Cardiol 1991; 14:513-21. [PMID: 1810690 DOI: 10.1002/clc.4960140611] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Subaortic stenosis has been described with increasing frequency as an ominous feature of atrioventricular septal defect (AVSD), especially following surgical correction of the anomaly in non-Down's syndrome patients. In order to study the surgical anatomy of the left ventricular outflow tract in this malformation, 48 hearts featuring AVSD were examined. Obstructive lesions were classified into unequivocal forms (class A, 13.5%) and potential ones (class B, 10.8%). In the remaining hearts (class C, 75.7%) no obstruction was noted. In class A, subaortic stenosis was due to exaggeration of the anticipated anomalous arrangement of atrioventricular valve tensor apparatus, to the persistence of a subaortic muscular infundibulum, and to a discrete fibrous diaphragm. A potential for subaortic stenosis is provided by the unwedged position of the aortic valve. The left ventricular outflow tract is transformed into a long, forward-displaced fibromuscular channel. Morphometric analysis showed in AVSD (with both common annulus and separate orifices) a significantly (p less than 0.01) lower inflow/outflow tract ratio, and a significantly (p less than 0.01) lower right ventricular/left ventricular outflow length ratio than normal hearts. These results suggest that AVSD is characterized not only, as commonly stated, by inflow tract shortening, but by outflow tract lengthening as well. On these anatomical grounds, nearly all cases of AVSD could harbor the potential for subaortic stenosis; however, this becomes a real hazard (class B) only when associated with forward displacement of the left anterior papillary muscle, or direct insertion on the ventricular septum of the anterior bridging leaflet, and it may be converted to an actual obstruction by the effects of surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P Gallo
- Department of Human Biopathology, La Sapienza University, Rome, Italy
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De Biase L, Di Ciommo V, Ballerini L, Bevilacqua M, Marcelletti C, Marino B. Prevalence of left-sided obstructive lesions in patients with atrioventricular canal without Down’s syndrome. J Thorac Cardiovasc Surg 1986. [DOI: 10.1016/s0022-5223(19)36064-7] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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