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Robert H. Anderson
Erik J. Meijboom
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Ann Thorac Surg 1986;41:483-488
© 1986 The Society of Thoracic Surgeons

Articles

The Surgical Anatomy of the Left Ventricular Outflow Tract in Atrioventricular Septal Defect

Tjark Ebels, M.D.*, Siew Yen Ho, Ph.D., Robert H. Anderson, M.D., M.R.C. (Path), Erik J. Meijboom, M.D., Anton Eijgelaar, M.D.

Division of Thoracic Surgery, University of Groningen, The Netherlands, Department of Paediatrics, Cardiothoracic Institute, Brompton Hospital, Fulham Road, London, England, and the Thoracic Unit, Hospital for Sick Children, Great Ormond St., London, England

Accepted for publication July 19, 1985.

* Address reprint requests to Dr. Ebels, Division of Thoracic Surgery, University Hospital, Oostersingel 59, 9713 EZ Groningen, The Netherlands

The left ventricular (LV) outflow tract (OT) in atrioventricular (AV) septal defect is an important structure that paradoxically is hardly ever seen by a surgeon. The LVOT is prone to develop obstruction following surgical procedures, such as left AV valve replacement, that seemingly do not affect the LVOT itself. We examined 15 hearts with AV septal defects and noted the anatomical boundaries of the LVOT. Additionally, the LVOT was examined microscopically, and it was sectioned to replicate echocardiographic images. A sham operation was performed to show the extent of the proposed resection for AV valve replacement. The mean length of this area was 91.8 ± 35.5% (range, 28.6 to 167.0%) of the diameter of the ascending aorta in our specimens of the Rastelli A variety. The mean diameter of the LVOT was 68.2 ± 13.5% (range, 42.9 to 100.0%) of the diameter of the ascending aorta. The posterior wall of the OT can either be resected or widened. Resection seems to be opportune at AV valve replacement, whereas widening could be performed when the OT is intrinsically stenotic. When one fully appreciates the concept of a five-leaflet common valve, it is clear that the length of the OT depends on the extent of adherence between the superior bridging leaflet and the septal crest. In hearts that have two separate AV valve orifices, the OT is fully developed; there is no potential for interventricular shunting ("ostium primum defect"), because the superior bridging leaflet is always tightly adherent to the septal crest. AV valve replacement in these cases is especially hazardous. Resection of the atrial fold (i.e., the posterior wall of the OT) might well be a solution to this problem.




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