Ann Thorac Surg 1996;61:1005-1006
© 1996 The Society of Thoracic Surgeons
Case Report
Pulmonary Autograft in Ventricular Septal Defect–Aortic Insufficiency Complex
Paul H. Schoof, MD,
Mark G. Hazekamp, MD,
Hans A. Huysmans, MD, PhD
Department of Cardiac Surgery, University Hospital Leiden, Leiden, the Netherlands
Accepted for publication September 13, 1995.
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Abstract
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Pulmonary autograft aortic root replacement in a child with the ventricular septal defect–aortic insufficiency complex is described. It offers all the advantages of the autograft, avoids closure of the ventricular septal defect, and prevents the use of prosthetic material.
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Introduction
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The association of doubly committed subarterial ventricular septal defect (VSD) and aortic valve incompetence (AI) is a well-known complex [1]. The valve incompetence in this syndrome does not usually appear until 2 to 5 years of age and should preferably be prevented by timely closure of the VSD. Once it appears, it gradually increases to severe within 10 years of age, and an aortic valve operation may become necessary [2, 3]. Closing the VSD is generally efficacious for first-grade AI [4] but when the AI is more than trivial, the aortic valve is repaired as well, for example by leaflet plication [5]. If valve replacement is required, however, prosthetic valve insertion is an unattractive possibility in the generally young patient population as is subcoronary implantation of a homograft in the often distorted aortic root in this syndrome. A patient is described in whom closure of the VSD could be avoided by replacing the aortic root with the pulmonary autograft.
A 9-year-old boy with slight dyspnea on exertion showed severe AI and a doubly committed subarterial VSD on echocardiography with significant prolapse of the right coronary cusp through the VSD into the right ventricular outflow tract. Besides dilatation of the left ventricle, a normal shortening fraction and a normal right ventricular pressure were found. We decided to perform closure of the VSD and aortic valve reconstruction.
At operation a normal ascending aorta was found. On cardiopulmonary bypass with moderate hypothermia and cold crystalloid retrograde cardioplegic arrest, the aortic valve was inspected and shown to be tricuspid with dilatation at annular level. The left and noncoronary cusps were slightly thickened. Considerable prolapse and enlargement of the right coronary cusp and an aneurysmatic sinus of Valsalva were found. The VSD was doubly committed subarterial immediately below the right coronary cusp.
The right coronary cusp was plicated at both commissures, resulting in large lumps of tissue causing improper leaflet coaptation and leaving an important aortic root distortion unattended. Therefore we decided on replacement of the valve and root with a pulmonary autograft with reimplantation of the coronary arteries and orthotopic implantation of a 23-mm cryopreserved pulmonary homograft in the right ventricular outflow tract (Ross operation).
The proximal anastomosis of the pulmonary autograft on the left ventricle could easily be established by continuing the running suture over the crest of the VSD without distorting the autograft and avoiding closure of the VSD with a patch (Fig 1
). After bypass was discontinued, epicardial echocardiography did not show aortic regurgitation, a residual VSD, or any significant gradient across the left ventricular outflow tract. The postoperative course was uneventful. The patient was returned to the ward on the second day and discharged from the hospital on the tenth postoperative day.
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Comment
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Many different surgical approaches have been advocated to treat AI in the VSD-AI complex [6–9]. They are all aimed at saving the aortic valve by several techniques of aortic valve repair. If the AI is associated with structural defects at the commissures, failures are reported to be more frequent [6]. For these patients, together with other children with more complex valve abnormalities, primary aortic valve or root replacement may be indicated. The Ross operation can be an attractive alternative in that case. The advantages of a living autologous valve substitute with growth possibility and without long-term structural failure are particularly valuable in children [10].
In the VSD-AI complex, the VSD, by nature, is commonly located immediately below some part of the right coronary leaflet of the aortic valve. Excision of the aortic root causes the inferior rim of the VSD to become part of the ring of left ventricular outflow tract, whereupon the pulmonary autograft can be anastomosed. This can be accomplished without distortion of the autograft and avoiding VSD closure with a patch or use of intravalvular pledgets for patch fixation. The omission of prosthetic material may be of particular value in patients with bacterial endocarditis in this syndrome. Postoperative recurrence of bacterial endocarditis, which is a well-known cause of surgical failures in aortic valve repair, may thus be prevented [6].
Pulmonary autograft aortic root replacement can be an attractive alternative in the VSD-AI complex when aortic valve replacement is necessary.
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Acknowledgments
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We thank Bas Blankevoort for illustrations.
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Footnotes
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Address reprint requests to Dr Schoof, Department of Cardiac Surgery, University Hospital Leiden, Rijnsburgerweg 10, 2300 RC Leiden, the Netherlands.
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References
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- Van Praagh R, McNamara JJ. Anatomic types of ventricular septal defect with aortic insufficiency: diagnostic and surgical considerations. Am Heart J 1968;75:604–19.[Medline]
- Ishikawa S, Morishita Y, Sato Y, Yoshida I, Otaki A, Otani Y. Frequency and operative correction of aortic insufficiency associated with ventricular septal defect. Ann Thorac Surg 1994;57:996–8.[Abstract]
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Abstract
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