Ann Thorac Surg 1996;61:854-860
© 1996 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Intraoperative TEE Assessment of Ventricular Septal Defect With Aortic Regurgitation
Maurice P. Leung, MD,
Kai-tung Chau, MBBS,
Clement Chiu, MBBS,
Tak-cheung Yung, MBBS,
Che-keung Mok, MBBS
Departments of Paediatrics and Surgery, Cardiological Division, Grantham Hospital, University of Hong Kong, Aberdeen, Hong Kong
Accepted for publication November 8, 1995.
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Abstract
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Background. It is desirable to repair but not replace the aortic valve in patients with ventricular septal defect and acquired aortic regurgitation. Precise definition of the valvar pathology with monitoring of its repair perioperatively would enhance the surgical management of this condition.
Methods. Fourteen consecutive patients (age, 10.6 ± 6 years; weight, 29.7 ± 5.7 kg) who underwent repair of ventricular septal defect with aortic regurgitation were studied by intraoperative transesophageal echocardiography. The severity of prolapse of each of the individual aortic cusps and its adjacent sinus was assessed and the valvar regurgitation quantified by Doppler-derived regurgitant indices. The echocardiographic and surgical findings were correlated and the preoperative and postoperative echocardiographic data were compared to assess the effectiveness of operation.
Results. Eight subarterial and six perimembranous defects were located accurately and their sizes (11.8 ± 3.0 mm) correlated well (r = 0.80) with the surgical measurements. Transesophageal echocardiography detected prolapse of the aortic valve and its sinus in all 14 patients. The severity of prolapse was severe in 10, moderate in 4, and mild in 5 leaflets. On the basis of these findings, together with the Doppler-derived mean regurgitant indices, exploration of the valve and valvuloplasty were executed appropriately in 12 of 14 patients. In all 14 patients, transesophageal echocardiography after bypass revealed no further cuspal prolapse and significant reduction of the mean regurgitant index (0.55 ± 0.23 to 0.17 ± 0.15, p < 0.0001). Residual ventricular septal defect was detected in 5 patients and the only patient with significant shunting who required reexploration was identified correctly.
Conclusions. Intraoperative transesophageal echocardiography can assess effectively the surgical repair of ventricular septal defect with aortic regurgitation and provide information that directs and alters surgical plans to the benefit of patients.
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Introduction
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Aortic regurgitation is a rare but important complication of ventricular septal defect. The valvar involvement often progresses and requires operation [1, 2]. The optimal surgical intervention aims at reducing the valvar leakage and preserving the native aortic valve. It has been reported that success of valvuloplasty was highest when the cuspal prolapse was a prominent part of the valve abnormality [3]. Hence, precise definition of the valvar pathology in relation to the septal defect and perioperative monitoring of the repair should greatly facilitate the management for this group of patients. Transesophageal echocardiography appears to offer such a dual benefit. The investigation has been shown to be of great value in assessing valvar diseases of the left heart in adults and children [4, 5]. In this study, we evaluate the role of transesophageal echocardiography in the management of patients who underwent repair of ventricular septal defect with aortic regurgitation.
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Material and Methods
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Between November 1992 and November 1994, 14 consecutive patients who underwent repair of a ventricular septal defect with aortic regurgitation were included. Their ages ranged from 2.3 to 21 years (mean, 10.6 ± 6 years) with a body weight ranging between 10 and 56 kg (29.7 ± 15.7 kg). The indications for operation were either a pulmonary-to-systemic blood flow value of 2:1 or more and/or significant aortic regurgitation of 2 or more on a four-point scale as documented by aortography. Preoperative clinical variables including pulse pressure, presence and grading of aortic regurgitation murmur, cardiothoracic ratio on chest radiography, and electrocardiographic evidence of left ventricular hypertrophy were documented. Transthoracic echocardiography was performed to locate the position of the septal defect [6] and to measure the left ventricular end-diastolic dimension and fractional shortening. Aortogram was used to assess the severity of the aortic regurgitation using a four-point scale [7].
Transesophageal Assessment on Morphology and Hemodynamics
Intraoperative transesophageal echocardiography was performed using an adult-sized biplane 5-MHz transducer fitted onto a Hewlett Packard Sono 1000 or 1500 model. The presence of aortic valvar prolapse and regurgitation and their relation to the ventricular septal defect were assessed by the five-chamber and short axis views of the aortic root (horizontal plane), and the ventricular outflow tract cuts (vertical plane) [5, 8]. Cineloops with frame-to-frame analysis was used for the evaluation. Optimal imaging was obtained by advancement and rotation but without any angulation of the transducer. Throughout the study, color flow gain was set and maintained at immediately below the level where artifacts appeared. All images were recorded on videotapes for both on and off-line analysis. The size and position of the septal defect was examined independent of the transthoracic approach. Prolapse of specific aortic cusps was graded on a three-point scale [9, 10] (Fig 1
): mild (buckling of aortic cusp down the left ventricular outflow tract with minimal herniation into the ventricular septal defect); moderate (prolapse of cusp with obvious herniation of it and its sinus into septal defect); and severe (prolapse of cusp and its sinus through the defect into the right ventricular outflow tract). Using the five-chamber (horizontal plane) and ventricular outflow tract (vertical plane) cuts, a regurgitant index was derived from the ratio of the maximal diameters of the regurgitant jet (mosaic color pattern) and the left ventricular outflow tract immediately below the aortic valve [11, 12] (Figs 1G,H and 2C). The regurgitant index from each echocardiographic plane and their mean value (mean regurgitant index) were derived independent of but subsequently related to the assessment of regurgitation by aortogram. Preliminary decision on exploration with or without plication of the aortic valve was based on the findings of grade II or more cuspal prolapse and/or moderate aortic regurgitation translated as a mean regurgitant index of 0.35 or more. The latter arbitrary cut-off was derived from data reported by Perry and colleagues [12]. The study after bypass was performed after readjustment of the central venous and systemic arterial pressure to the before bypass values. The effectiveness of the surgical procedure was assessed in terms of (1) any residual shunting through the repaired defect, (2) residual prolapse of the aortic cusp with its sinus, and (3) severity of the residual valvar regurgitation as assessed by the regurgitant index.
Operation
Transatrial and transpulmonary approaches were used to locate the site of the perimembranous and subarterial defects, respectively. Visualizing through the defect, cold cardioplegia was perfused into the coronary arterial sinus to facilitate identification of any cuspal prolapse. The severity of prolapse was graded using similar guidelines set for echocardiograms. Patients selected for aortic valve exploration had a transverse aortotomy and the valve was further inspected for redundancy, cuspal, and commissural abnormalities. This information was related to the transesophageal echocardiographic findings. On the basis of the surgical anatomy and imaging results, definitive valvuloplasty was executed if the cuspal prolapse and regurgitation were moderate to severe in intensity (grade II or more). A stay suture was placed in the corpus Arantii of the normal leaflets and the center of the prolapsed leaflet. Excessive valve tissue was plicated and sutured with pledgets to the commissural margins close to the aortic wall [13]. The ventricular septal defect was closed with a prosthetic patch.
Follow-up Studies
The patients were followed up and the clinical and transthoracic echocardiographic variables were recorded at the latest outpatient appointment.
Statistics
Pre- and postoperative parametric and nonparametric data were compared using paired Student's t test, 
2 and sign rank tests where appropriate. Statistical significance was assumed at the 5% level. The sizes of the defects as detected by transesophageal echocardiography and operation were related using simple correlation coefficient. Using the surgical findings as the standard, the sensitivity of transesophageal echocardiography in detecting normal and abnormal aortic cusp, and the specific cuspal involvement were calculated as (No. of normal and abnormal aortic cusps accurately detected by transesophageal echocardiography)/(No. of normal and abnormal aortic cusps found at operation) and (No. of specific cusp involvement accurately detected by transesophageal echocardiography)/(No. of abnormal cusps found at operation), respectively.
The severity of aortic regurgitation as assessed by aortogram and the Doppler-derived regurgitant indices were related using the Spearman rank correlation coefficient.
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Results
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Transesophageal Echocardiographic Assessment
The eight subarterial and six perimembranous defects were all located accurately and their sizes correlated well with the surgical measurements (r = 0.80) (Table 1)tab 1. All 14 patients had varying severity of aortic cusp prolapse, 9 had involvement of single, and 5 of double leaflets. The severity of prolapse was graded as severe (grade III) in 10, moderate (grade II) in 4, and mild (grade I) in 5 leaflets (Table 2)tab 2. All except 2 patients (with grade I cuspal prolapse and a mean regurgitation index of less than 0.35) underwent concomitant aortic valvuloplasty. The sensitivity of detecting normal and abnormal aortic cusp, and identifying the specific cuspal involvement were 98% and 95%, respectively (Table 1).
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Table 2. . Transesophageal Echocardiographic Assessment on the Ventricular Septal Defect and the Aortic Cusps Involvement, Severity of Cuspal Prolapse, and Valvar Regurgitation Index
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Subarterial defects, together with the right and left aortic cusps, were best identified in the ventricular outflow tract cut (vertical plane). This defect tended to be associated with prolapse of the right aortic leaflet. Six of the 8 patients with a subarterial defect had severe prolapse (Table 2
) of the right aortic leaflet and its sinus. In all patients, the defect was partly or completely obliterated by the prolapsed valve and its sinus at systole. During diastole, the herniated leaflet sagged onto the crest of the ventricular septum, producing incomplete valvar coaptation and severe regurgitation. On the other hand, the noncoronary leaflet normally would not show up in this echocardiographic plane. Prolapse of it down the left ventricular outflow tract resulted in it being imaged beyond the lower margin of the right aortic leaflet. With horizontal planar echocardiogram at the aortic root, the prolapsed aortic leaflet that herniated into the septal defect could also be imaged. The sinus of the involved leaflets were often enlarged.
Perimembranous defects tended to be associated with prolapse of the noncoronary cusp and were best visualized by the five-chamber view (horizontal plane). Again the enlarged sinus would give a clue to the presence of moderate to severe prolapsing cusp. Further down the left ventricular outflow, any regurgitation jet could be detected and its origin traced to the specific aortic leaflet accountable for the valvar incompetence (Fig 2A,B). The regurgitant index (horizontal plane) could also be mapped out from the color Doppler flow (Fig 2C). Herniation of the prolapsed noncoronary cusp (with or without involvement of the right coronary leaflet) into the right ventricular outflow tract was best visualized by the ventricular outflow tract cuts (vertical plane). Three of the 6 patients with this defect had severe prolapse of the noncoronary cusp, whereas 1 patient had severe and moderate prolapse of both the right and noncoronary cusp, respectively (Fig 3). Their respective sinuses were similarly involved.
Transesophageal echocardiographic assessment after bypass revealed residual ventricular septal defect in 5 patients (4 of subarterial, 1 of perimembranous). In 1 patient with significant shunting, cardiopulmonary bypass was reinstituted and the loosened stitches of the repair were tightened, leaving no further residual shunting. The other 4 patients were judged to have only a small shunt by echocardiography and required no intervention. In all 14 patients, after closure of their defects with or without aortic valvuloplasty, no further cuspal prolapse was detected (Fig 4). Their adjacent sinuses were prevented from herniating through the defect by the Dacron patch. The preoperative mean regurgitant indices were also significantly reduced after operation (p < 0.0001) (Table 2). These preoperative regurgitant indices (vertical plane and the mean between vertical and horizontal plane) correlated well with the assessment of valvar regurgitation by aortogram (r = 0.85, 0.79). Postoperatively, no or trivial regurgitation was detected in 8 patients (mean regurgitant indices, less than 0.20), whereas the other 6 patients had residual aortic regurgitation judged to be of mild to moderate degree (mean regurgitant indices ranged between 0.20 and 0.43). The valvuloplasty in these latter 6 patients were accepted as none had further cuspal prolapse. The 2 patients who had simple closure of their defects had no or only trivial residual aortic regurgitation.
Follow-up
The mean follow-up period was 13.3 ± 3.5 months. There was statistically significant reduction in the intensity of the diastolic murmur, pulse pressure, cardiothoracic ratio on chest radiography, left ventricular hypertrophy on electrocardiogram, and echocardiographic left ventricular end-diastolic dimension and fractional shortening after operation (Table 3)tab 3.
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Comment
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Intraoperative transesophageal echocardiography has been recognized as a useful investigatory tool to provide important surgical information, directing corrective operation, and assessing immediate surgical results [14, 15]. Its utility in surgical correction of congenital heart diseases has also been reported. In this study, we evaluated the role of transesophageal echocardiography in the surgical repair of ventricular septal defect with aortic regurgitation. Because of the small number of patients involved, we did not attempt to compare the efficacy of transesophageal over that of transthoracic echocardiography. Nevertheless, the superior images of transesophageal echocardiography allowed precise location and sizing of the ventricular septal defects. Cineloop with frame to frame analysis facilitated clear definition of any prolapsed leaflet with its adjacent sinus herniating through and partly obstructing the defect. Underestimating the size of the defect could then be avoided. Color Doppler mapping further detected and clearly related any aortic regurgitation to the incomplete valvar coaptation, which in turn was secondary to the prolapsed cusps herniating through the septal defect. Real-time detailing of the disturbed physiology and demonstration of the involvement of the leaflet and its adjacent sinus in the prolapsing process concorded with the pathology described in studies from Japan [16–18]. This would lend support to early closure of ventricular septal defect, especially subarterial defects, associated with secondary aortic valve involvement. Moreover, accurate assessment of the severity of the prolapsed leaflet and quantifying the aortic regurgitation by the Doppler derived index, allowed our surgeons to explore and execute valvuloplasty appropriately. At operation, the surgical anatomy related well with the echocardiographic findings. By maintaining the settings of the Doppler gain on the ultrasonic machine, the venous filling pressure, and the heart rate of the patient before and after bypass, any reduction in the regurgitant indices reflected the success of aortic valvuloplasty. Our follow-up data, both clinical and transthoracic echocardiographic findings, further attested to the optimal surgical repair of the valves and defects. On the other hand, unnecessary valvuloplasty was avoided in 2 patients when the echocardiographic and Doppler-derived indices showed mild aortic prolapse and regurgitation, respectively. In addition, shunting through a residual ventricular septal defect was also detected intraoperatively. Therefore, transesophageal echocardiography provided immediate assessment of the surgical results before the decision of discontinuing cardiopulmonary bypass. The investigation benefited one of our patients as the detected significant shunt through a residual ventricular septal defect was abolished by tightening the stitches of the patch repair. Reexploration for minor residual shunting was spared in 4 other patients.
In conclusion, intraoperative transesophageal echocardiography is a valuable tool for precise assessment before and after bypass of surgical repair of ventricular septal defects with aortic regurgitation. It can provide information that directs and alters surgical plans to the benefit of patients. The regurgitant index, derived from color Doppler flow mapping, can serve as a semiquantitative index for the surgical outcome of aortic valvuloplasty.
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Acknowledgments
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This project is supported by the University and Polytechnic Grants Committee, Hong Kong Heart Foundation and the Paediatric Cardiac Fund of the Grantham Hospital.
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Footnotes
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Address reprint requests to Dr Leung, Department of Paediatrics, Grantham Hospital, 125 Wong Chuk Hang Rd, Aberdeen, Hong Kong.
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References
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Abstract
Introduction
