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Ann Thorac Surg 1996;62:626-628
© 1996 The Society of Thoracic Surgeons
Departments of Cardiothoracic PPediatri Cardiology, Beilinson Medical Center, Petach Tikva 49100, Israel
To the Editor:
We read with great interest Zhou and colleagues' article entitled "Unidirectional Valve Patch for Repair of Cardiac Septal Defect With Pulmonary Hypertension" [1]. We congratulate the authors on their excellent results in this group of patients who present a particular challenge to every surgical team.
We would, however, like to remark on the omission of any reference to our work entitled "A One-Way, Valved, Atrial Septal Patch in the Management of Postoperative Right Heart Failure," which has been presented at several international scientific gatherings since 1989, including the Third World Cardiology Congress of Pediatric Cardiology held in Bangkok, Thailand in 1989 and in The Journal of Thoracic and Cardiovascular Surgery [2–4]. Furthermore, Dr David A. Fullerton, in his invited commentary, described Dr Zhou and colleagues' work as "...a very innovative technique," which is incorrect.
Our device (Fig 1
) is fashioned in two layers, one of polytetrafluoroethylene cardiovascular patch and the other of woven Dacron. A central opening, 3 to 4 mm in diameter, is created in the polytetrafluoroethylene layer and covered by a second, smaller layer of woven Dacron ("curtain"), which is sutured to the polytetrafluoroethylene along one side only. This creates a simple, one-way valve. The device is sutured to the interatrial septum through the right atrium so that the curtain is facing the left atrium and closes toward the right atrium.
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Group B consisted of 6 patients, aged 2 to 59 years, with high pulmonary vascular resistance due to a large right-to-left shunt from an atrial or ventricular septal defect. In this group of patients, we agree with Dr Fullerton's comment that the degree of reversibility of the pulmonary vascular disease should be evaluated according to the pulmonary vascular resistance and not pulmonary vascular pressure to estimate the operative risk for a complete repair using the usual methods employed during cardiac catheterization [7]. During correction of the congenital malformation, the one-way, valved, septal atrial patch always was used in the interatrial septum. Right-to-left interatrial shunting was documented in all patients immediately on weaning from cardiopulmonary bypass. In all patients but 1, the device closed spontaneously during the first postoperative week (1 to 6 days). In 1 patient, a 23-year-old woman who had a large perimembranous ventricular septal defect with a fixed pulmonary vascular resistance of 7.1 U/m2, a progressive decrease in pulmonary artery pressure occurred over the first 8 postoperative months, with a significant improvement in right ventricular function. This led to a spontaneous closure of the device 8 months postoperatively. In addition, her general condition improved and she is now in New York Heart Association functional class I.
Group C consisted of patients with intraoperative acute right heart failure after complete repair of a congenital malformation. The right heart failure was resistant to maximal pharmacologic treatment, and the device was implanted as a last resort and only after repeated failures to wean them from cardiopulmonary bypass. In no patient in this group was there any morbidity that could be ascribed to the use of the one-way, valved, septal atrial patch. On discharge, all patients received aspirin as prophylaxis against thrombus formation on the device and subacute bacterial endocarditis prophylaxis. During the follow-up period, no thrombus formation or subacute bacterial endocarditis was documented.
Four weeks ago, a one-way, valved, septal ventricular patch was used at the level of the interventricular septum in a 3
-year-old boy with tetralogy of Fallot and pulmonary atresia. The child had undergone three operations for left and right unifocalization through a bilateral thoracotomy, and was now being hospitalized for the final-stage operation. In this operation, the right and left sacks were connected using a 14-mm polytetrafluoroethylene tube and then connected to the right ventricle with a 19-mm pulmonary homograft. The ventricular septal defect was then closed with a one-way patch with the curtain facing toward the left ventricle. The curtain was kept in its closed position with three parallel side stitches. During the first 6 postoperative days, right-to-left interventricular shunting was documented, but not thereafter. In this instance, the one-way patch decompressed the failing right ventricle at the level of the ventricles and closed spontaneously when right ventricular pressure decreased. The curtain was sutured in such a way as to prevent it from becoming entrapped in the open position in the left ventricular cavity.
Based on our clinical experience, we believe that when indicated the use of the one-way, valved, atrial septal patch as part of the surgical repair may, in many cases, prevent postoperative right heart failure, ease the early postoperative course, and further improve operative results.
References
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