Ann Thorac Surg 1997;63:1803-1804
© 1997 The Society of Thoracic Surgeons
How To Do It
Alternative Technique for the Ostium Primum Defect Repair: A Free Wall Flap of Right Atrium
Massimo Massetti, MD,
Gerard Babatasi, MD,
Eugenio Neri, MD,
Andre Khayat, MD
Thoracic and Cardiovascular Surgery Department, Centre Hospitalier Universitaire, Caen, France
Accepted for publication December 26, 1996.
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Abstract
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An alternative surgical technique of repair of the ostium primum septal defect without the use of any patch is reported. The potential technical difficulties and surgical consideration are discussed.
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Introduction
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The ostium primum septal defect is commonly considered a complex type of atrioventricular defect and sometimes referred to as a partial form of atrioventricular canal [1, 2]. The defect is located in the inferior atrial septum and results from abnormal growth of the endocardial cushions [1]. Generally the distance between the crescentic atrial margin of the defect and the atrioventricular valves (and thus the dimension of the interatrial communication) is moderate in size. Associated minor anomalies involve the left ventricular chamber, the papillary muscles, and the mitral valve, which always shows a cleft of variable importance in the anterior leaflet with or without valvar regurgitation [2]. With regard to the operative management of this condition, although there has been controversy about whether to repair the valvular cleft, a consensus has been reached about the use of a patch in the closure of the septal defect [3]. A Dacron or pericardial patch is commonly employed [4]. According to the principle that, whenever it is possible, it is preferable to avoid the use of foreign materials in intracardiac reconstructions, we have performed ostium primum septal defect repair employing a rotational flap of free right atrial wall to close the septum.
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Technique
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The heart is usually approached through a median sternotomy; for cosmetic reasons, in some circumstances (isolated atrial septal defect in young female patients), a right anterolateral thoracotomy is preferred. The ascending aorta is cannulated in the usual manner; the venae cavae are cannulated through the atrial wall as close as possible to their origin. Special attention is paid to avoid damage to the sinoatrial region. After aortic cross-clamping, cardioplegic arrest of the heart is obtained by infusion of cold crystalloid cardioplegic solution into the aortic root and maintained by repeated infusions according to the myocardial temperature as measured by a probe. The free atrial wall is incised in a curved fashion to create an omega-shaped flap (parabolic flap). This flap has to be tailored in the central part of the right atrium; its attachment base must lie in the interatrial groove to allow the atrial flap to rotate freely so it can be sutured to the septum. The atriotomy edges are retracted with fine sutures. The presence and severity of mitral regurgitation are carefully assessed by forced injection of saline solution through the valve. The cleft on the anterior leaflet of the mitral valve is not repaired unless there is valvular incompetence; in this case the edges of the cleft are approximated with fine sutures of 6/0 or 7/0 polypropylene. When all the maneuvers to evaluate the adequacy of mitral valve repair have been completed, the atrial septal defect can be repaired.
A counterincision of the septum in the region of fossa ovale is made (Fig 1
) to mobilize the free edge of the ostium primum; in this way the septum can be lowered to the leaflet plane of the atrioventricular valve for repair of the primum defect (Fig 2). Continuous suture is performed with a double-armed 6/0 polypropylene suture. Every precaution should be taken to prevent any injury of the conduction tissue, suturing with superficial bites as far as possible from this sensitive region. The primum defect is now transformed to a secundum-type defect.
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Fig 1. . A septal incision, lateral to the fossa ovale, is performed to mobilize the free edge of the ostium primum (arrows) to the leaflet plane of the atrioventricular valves.
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Fig 2. . Once the ostium primum defect has been repaired, the atrial septal defect is transformed to an ostium secundum-type defect.
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The free wall of right atrium, tailored in an omega fashion, is then trimmed to the appropriate shape and size of the "neo-secundum defect," rotated to the plane of the septum, and sutured with a 5/0 polypropylene suture to close the defect (Fig 3). Usual deairing techniques are performed to avoid air trapping in the left atrium. Finally, closure of the right atrium is achieved by suturing, with two 4/0 polypropylene continuous sutures, the superior edge of the atriotomy to the inferior edge, which is constituted (laterally) by the native inferior edge and (in the center) by the bent base of the flap.
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Fig 3. . The ostium secundum defect is closed with a free wall flap of right atrium rotated (90 degrees) to the septal plane. The right atrium is then closed by suturing of the superior edge of the atriotomy to the base of the flap (interatrial groove).
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Comment
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The goals of ostium primum atrial septal defect surgery are closure of the atrial septal defect; maintenance or creation of two competent, nonstenotic atrioventricular valves; and avoidance of damage to the atrioventricular node and bundle of His. All the techniques, if properly used, appear to provide good results. This technique allows repair of the ostium primum atrial septal defect with the use of an autologous pedicled patch. The theoretic advantages consist of a lower risk of thromboembolic complications, a lower risk of endocarditis, and the reduction of the aortic cross-clamping time. An essential step of the proposed technique, inspired by the Senning operation, is the rotation (90 degrees) of a pedicled flap running from the free wall of the right atrium to the septum; the crucial aspect of this technique is the exact positioning of the first atrial incision. The closure of the free wall is performed without tension because of the great surface of the right atrium developed in consequence of the left-to-right shunt. This technique has been performed in 9 patients affected by partial atrioventricular canal defect and no complication related to the technique was observed. We think that this technique theoretically can be used in all types of atrial septal defect.
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Acknowledgments
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We acknowledge Dr Michel Iselin for his medical contribution to our work.
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Footnotes
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Address reprint requests to Dr Massetti, Thoracic and Cardiovascular Surgery Department, CHU, 14000 Caen, France.
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References
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- Baron MG. Abnormalities of the mitral valve in endocardial cushion defects. Circulation 1972;45:672–80.[Abstract/Free Full Text]
- Bharati S, Lev M, McAllister HA Jr, Kirklin JW. Surgical anatomy of the atrio-ventricular valve in the intermediate type of common atrioventricular orifice. J Thorac Cardiovasc Surg 1980;79:884–9.[Abstract]
- Gutgesel HP, Huhta JC. Cardiac septation in atrio-ventricular canal defect. J Am Coll Cardiol 1986;8:1421–5.[Abstract]
- Bailey SC, Watson DC. Atrio-ventricular septal defect repair in infants. Ann Thorac Surg 1991;52:33–7.[Abstract]
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