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Ann Thorac Surg 1997;64:508-510
© 1997 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Patch Augmentation of Regurgitant Common Atrioventricular Valve in Univentricular Physiology

Department of Cardiac Surgery, Herzzentrum, University of Leipzig, Leipzig, Germany

Accepted for publication January 28, 1997.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Regurgitation of the common atrioventricular valve in patients with univentricular atrioventricular connection has a negative impact on outcome in the Fontan operation. Because severe regurgitation of the common atrioventricular valve may not be sufficiently reduced by a volume-reducing operation alone, the addition of a valvuloplasty may be a necessary adjunct to achieve competence of the common atrioventricular valve. A modified technique of valvuloplasty of the common atrioventricular valve and its medium-term results are presented.

Methods. Two infants and 1 young child with isomeric right atrial appendages, complete atrioventricular canal, univentricular atrioventricular connection with a double-inlet right ventricle through a common atrioventricular valve, pulmonary atresia (n = 2) or pulmonary stenosis (n = 1), and bilateral superior venae cavae presented with marked dilatation of the annulus of the common atrioventricular valve and severe regurgitation between the bridging leaflets. All 3 patients previously had been palliated with a generous central aortopulmonary shunt. The repair technique consisted of patch augmentation of the central bridging leaflets with an autologous pericardial patch. In addition, bilateral bidirectional cavopulmonary anastomoses were constructed and additional sources of pulmonary blood flow were eliminated.

Results. Intraoperative echocardiography demonstrated competence of the large central leaflet, excellent coaptation between the central leaflet and the bilateral mural leaflets, and decrease of the anteroposterior diameter of the annulus of the atrioventricular valve from 24, 29, and 34 mm preoperatively to 20, 23, and 29 mm, respectively. In all 3 patients, echocardiographic follow-up at 17, 14, and 6 months showed continued competence of the atrioventricular valve.

Conclusions. Pericardial patch augmentation of the bridging leaflets may be a valuable adjunctive technique in the reconstruction of the regurgitant common atrioventricular valve in hearts with univentricular atrioventricular connection, especially if a volume-reducing operation alone does not result in competence of the valve.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Hearts with isomeric atrial appendages, especially if morphologically right, are likely to have a univentricular atrioventricular (AV) connection through a common AV valve. Particularly if there is a large volume load on the ventricle, there may be progressive regurgitation of the AV valve secondary to ventricular and annular dilatation, and the intrinsic abnormalities of this valve. Regurgitation of the common AV valve is known to have a negative impact on outcome in the Fontan operation [1]. Concern about residual regurgitation of the common AV valve after a volume-reducing operation alone and the poor results of valve replacement in this setting have stimulated our interest in further modification of valvuloplasty techniques.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Three patients (aged 4, 9, and 15 months) with isomeric right atrial appendages, a complete AV canal, a double-inlet right ventricle through a common AV valve with a rudimentary and incomplete left ventricle, pulmonary atresia (n = 2) or pulmonary stenosis (n = 1), a total anomalous pulmonary venous connection (n = 1), and bilateral superior venae cavae were referred to our institution for surgical treatment. All 3 patients, at other institutions, had undergone previous palliation with a 4-mm (n = 2) or 5-mm (n = 1) central aortopulmonary shunt. Clinically, the patients had symptoms of moderate to severe congestive heart failure, hepatic congestion, and varying degrees of ascites. Two patients had free-floating bridging leaflets (Fig 1A) and in the third patient, the left lateral segment of the superior leaflet was displaced inferiorly with its chordae tendineae straddling into the right ventricle and also attaching to the deeply "scooped out" and extremely leftward located ventricular crest (Fig 1B). Echocardiography demonstrated, secondary to the chronic volume overload, extreme dilatation of the annulus of the common AV valve with resultant failure of coaptation of the central bridging leaflets; in the patient with inferior displacement of the superior bridging leaflet, there was additional regurgitation between the superior bridging leaflet and the superior aspect of the left mural leaflet.

View larger version (49K): [in this window] [in a new window]   Fig 1. . Common atrioventricular valve in a heart with isomeric right atrial appendages, a double-inlet right ventricle, and a rudimentary left ventricle. Dilatation of the annulus results in marginal or absent coaptation of the bridging leaflets, especially in the central area. (A) Free-floating superior and inferior bridging leaflets. (B) Inferior displacement of the left lateral segment of the superior leaflet due to straddling of the chordae tendineae into the right ventricle and attachment of the chordae to the ventricular crest. The left mural leaflet is retracted to expose the extremely leftward located ventricular crest.

A large autologous pericardial patch was harvested, cardiopulmonary bypass was instituted, and the aortopulmonary shunt was doubly ligated and divided. The common AV valve was exposed through a right-sided atriotomy after cross-clamping of the aorta and administration of cardioplegic solution into the aortic root. In the two patients with free-floating bridging leaflets, the lateral edges of the superior and inferior bridging leaflets were sutured together with two interrupted 6-0 polypropylene sutures (Prolene; Ethicon, Inc, Somerville, NJ). Direct suturing of the central segment of the bridging leaflets would have resulted in undue tension; therefore, an untreated pericardial patch was fashioned to the size and configuration of the tissue deficiency between the bridging leaflets and subsequently sutured to their free edges with a continuous suture technique (Fig 2A). In one patient, an additional single-stitch plasty of the left inferoposterior commissure was added. In the patient with inferior displacement of the superior leaflet, the chordae to the ventricular crest were divided, the free margins of the left lateral segment of the superior leaflet and the superior segment of the left mural leaflet were partially sutured together, and the central segments of the bridging leaflets were augmented with an elliptical pericardial patch (Fig 2B). In all 3 patients, injection of saline solution into the dominant right ventricle after completion of the valve reconstruction demonstrated competence of the central leaflet and excellent coaptation between the central leaflet and the bilateral mural leaflets. Subsequently, after closure of the atriotomy, removal of air from the heart, and removal of the aortic cross-clamp, bidirectional cavopulmonary anastomoses were constructed bilaterally with the heart beating. In the patient with pulmonary stenosis, the pulmonary artery was divided and both ends, including the pulmonary valve, were oversewn.

View larger version (42K): [in this window] [in a new window]   Fig 2. . Technique of pericardial patch augmentation of a common atrioventricular valve in a heart with a univentricular atrioventricular connection. (A) The lateral free edges of the bridging leaflets are sutured together, an untreated pericardial patch is tailored to the size and configuration of the central defect, and the patch is sutured to the free edges of the superior and inferior leaflets. (B) In the presence of chordal attachments of the superior bridging leaflet to the ventricular crest, the chordae are detached from the ventricular crest, and the free edges of the left lateral segment of the superior leaflet and the superior segment of the left mural leaflet are (partially) sutured together. The defect between the superior and inferior leaflets is closed with the pericardial patch.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
In approximately 75% of hearts with isomeric right atrial appendages, there is a univentricular AV connection with either a common AV valve or two separate AV valves entering the dominant ventricle [2]. In the presence of a common AV valve in this anatomic setting, its annular attachment is almost always nonplanar [3]. In the heart with a univentricular AV connection and a common AV valve, unloading of the ventricle through the cumulative reduction of the volume load, achieved by the creation of a bidirectional cavopulmonary anastomosis and division of the main pulmonary artery, by the ligation of an aortopulmonary shunt, or by both techniques, results in a reduction in the ventricular end-diastolic diameter and the diameter of the annulus of the common AV valve [4], potentially increasing the zone of coaptation between the bridging leaflets and between the bridging leaflets and the mural leaflets. In the presence of mild to moderate regurgitation of the common AV valve associated with ventricular volume overload, volume reduction may sufficiently enlarge the zone of coaptation between the leaflets. If there is severe regurgitation of the common AV valve in the setting of ventricular volume overload, the effect of volume unloading on the competence of the common AV valve is difficult to predict. In our limited experience, in such a circumstance, satisfactory function of the common AV valve may not be achieved with volume reduction alone. In this setting, the addition of a valvuloplasty of the common AV valve may be the best option, all the more because replacement of the valve often is followed by severe ventricular dysfunction. In our experience, intraoperative echocardiography and synchronous measurement of the atrial pressure during temporary occlusion of the aortopulmonary shunt provide useful data regarding the severity and hemodynamic relevance of the AV valve regurgitation. Subsequent intraoperative assessment of the anatomy of the common AV valve further dictates the specific type of repair.

In the presence of a well-developed common AV valve with sufficient leaflet tissue, the superior and inferior bridging leaflets simply may be sutured together to obtain competence [5]. In the absence of sufficient AV valve tissue associated with annular dilatation, suturing of the superior leaflet to the inferior leaflet may lead to excessive tension on the central segment of the AV valve, with an inherent risk of dehiscence. In such a circumstance, in analogy to patch augmentation of the left or right AV valves in common atrioventricular canal [6, 7], the technique of patch augmentation of the central segments of the bridging leaflets as reported here is a useful adjunct for reconstruction of the AV valve. It is important to use an untreated pericardial patch as opposed to a glutaraldehyde-preserved pericardial patch, because an untreated patch is more mobile and pliable. A second benefit of this technique is that a maximal diameter of the central component of the AV valve is maintained or obtained, leaving or creating more surface for coaptation with the bilateral mural leaflets. Performance of the valvuloplasty as reported here also clarifies the location of residual regurgitation at one or more commissures, if present. An additional Kay-Reed annuloplasty may be necessary to achieve competence of the commissures. In general, we do not favor a DeVega type of annuloplasty or the use of an annuloplasty ring in young patients because of its potential negative influence on growth of the AV annulus [8]. In addition, the latter procedures carry an increased risk of conduction disturbance by surgical stitches because in the heart with a univentricular AV connection and right ventricular morphology, the AV node is located near the cardiac crux, rarely at the anterior portion of the AV annulus [9]. In all 3 patients in this series, an extensive annuloplasty was avoided and we were able to demonstrate growth of the AV annulus.

As illustrated by the 3 patients in this report, in ductus-dependent univentricular physiology, construction of a generous aortopulmonary shunt, particularly if placed centrally, leads to volume overload of the ventricle with a high likelihood of the development of AV valve regurgitation. To avoid this complication, we believe that it is preferable to construct a 3.5- or 3-mm (in neonates with a body weight of less than 3 kg) modified Blalock-Taussig shunt. Normalization of the pulmonary vascular resistance after the fourth week of life subsequently allows early construction of a bidirectional cavopulmonary anastomosis and division of the modified Blalock-Taussig shunt. In non–ductus-dependent physiology, we attempt to treat the neonate medically until primary construction of a bidirectional cavopulmonary anastomosis becomes feasible. In both physiologic settings, the drastic reduction of the volume work of the ventricle and the remodeling of the ventricular geometry achieved by the construction of a bidirectional cavopulmonary anastomosis at an early age prevents the deterioration of ventricular function and its detrimental sequelae, such as AV valve regurgitation and subaortic obstruction [10].

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr van Son, Herzzentrum, University of Leipzig, Russenstrasse 19, D-04289, Leipzig, Germany.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Driscoll DJ, Offord KP, Feldt RH, Schaff HV, Puga FJ, Danielson GK. Five- to fifteen-year follow-up after Fontan operation. Circulation 1992;85:469–96.[Abstract/Free Full Text]
2. Sapire DW, Ho SY, Anderson RH, Rigby ML. Diagnosis and significance of atrial isomerism. Am J Cardiol 1986;58:342–6.[Medline]
3. Uemura H, Ho SY, Anderson RH, Kilpatrick LL, Yagihara T, Yamashita K. The nature of the annular attachment of a common atrioventricular valve in hearts with isomeric atrial appendages. Eur J Cardiothorac Surg 1996;10:540–5.[Abstract/Free Full Text]
4. Van Son JAM, Falk V, Walther T, et al. Instantaneous subaortic outflow obstruction after volume reduction in hearts with univentricular atrioventricular connection and discordant ventriculoarterial connection. Mayo Clin Proc 1997;72:309–14.[Abstract/Free Full Text]
5. Tatsuno K, Suzuki K, Kikuchi T, Takahashi Y, Murakami Y, Mori K. Valvuloplasty for common atrioventricular valve regurgitation in cyanotic heart diseases. Ann Thorac Surg 1994;58:154–7.[Abstract/Free Full Text]
6. Van Son JAM, Van Praagh R, Falk V, Mohr FW. Pericardial patch augmentation of the tissue-deficient mitral valve in common atrioventricular canal. J Thorac Cardiovasc Surg 1996;112:1117–9.[Free Full Text]
7. Falk V, van Son JAM, Mohr FW. Pericardial patch augmentation of right atrioventricular valve in atrioventricular canal. Ann Thorac Surg 1996;62:288–90.[Abstract/Free Full Text]
8. Okita Y, Miki S, Kusuhara K, et al. Annuloplastic reconstruction for common atrioventricular valvular regurgitation in right isomerism. Ann Thorac Surg 1989;47:302–4.[Abstract/Free Full Text]
9. Dickinson DF, Wilkinson JL, Anderson KR, Smith A, Ho SY, Anderson RH. The cardiac conduction system in situs ambiguus. Circulation 1979;59:879–85.[Abstract/Free Full Text]
10. Chin AJ, Franklin WH, Andrews BAA, Norwood WI. Changes in early geometry after Fontan operation. Ann Thorac Surg 1993;56:1359–65.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jacques A. M. van Son Thomas Walther Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by van Son, J. A. M. Articles by Mohr, F. W. Search for Related Content PubMed PubMed Citation Articles by van Son, J. A. M. Articles by Mohr, F. W.