Ann Thorac Surg 1998;65:566
© 1998 The Society of Thoracic Surgeons
How to Do It
Leaflet’s Free Edge Suspension for Correction of Aortic Insufficiency Associated With Ventricular Septal Defect
Afksendiyos Kalangos, MD, PhD,
Maurice Beghetti, MD,
Nicolas Murith, MD,
Bernard Faidutti, MD
Clinic for Cardiovascular Surgery, University Cantonal Hospital of Geneva, Geneva, Switzerland
Clinic for Pediatric Cardiology, University Cantonal Hospital of Geneva, Geneva, Switzerland
Accepted for publication September 3, 1997.
Dr Kalangos, Clinic for Cardiovascular Surgery, University Cantonal Hospital of Geneva, 24, rue Micheli-du-Crest, 1211 Geneva 14, Switzerland.
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Abstract
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Aortic valve regurgitation in association with ventricular septal defect results from the mechanical effect of the ventricular septal defect, which primarily affects the free edge. The elongated free edge can be repaired by plicating it using several techniques designed to restore a normal geometry to the prolapsing aortic leaflet. We describe 4 cases in which aortic insufficiency was treated by a technique of plication that allows suspension of the free edge along a pericardial strip applied from one commissure to the other.
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Introduction
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Aortic insufficiency (AI) that develops in association with a ventricular septal defect (VSD) is usually caused by prolapse of the right coronary (RC) leaflet, the noncoronary (NC) leaflet, or both. In the event of significant AI, several techniques enable surgeons to offer an effective repair of the aortic leaflet prolapse due to elongation of the free edge [1] [2] [3] [4]. We describe another technique of free edge plication that allows correction of AI by shortening and resuspension of the elongated leaflet’s free edge.
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Patients and Results
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From 1993 to 1997, four patients ranging in age from 6 to 12 years (mean age, 8.5 years) were operated on for a VSD and AI using the technique described in this report. Demographic data, position of the VSD, and hemodynamic data are listed in Table 1. Aortic insufficiency was assessed preoperatively by transthoracic Doppler color flow mapping and graded as severe in all patients, who had prolapse involving both the RC and NC leaflets. All patients underwent transesophageal Doppler color flow mapping at the end of cardiopulmonary bypass to assess the quality of aortic valve repair. In the first 2 patients, AI was completely relieved. The remaining 2 patients, who had a shallower commissure between the RC and NC leaflets, had only minimal central aortic leaks postoperatively. In the first 2 patients, no residual or recurrent AI has been seen in repeat transthoracic echocardiographic controls in the period of follow-up extending up to 4 and 3 years, respectively. In the last 2 patients with commissural malformation, transthoracic echocardiographic controls at 18 and 10 months postoperatively showed only minimal AI.
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Technique
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The operation was performed through a median sternotomy. Conventional cardiopulmonary bypass with a membrane oxygenator and general hypothermia to 25°C was used. After the initiation of bypass, the aorta was cross-clamped and a curved transverse aortic incision extended into the noncoronary sinus was made. Cardioplegic solution was then infused selectively into both coronary ostia. All aortic leaflets were first inspected and measured with particular regard to the length of the free edge, height of the leaflets and commissures, and appearance of the sinus of Valsalva and aortic annulus. Thereafter, as described by Frater, the corpora arantii were sutured together to determine the extent of free edge redundancy of the usually prolapsing RC or NC leaflet (Fig 1A). In all cases, the height of the prolapsed leaflets was equal to that of the left coronary leaflet. The elongated free edge was then plicated using a fresh autologous pericardial strip 2 mm in width secured along the aortic aspect of the entire free edge between two commissures. The plication was performed by a running suture using the two halves of a 6/0 monofilament passed up and down through the free edge of the leaflet and the pericardial strip (Fig 1B). The beginning and the end of this suture were supported with pericardial pledgets at each corresponding commissural level in the extraaortic position. The length of the pericardial strip was sized, when the two halves of the suture were tied, according to the degree of free edge plication necessary to resuspend adequately the prolapsing leaflet for reestablishing normal apposition between leaflets (Fig 1C). The procedure was repeated for each prolapsing leaflet.
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(A) The right coronary (rc) and noncoronary (nc) leaflets are redundant. Apposition stitch of Frater at the Arantius bodies of three leaflets helps to determine extent of free edge redundancy of the prolapsing leaflets. (B) Excess free edge of the leaflet is harmoniously plicated using a pericardial strip applied from one commissure to the other. (C) Final view of corrected free margin length of the right coronary and noncoronary leaflets.
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In the first 3 patients, the VSD was infracristal with no evidence of aortic wall deficiency. The defect was closed through a right ventriculotomy by a Dacron patch sewn to the right ventricular aspect with a running 5/0 Ticron (Davis+Geck, Wayne, NJ) suture. In the last case, the VSD was supracristal with no intervening muscular tissue on the upper margin where the aortic and pulmonary valves were in direct apposition. The defect was closed through a right ventriculotomy by a Dacron patch sewn to the right ventricular aspect and slightly toward the pulmonary cusp on the upper margin with a running 5/0 Ticron suture. In this case, the patch reinforced the lack of support of the aortic annulus and the dilated right sinus of Valsalva.
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Comment
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Ventricular septal defect associated with major degrees of AI usually requires simultaneous surgical management of both conditions. Because elongation and subsequent prolapse of the RC or NC cusps is the most frequent abnormality, a variety of procedures aimed at shortening the elongated leaflet’s free edge was developed and employed. Plication can be done in several ways, the most familiar being that described by Trusler and associates [1], which consists of folding the amount of excess leaflet at one or both commissures and securing it to the aortic wall with pledgeted mattress sutures. Other plication procedures included folding of the free edge by a continuous suture [2] [3] or creation, by suturing, of tucks in various portions of the prolapsing edge [2]. Another approach to prolapsed leaflet was achieved by wedge excision of the central part of the leaflet with subsequent reapproximation by suturing [4]. We think that a plicated segment anchored to a fixed point near the commissures has a greater likelihood of dehiscence than one that remains mobile. Moreover, Teflon buttress sutures used for reinforcement of plicated thin and weak cuspal free edges near the commissures create protrusions that could later have an impact on the secondary cuspal changes by enhancing turbulence during opening and closure of aortic leaflets. Ohkita and associates [5] reported that significant residual or recurrent AI in patients who initially underwent leaflet plication at the commissural level was due to tears and perforation of repaired leaflets. Although more long-term follow-up is mandatory to determine the fate of our plication technique, we suggest that plication of the free cuspal edge using a thin pericardial patch applied along the free edge by a continuous suture avoids the use of buttress sutures and ensures well-balanced sharing of the tension at the commissural level.
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References
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- Trusler GA, Moes CAF, Kidd BSL Repair of ventricular septal defect with aortic insufficiency. J Thorac Cardiovasc Surg 1973;66:394-403.[Medline]
- Spencer FC, Doyle EF, Danilowicz DA, Bahnson HT, Weldon CS Long-term evaluation of aortic valvuloplasty for aortic insufficiency and ventricular septal defect. J Thorac Cardiovasc Surg 1973;65:15-31.[Medline]
- Soyer R, D’Allaines CL, Blondeau P, Piwnica A, Carpentier A, Dubost C Insuffisance aortique associée à une communication interventriculaire. Ann Chir Thorac Cardiovasc 1975;14:99-104.[Medline]
- Chavaud S, Serraf A, Mihaileanu S, et al. Ventricular septal defect associated with aortic valve incompetence: results of two surgical managements. Ann Thorac Surg 1990;49:875-880.[Abstract]
- Ohkita Y, Miki S, Kusuhara K, et al. Reoperation after aortic valvuloplasty for aortic regurgitation associated with ventricular septal defect. Ann Thorac Surg 1986;41:489-491.[Abstract]
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Abstract
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