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Ann Thorac Surg 1998;66:310
© 1998 The Society of Thoracic Surgeons
a Divisioni di Cardiochirurgia e Cardiologia, Ospedale Infantile Regina Margherita, Piazza Polonia 96, 10126 Torino, Italy
To the Editor
We read with great interest the article entitled "Predicting Feasibility of Biventricular Repair of Right Dominant Unbalanced Atrioventricular Canal" by van Son and colleagues [1].
We share a similar experience. We have encountered several patients with unbalanced atrioventricular canals and left ventricular dimensions apparently too small for biventricular repair but still adequate to sustain a systemic output maintaining the patient alive (ie, no ductal dependency). Under these circumstances we have recently speculated that correcting the malformation would decrease the right ventricular volume overload, thus causing a beneficial shift to the right of the ventricular septum, which would increase the left ventricular volume.
Starting in June 1996, we have therefore operated on 4 patients with such a malformation. They all had the incomplete form of the atrioventricular canal with a restrictive or absent ventricular septal defect. Similar to the patients of van Son and colleagues, 2 of them had a double-orifice left component of the common atrioventricular valve, and 3 had an associated aortic coarctation. In each case a severe degree of pulmonary hypertension was also present.
All patients underwent corrective procedures and they all survived. No patient was offered a palliative procedure during the same time interval.
As hypothesized, in each patient a dramatic increase of the left ventricular/right ventricular volume ratio occurred after the operation. This was due to the change in the curvature of the interventricular septum, the convexity of which, initially to the left (banana-shaped left ventricle), returned to normal. The reversal of septal bowing was probably due not only to the relative change of the ventricular volume loads but also to the significant decrease in the pulmonary pressure that we observed in each patient.
Encouraged by the good result in our first patient (3 months old), whose left ventricle continued to enlarge, still maintaining a good ventricular function, we widened the indications and we operated on younger patients with smaller ventricles. However, a word of caution must be given because some of these patients have tiny valvular structures (mitral and aortic) with dimensions that do not follow the impressive ventricular enlargement, thus posing a possible future surgical problem.
In summary, we agree with van Son and colleagues that even minuscule preoperative left ventricular dimensions, as we also observed, should not contraindicate biventricular repair, even though the future behavior of the valvular structures remains to be evaluated. Perhaps the most promising aspect of these two similar experiences is that in both institutions no patient was offered a palliative procedure during the same time interval, thus showing that biventricular repair is probably feasible in most patients with such a malformation.
References
This article has been cited by other articles:
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