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Ann Thorac Surg 1999;68:1746-1750
© 1999 The Society of Thoracic Surgeons

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Original Articles

Left atrioventricular valve repair technique in partial atrioventricular septal defects

^a Department of Cardiovascular Surgery, Gülhane Military Medical Academy, Ankara, Turkey

Address reprint requests to Dr Kuralay, Gülhane Lojmanlari Pamir Apt. No: 15, Etlik/Ankara, Turkey 06010;
e-mail: ekural{at}gata.edu.tr

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. The aim of our study was to evaluate the effect of chordal transfer around the cleft on left atrioventricular valve competence in the late postoperative period.

Methods. Forty-four adult patients underwent surgical correction of partial atrioventricular septal defect between 1983 and 1997. Fenestration was found in 8 patients (18.2%) and cleft, in 35 (79.5%). There was no chordal support of the free edges of the left superior and left inferior leaflets around the cleft in 18 patients. Two chordae were mobilized from the left lateral leaflet and reimplanted into the tip of the left superior and left inferior leaflets around the cleft.

Results. At 5 years postoperatively, left atrioventricular valve insufficiency was severe in 5 patients and moderate in 11 patients who had had cleft closure alone. In contrast, severe valvular insufficiency was present in only 1 patient in the group with chordal transfer (p < 0.05). Reoperation was done in 5 patients with isolated cleft closure. Left AV valve replacement was performed in 1 patient.

Conclusions. Chordal transfer plus cleft closure with interrupted sutures significantly reduces early and late left atrioventricular valve incompetence and also decreases the rate of reoperation.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Partial or incomplete atrioventricular (AV) septal defects are characterized anatomically by the presence of an ostium primum atrial septal defect occupying the portion of the atrial septum just superior to the separately formed tricuspid and mitral valves [1]. Varying degrees of clefting of the anterior leaflet of the left AV valve and deficiency of the septal leaflet of the right AV valve can be present in this congenital malformation. The terms left AV valve and right AV valve have been used instead of mitral valve and tricuspid valve, respectively [2]. In addition, several authors [2–4] have used the term septal commissure instead of cleft to indicate the gap between the left superior and left inferior leaflets.

Successful repair of partial AV septal defect continues to challenge surgeons [5, 6]. A high incidence of late left AV valve incompetence after correction of partial AV septal defect has been reported [7, 8]. Despite many modifications in surgical technique and a flexible approach to left AV valve repair, left AV valve incompetence remains a major factor in postoperative mortality and morbidity. Left AV valve incompetence is the most frequent indication for reoperation after correction of AV septal defects [2, 3, 8–13]. The objective of this study was to identify the causes of critical left AV valve incompetence and to describe the technique of chordal transfer around the cleft to reduce late AV valve incompetence and to avoid reoperations.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Forty-four adult patients underwent surgical correction of partial AV septal defect between 1983 and 1997. There were 11 female and 33 male patients ranging in age from 15 to 29 years (average age, 23.2 years). Eleven patients had symptoms of mild congestive heart failure, 13 patients had failure to thrive, 1 patient had minimal cyanosis on exertion, 12 patients had arrhythmias, and 11 patients had no symptoms. On physical examination, 27 patients had an overactive precordium, all patients had a pulmonary flow murmur, and 27 patients had a second-degree systolic murmur in the mitral area. Cardiomegaly and increased pulmonary vasculature were present on the chest roentgenogram for 38 patients.

All patients underwent preoperative cardiac catheterization and angiography to establish the diagnosis, assess left and right AV valve function, and calculate pulmonary vascular resistance. Transesophageal echocardiographic (TEE) examination was routinely performed in the preoperative, operative, and postoperative period after 1992. The Monoplane TEE probe was used until 1995, and the Omniplane TEE probe has been our choice since then. Hewlett-Packard Sonos 1000 and 2500 consoles were used for TEE studies. Both AV valves and the subvalvular apparatus were evaluated by TEE examinations.

Right ventricular peak systolic pressure ranged from 27 to 94 mm Hg (mean pressure, 42 mm Hg), and pulmonary to systemic flow ratio ranged from 2.1 to 4.8 (mean ratio 3.2). Pulmonary valve stenosis was present in 3 patients, persistent left superior cava in 1 patient, and partial anomalous pulmonary venous return in 3 patients.

Right AV valve incompetence was detected in 28 patients (63.6%). The right inferior leaflet was hypoplastic in 17 patients (38.6%). Four patients had grade 4 right AV valve incompetence, 3 patients had grade 3, 17 patients had grade 2, and 4 patients, grade 1. The angiographic quantitative method described by Cha and Gooch [14] was used to evaluate right AV valve incompetence.

Left AV valve incompetence was graded using the method of Nanda and coworkers [15]. Left AV valve incompetence as defined by cineangiographic criteria was severe (regurgitant fraction > 25%) in 5, moderate (regurgitant fraction between 15% and 25%) in 26, and mild (regurgitant fraction < 15%) in 9 patients in the preoperative period; normal left AV valve coaptation was found in only 4 patients. No double-orifice left AV valve was found in any patient.

Patients were followed by echocardiography in 6-month intervals postoperatively. Informed consent was obtained from all patients.

Surgical technique
Surgical repair was accomplished using total cardiopulmonary bypass with moderate hypothermia (25° to 28°C), aortic cross-clamping, and cold cardioplegic myocardial protection. A right atriotomy was performed, and the anatomic configurations of both AV valves, subvalvular apparatus, atrial septum, coronary sinus, and additional congenital defects were evaluated.

Fenestrations (> 1 mm in diameter) of the left superior and left lateral leaflets were found in 8 patients (18.2%) and were primarily sutured with 5-0 polypropylene.

A cleft between the left superior and left inferior leaflets was found in 35 patients (79.5%). Seventeen of these patients had cleft closure alone. In the other 18, there was no chordal support of the free edges of the left superior and left inferior leaflets around the cleft (Fig 1). Two chordae were mobilized from the left lateral leaflet and reimplanted into the tip of the left superior and left inferior leaflets just around the cleft with two separate 5-0 polypropylene sutures in these 18 patients (Fig 2). Then the cleft was sutured with interrupted 5-0 polypropylene sutures (Fig 3). We found that the left lateral leaflet had excessive primary chordae and that mobilization of the chordae to a suitable localization did not affect coaptation of the left lateral leaflet. After completion of the repair, saline solution was injected into the left ventricle to evaluate the competence of the left AV valve.

View larger version (43K): [in this window] [in a new window]   Fig 1. Anatomy of left atrioventricular valve in partial atrioventricular septal defect. (LIL = left inferior leaflet; LLL = left lateral leaflet; LSL = left superior leaflet.)

View larger version (37K): [in this window] [in a new window]   Fig 2. Two chordae were mobilized from the left lateral leaflet (LLL) and attached to both sides of the cleft, one to the left superior leaflet (LSL) and the other to the left inferior leaflet (LIL).

View larger version (35K): [in this window] [in a new window]   Fig 3. Completed repair of left atrioventricular valve. Cleft was closed using interrupted sutures after chordal transfer. (LIL = left inferior leaflet; LLL = left lateral leaflet; LSL = left superior leaflet.)

Transesophageal echocardiography was routinely performed after the operation. Severe left AV valve insufficiency was found in 4 patients, and a left atriotomy was done to perform a Wooler-Kay annuloplasty.

Statistical analysis
Statistical analysis was done using the Mann-Whitney U test. A p value of less than 0.05 was considered significant.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
There was no operative mortality. Complete heart block developed in 5 patients (11.4%); it resolved spontaneously within 10 days in 3 of them, and a permanent pacemaker was implanted in the other 2. Clinical and echocardiographic follow-up ranged between 1.5 and 12 years (mean follow-up, 7.6 years). There were no late deaths.

Patients were routinely examined by transthoracic echocardiography. When valve insufficiency exceeding grade 1 (mild) was found, a TEE examination was also performed. All images were recorded and stored. Left AV valve insufficiency was evaluated in both the midesophageal and transgastric positions. The first echocardiographic study was done on postoperative day 30. In the group who had cleft closure alone, severe left AV valve insufficiency was found in 2 patients, moderate insufficiency in 5, and mild insufficiency in 9 (Table 1). We noticed that left AV valve insufficiency gradually increased. By the second year of follow-up, it was severe in 3, moderate in 8, and mild in 6 patients. At 5 years of follow-up, AV valve insufficiency was severe in 5, moderate in 11, and mild in 1 patient undergoing isolated cleft closure.

In contrast with the results in the group having isolated cleft closure, severe left AV valve insufficiency was present in only 1 patient in the chordal transfer group (p < 0.05) at 5 years postoperatively. In this patient, moderate left AV valve insufficiency gradually increased to severe status during 5 years, and the patient would not undergo reoperation (see Table 1). Nine of the other 17 patients in this group had mild insufficiency, and 8 patients had left AV valve insufficiency.

Several patients required reoperation. The 5 patients who underwent isolated cleft closure (ie, without chordal transfer) and had severe late left AV valve insufficiency had reoperation. Cleft suture dehiscence was found in 4 patients who had undergone cleft repair with continuous suture technique at the initial operation. At reoperation using interrupted sutures, the cleft was supported using our method of chordal transfer. A Wooler-Kay annuloplasty was also performed in 4 patients, and extensive fibrotic deformity necessitated prosthetic valve replacement in 1 patient. Two additional patients whose cleft had not been repaired at the initial operation in another cardiac center underwent reoperation at our institution according to our concept. Prominent dilatation of the annulus was found, and annuloplasty with Carpentier ring implantation was also done in these 2 patients.

Right AV valve insufficiency was also routinely evaluated. No major insufficiency was detected in the early postoperative period. Grade 1 valvular insufficiency was found in 25 patients and grade 2 insufficiency, in 7 patients. There was no increase in right AV valve insufficiency in the late postoperative period. Complete AV block developed late in 2 patients, at 2 years in 1 and at 5 years in the other. A permanent pacemaker was implanted in each patient.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
The technical challenge in the operation for partial AV canal defect is the repair of left AV valve deformity. Primary valve repair is possible in most infants, children, and young adults. Despite the use of flexible, individualized approaches to left AV valve repair, residual valvular incompetence remains a major factor in postoperative mortality and morbidity and is virtually the only indication for reoperation late after repair [3, 9–12, 16]. In some cases, the residual incompetence is caused by an inadequate left AV valvuloplasty and in others, a marked lack of left AV valve tissue. King and coworkers [17] performed left AV valve replacement in 5 patients older than 50 years. In their study, the overall incidence of mitral valve replacement at initial operation was reported as 2.5%.

Some authors [7, 17] advocate routine left AV cleft closure. Carpentier [2] recognized the complexity of this malformation, which involves all components of the left AV valve, and recommended that the malformation be considered a three-leaflet valve structure and repaired accordingly. According to him, the repair should not be standardized; instead there first should be a careful assessment of all components, and then the repair should comprise individualized plastic procedures. Abbruzzese and colleagues [3, 18] based the decision on whether to construct a two-leaflet or three-leaflet left AV valve on the size of the mural leaflet. They reserve the three-leaflet repair for those cases where the insertion of the mural leaflet at the annulus is less than one third of the circumference of the annulus, as, in that case, closure of the cleft would restrict the motion of the anterior leaflet. In an attempt to respect the three-leaflet anatomy of the left AV valve, this group has avoided routine closure of the cleft.

Although some surgeons prefer to leave the cleft unsutured, it has been found that this can lead to poor clinical results and major postoperative AV valve incompetence [13, 16, 19–22]. A more secure technique of cleft closure in small infants and in patients with fragile valvular tissue is necessary; cleft sutures reinforced with pericardial pledgets should be considered in such cases [19]. In our general practice, we have been using individual interrupted sutures instead of a continuous suture technique to avoid suture line dehiscence. We believe that an individual interrupted suture technique will affect left AV valve coaptation positively.

In a study by Alexi-Meskishvili and coworkers [23], the cleft was routinely closed at the initial operation. They reported a reoperation rate of 6.8% for marked left AV valve incompetence. The incidence of late left AV valve replacement was 0.8% for complete AV canal defects and 1.4% for partial AV septal defects in another study by this group [24]. We found a cleft in the left AV valve in 35 (79.5%) of our 44 adult patients. We routinely evaluated the subvalvular apparatus during the initial operation and did not find adequate chordal support of the left superior and inferior leaflets in the cleft area. We think that absent or weak chordal support can lead to late left AV valve incompetence; consequently we believe that chordal transfer to both sides of the cleft is relevant. For cleft closure, we prefer interrupted sutures to continuous suture. Chordal transfer reduces excessive traction on the leaflets during the end-systolic period and thereby prevents suture dehiscence of the cleft in the late follow-up. To date, we have not encountered suture dehiscence in patients who underwent chordal transfer.

We conclude that use of the chordal transfer technique together with interrupted sutures to close the AV cleft reduces substantially both early and, especially, late left AV valve incompetence and hence the reoperation rate. Chordal transfer and cleft closure using interrupted sutures, and annuloplasty when necessary, is an ideal technique for repair of the left AV valve in partial AV septal defect in adults.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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