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Ann Thorac Surg 2001;71:1067
© 2001 The Society of Thoracic Surgeons

Correspondence

Temporary tricuspid detachment in closure of ventricular septal defect

Goris Bol-Raap, MDa, Peter L. de Jong, MDa, Ad J.J.C. Bogers, MD, PhDa

a Department of Cardiothoracic Surgery, University Hospital Rotterdam, Thoraxcentre, Bd 156, PO Box 2040, 3000 CA Rotterdam, The Netherlands

e-mail: klomp{at}thch.azr.nl

To the Editor

With great interest we read the How to Do It report by Kapoor and colleagues describing temporary detachment of tricuspid chordal attachment to improve exposure in closure of ventricular septal defect in cases with obstructing chordae tendinae of the septal leaflet [1]. Although Kapoor and colleagues do not present any follow-up data, they put temporary chordal detachment forward as an alternative to temporary detachment of the anterior or septal tricuspid leaflet from the tricuspid annulus, as described by us and originally by Hudspeth and colleagues [2, 3]. Apparently temporary chordal detachment is applicable, but the arguments being put forward are arguable. We fully agree that optimal exposure is the main goal of these techniques and that these techniques are only to be applied in a limited number of operations. Moreover, in our experience, it is not the inferior rim of the ventricular septal defect that poses a technical problem in situations with a limited exposure.

Exposure through detached leaflet tissue depends on an adequate length of the detachment incision. The location and extent of the detachment incision may vary according to the location of the ventricular septal defect. If, in this regard, a retractor is still necessary instead of stay sutures, it is not to be used for traction as Kapoor and colleagues state, but just for holding.

Any surgical technique should be applied in a technically adequate and accurate way in order to avoid unnecessary "awkward" [1] situations. In this regard, temporary tricuspid detachment intrinsically involves a rim of about 1 mm at the base of the tricuspid annulus, onto which the ventricular septal defect patch as well as the detached tricuspid leaflet are sutured.

Temporary chordal detachment to improve exposure in closure of ventricular septal defect may be useful in selected cases. Arguments in favor, however, should preferably come from obvious advantages or from careful follow-up.

References

  1. Kapoor L., Gan M.D., Bandyhopadhyay A., Das M.B., Chatterjee S. Improved exposure of isolated perimembraneous ventricular septal defect. Ann Thorac Surg 2000;69:291-292.[Abstract/Free Full Text]
  2. Bol-Raap G., Bogers A.J.J.C., Boersma H., de Jong P.L., Hess J., Bos E. Temporary tricuspid valve detachment in closure of congenital ventricular septal defect. Eur J Cardio-thorac Surg 1994;8:145-148.[Abstract/Free Full Text]
  3. Hudspeth A.S., Cordell A.R., Meredith J.H., Johnston F.R., Winston-Salem N.C. An improved transatrial approach to the closure of ventricular septal defects. J Thorac Cardiovasc Surg 1962;43:157-165.

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