Ann Thorac Surg 2001;71:1344-1346
© 2001 The Society of Thoracic Surgeons
Case report
Midterm results after ventricular septation for double-inlet left ventricle in early infancy
Yasuaki Naito, MDa,
Keiichi Fujiwara, MDa,
Hiroyoshi Komai, MDa,
Shigeru Uemura, MDb
a Department of Thoracic and Cardiovascular Surgery, Wakayama Medical College, Wakayama, Japan
b Department of Pediatrics, Wakayama Medical College, Wakayama, Japan
Accepted for publication May 30, 2000.
Address reprint requests to Dr Naito, Department of Thoracic and Cardiovascular Surgery, Wakayama Medical College, 811-1, Kimiidera, Wakayama, 641-0012 Japan
e-mail: fujiwara{at}wakayamamed.ac.jp
 |
Abstract
|
|---|
We performed ventricular septation for a 40-day-old boy with double-inlet left ventricle and discordant ventriculoarterial connection but without pulmonary stenosis. Postoperative cardiac function is satisfactory, with no evidence of pulmonary hypertension or subaortic stenosis. Nine years after the operation, the patient has an active life, is free from symptoms, and requires no medication. He may be the first patient to survive ventricular septation for double-inlet left ventricle in early infancy.
|
Introduction
|
|---|
Ventricular septation is considered a hemodynamically ideal surgical procedure for patients with double-inlet left ventricle. Those who have a dominant left ventricle without pulmonary stenosis or atresia are especially good candidates for this procedure. The indications for ventricular septation in early infancy, however, are controversial, and postoperative long-term results are not well known because, to the best of our knowledge, no successful case of primary septation has been reported. Here we describe the midterm results after ventricular septation in an infant.
A 33-day-old male infant was admitted to the department of pediatrics in our medical college hospital because of decreased nutritional intake, cough, and cyanosis when crying. The chest roentgenogram showed remarkable cardiomegaly and pulmonary engorgement. Echocardiography demonstrated double-inlet left ventricle with two atrioventricular valves, an enlarged dominant left ventricle, a left anterior rudimentary subaortic right ventricle, and no pulmonary stenosis. Because of the patient’s persisting shock status and progressive congestive heart failure, we decided to perform urgent ventricular septation without cardiac catheterization when he was 40 days of age (October 9, 1990).
Septation was done with a Dacron patch according to our previously reported procedure for prevention of atrioventricular block [1]. Briefly, the suture line for the septation is placed parallel to the conduction axis, which is histologically determined by the method of Anderson and colleagues, never crosses the nonbranching bundle, and transfers to the free wall of the dominant left ventricle after reaching the branching bundle (Fig 1) [2]. The landmark for this point of transfer is the area in which the dimensions of the muscles of the ventricular septum change. In the vicinity of the ventricular septal defect, all sutures are placed at the margin of the defect from inside the rudimentary right ventricle. If necessary, the ventricular septal defect is enlarged by resection of its inferior margin. However, in the case of this patient, the ventricular septal defect did not require enlargement because it was as big as 15 mm in diameter.
View larger version (26K):
[in this window]
[in a new window]
|
Fig 1. Our suture line (broken line) for septation for double-inlet left ventricle with left anterior rudimentary right ventricle and discordant ventriculoarterial connection. (Ao = aorta; LA = left atrium; LAVV = left atrioventricular valve; PA = pulmonary artery; RA = right atrium; RAVV = right atrioventricular valve; VSD = ventricular septal defect.) (Reprinted from Naito and colleagues [1] by permission of Futura Publishing Company, Inc.)
|
|
The patient had an uneventful postoperative course and was discharged from the hospital 2 months after the operation. Three months later during follow-up, regurgitation in both atrioventricular valves and paroxysmal atrial flutter appeared. The gradual development of cardiomegaly led us to perform bilateral atrioventricular annuloplasty using two figure-of-eight stitches by the technique of Kay 2 years 5 months after septation. The operation was successful, and the patient soon returned to the outpatient clinic.
Postoperative catheterization 5 years after septation revealed normal pulmonary artery pressure (15/6 mm Hg; mean pressure, 10 mm Hg), normal bilateral ventricular end-diastolic pressures, and a pressure gradient through the subaortic region of only 4 mm Hg. Angiocardiography showed mild bilateral atrioventricular regurgitation, no evidence of obstruction in the left ventricular outflow tract, and no interventricular left-to-right shunt (Fig 2). Using volumetry, we estimated that end-diastolic volume index and ejection fraction were 103 mL/m2 and 63.1% in the pulmonary ventricle and 101 mL/m2 and 45.2% in the systemic ventricle, respectively. The patient is now 9 years old and is doing well with no limitations and no medications.
View larger version (101K):
[in this window]
[in a new window]
|
Fig 2. Angiocardiograms made 4 years 7 months after ventricular septation. Pressure in the pulmonary artery (PA) was 15/6 mm Hg (mean pressure, 10 mm Hg); in the pulmonary ventricle (PV), 20/5 mm Hg; in the aorta (Ao), 89/56 mm Hg (mean pressure, 72 mm Hg); and in the rudimentary systemic ventricle (SV), 93/3 mm Hg. (IVF = interventricular foramen; rud. RV = rudimentary right ventricle.)
|
|
|
Comment
|
|---|
A recent surgical strategy for infants with double-inlet left ventricle with pulmonary hypertension like our patient has been banding of the pulmonary trunk to prevent progressive pulmonary vascular obstructive disease in preparation for the Fontan operation, even if the potential for a two-ventricle repair exists. Freedom and colleagues [3], however, reported that banding frequently produces progressive restriction of the ventricular septal defect by myocardial hypertrophy, thus producing subaortic stenosis in the patient with discordant ventriculoarterial connection. Their strategy in early infancy is to undertake the Norwood procedure or to construct a shunt from the pulmonary trunk to the descending aorta and to band the proximal pulmonary trunk in preparation for a future Fontan operation. Nevertheless, the Fontan operation is considered a palliative operation and is associated with late postoperative morbidity and mortality as a result of atrial arrhythmias, ventricular dysfunction, protein-losing enteropathy, and thrombus formation [4, 5].
We chose septation for our infant because, like Kurosawa and coauthors [6], we thought it a physiologically and hemodynamically better option than the Fontan operation. Also, we judged the chances of survival with septation to be equal to or better than those with the alternative palliative procedures. Known major problems occurring after ventricular septation are iatrogenic atrioventricular block and atrioventricular valve regurgitation during follow-up [7]. Surgical block can be prevented by suitable technique [1] as performed in this patient. The patient also, had development of regurgitation in both atrioventricular valves, but this was successfully treated by bilateral annuloplasty. Hemodynamic studies during follow-up showed that cardiac function was satisfactory. The patient has an active life without limitations 9 years after septation. These results suggest that ventricular septation is a reasonable option for surgical repair of double-inlet left ventricle, even in early infancy.
|
References
|
|---|
-
Naito Y., Fujiwara K., Higashiue S., Yagihara T., Fujita T. A surgical procedure for the prevention of atrioventricular block in septation for double inlet left ventricle. In: Crupi G., Parenzan L., Anderson R.H., eds. Perspectives in pediatric cardiology; vol 2: Pediatric cardiac surgery, part 3. Mt. Kisco, NY: Futura, 1990:293-296.
-
Anderson R.H., Becker A.E., Ho S.Y., Zuberbuhler J.R., Wilkinson J.L. Disposition of the conduction tissue. In: Anderson R.H., Crupi G., Parenzen L., eds. Double inlet ventricle. Tunbridge Wells, Kent, UK: Castle House Publications Ltd, 1987:72-97.
-
Freedom R.M., Benson L.N., Smallhorn J.F., Williams W.G., Trusler G.A., Rowe R.D. Subaortic stenosis, the univentricular heart, and banding of the pulmonary artery: an analysis of the courses of 43 patients with univentricular heart palliated by pulmonary artery banding. Circulation 1986;73:758-764.[Abstract/Free Full Text]
-
Gentle T.L., Gauvreau K., Mayer J.E., et al. Functional outcome after the Fontan operation. Factors influencing late morbidity. J Thorac Cardiovasc Surg 1997;114:392-403.[Abstract/Free Full Text]
-
Shirai L.K., Rosenthal D.N., Reitz B.A., Robbins R.C., Dubin A.M. Arrhythmias and thromboembolic complications after the extracardiac Fontan operation. J Thorac Cardiovasc Surg 1998;115:499-505.[Abstract/Free Full Text]
-
Kurosawa H., Imai Y., Fukuchi S., et al. Septation and Fontan repair of univentricular atrioventricular connection. J Thorac Cardiovasc Surg 1990;99:314-319.[Abstract]
-
Stefanelli G., Kirklin J.W., Naftel D.C., et al. Early and intermediate-term (10-year) results of surgery for univentricular atrioventricular connection ("single ventricle"). Am J Cardiol 1984;54:811-821.[Medline]
This article has been cited by other articles:
|
|
|
|
 
J. Ottenkamp and M. G. Hazekamp
Double-inlet left ventricle: successfully staged ventricular septation with 12.5 years follow-up
Ann. Thorac. Surg.,
February 1, 2002;
73(2):
699 - 699.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
