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Ann Thorac Surg 2001;72:430-432
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Direct closure of ostium primum defect in the repair of atrioventricular septal defect

^a Divisions of Cardiovascular Surgery and Cardiology, National Children’s Hospital, Tokyo, Japan

Accepted for publication May 1, 2001.

Address reprint requests to Dr Chikada, Division of Cardiovascular Surgery, National Children’s Hospital, 3-35-31 Taishido, Setagaya-ku, Tokyo, 154-8509, Japan
e-mail: chikada{at}nch.go.jp

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Patch closure is generally performed for atrial septation of an atrioventricular septal defect. We recently developed a new surgical technique for repairing atrioventricular septal defects that avoids the use of any patch material for closing the atrial septal defect. We report our experience with this procedure.

Methods. Seven patients (complete type: 5, partial type: 2) underwent this new operation. The diameters of the atrial septal defects were measured by transesophageal echocardiography. The preoperative electrocardiograms were compared with those taken after the operations.

Results. Diameters of the atrial defects ranged from 3 to 10 mm. Electrocardiograms before and after the operations did not change. No significant atrioventricular valve regurgitation and no residual shunts were detected by postoperative echocardiography.

Conclusions. This method simplifies the repair of atrioventricular septal defects. In the short-term results, no arrhythmia and no valve regurgitation was seen.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
The first successful repair of atrioventricular septal defect (AVSD) was performed in 1955 [1]. Since then, single or double patches have been used for atrial septation and ventricular septation [2, 3]. Two recent reports have shown a new, simplified technique for avoiding the use of any ventricular septal patch material [4, 5]. In our method, we avoid the use of any atrial septal patch to repair partial or complete AVSD, and this article describes the use of a single Dacron patch (Meadox Medicals Inc, Oakland, NJ) to close the ventricular septal defect. The purpose of this study is to evaluate an advantage of this method.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Between July 1998 and April 2000, 7 consecutive patients who had either complete or partial AVSD were included in this study. Other methods were not used during this period. Patients with major cardiac abnormalities (tetralogy of Fallot, double-outlet right ventricle, interrupted aortic arch, aortic coarctation) were excluded. Four patients had Down’s syndrome. Five patients presented complete AVSD (Rastelli’s classification type A: 2, type C: 3) and 2 patients presented partial AVSD. Four patients with complete AVSD underwent pulmonary artery banding before total correction. Age at the time of repair ranged from 7 months to 7.1 years (median, 1.7 years) and the weights from 4.8 to 19.4 kg (median, 9.7 kg) (Table 1).

In patients with complete AVSD, the ventricular septal defect was closed with a semicircular Dacron patch (Meadox Medicals Inc, Oakland, NJ) and interrupted 4-0 polyester sutures, keeping the suture line slightly to the right of the crest of the ventricular septum. At the anterior edge of the patch, the atrioventricular (AV) valves were partitioned and fixed with interrupted 4-0 polyester sutures to the patch. The anterior commissure and cleft of the left AV valve was completely closed with interrupted 6-0 polypropylene sutures. The competence of the AV valves was tested by injection of cold saline into the ventricle.

In all patients, ostium primum defect could be closed directly without any patch material. The suture line to close the ostium primum atrial septal defect (ASD) was placed on either the artificial or the native ventricular septal crest and was continued leftward above the annulus of the inferior leaflet of the AV valve at its posteroinferior corner to avoid possible damage to conduction tissue. The coronary sinus was left draining into the right atrium in all patients. Horizontal mattress or simple stitches were used in all patients, especially in the posterior part of the suture line to avoid distorting the left side AV valve leaflet (Fig 1). The secundum ASD, if present, was closed with a continuous 6-0 polypropylene suture. All patients underwent intraoperative transesophageal echocardiography before cardiopulmonary bypass was discontinued. The residual shunts and atrioventricular valve functions were investigated.

View larger version (33K): [in this window] [in a new window]   Fig 1. Placement of interatrial patch suture lines in complete atrioventricular septal defect. (CS = coronary sinus; LAVV = left side atrioventricular valve; RAVV = right side atrioventricular valve; VSD = ventricular septal defect.)

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
No early death occurred, but there was one late death in this series. This patient was a 1-year-old boy with complete AVSD and Down’s syndrome. He died of severe pneumonia 3 months after repair. No AV valve regurgitation or significant arrhythmia was recognized in this patient postoperatively. The mean duration of follow-up was 1.9 years (range, 1.2 to 3.0 years). No complete atrioventricular block occurred and postoperative arrhythmia was not observed on follow-up electrocardiogram.

The sizes of atrial component of the AVSDs, measured during intraoperative transesophageal echocardiography, ranged from 3 mm to 10 mm. All ostium primum defects were closed directly. No dehiscence of the suture lines occurred. The aortic cross-clamp times ranged from 37 to 139 minutes (median, 87 minutes). The aortic cross-clamp times of 7 consecutive patients, by using the traditional technique before this study period (complete: 5, partial: 2) ranged from 60 to 141 minutes (median, 117 minutes). Aortic cross-clamp times have a tendency to be shorter by using this technique (p = 0.08).

Follow-up echocardiography was performed on all patients. The preoperative degree of AV valve regurgitation was moderate to severe in 2 patients, moderate in 2 patients, mild in 1 patient, and nil to trivial in the remaining 2 patients. Postoperatively, in all but 2 patients, AV valve regurgitation was absent to trivial. One patient with partial AVSD had mild mitral valve regurgitation 1 year postoperatively. One patient with complete AVSD, who had moderate to severe regurgitation before repair, had mild left AV valve regurgitation 2 years postoperatively in all cases. No echocardiographic evidence of AV valve stenosis was detected postoperatively. No residual shunt or left ventricular outflow tract obstruction was detected on follow-up echocardiography. All survivors were doing well and according to New York Heart Association’s functional class I at most recent follow-ups.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Surgical repair of complete AVSD was performed by the one-patch or two-patch method [2, 3]. Both methods have yielded good AV valve function, but patch material was always used for atrial and ventricular septation. In 1997, Wilcox and associates [4] reported direct closure of the ventricular element of the defect by direct suturing of the common AV valve leaflets to the crest of the ventricular defect, and by the use of a single pericardial patch to close the atrial component of the defect. They did not try to close large defects. In 1999, Nicholson and colleagues [5] introduced a similar direct suture technique using only the atrial septal patch and avoiding a ventricular septal patch. They were not selective in applying their technique and included a form of anterior annuloplasty during partitioning of the common valve.

We previously used the two-patch method to repair complete AVSDs. A Dacron patch (Meadox Medicals Inc, Oakland, NJ) was used for ventricular septation, and a xenopericardium to close the atrial component of the complete AVSD in these cases, which usually but not always left the coronary sinus on the left side. We considered that if the atrial segment of an AVSD is small, direct closure of the ASD is probably possible. This technique could reduce the use of patch material. Since 1998, we have tried to close the atrial septal component of complete AVSDs directly and have used the same method to repair partial AVSDs without any patch material. In an article from El-Najdawi and associates from the Mayo Clinic [7] only 8 (2%) of 344 patients with partial VSD underwent direct suture closure of the atrial septal defect component. In contrast, our 2 patients with partial AVSD underwent direct closure without any complications.

Placement of interatrial suture lines was, as previously described, the coronary sinus left to drain into the right atrium [8]. We used horizontal mattress or simple suturing for interatrial repair to avoid damage to conduction tissue and to prevent dehiscence of the atrial and ventricular septation. According to previous reports, the incidence of complete AV blockage ranged from 0% to 2.7% in partial AVSD [7–10] and 0% to 4% in complete AVSD [2, 3, 11, 12]. The reported incidence of residual AVSD ranged between 0% and 27% [2–5, 7–12]. Our method caused no AV block and no residual AVSD, which was comparable with the low incidence obtained in previous reports. Regarding AV valve function, 2 of 6 surviving patients had mild left AV valve regurgitation without any other significant problems detected. We considered this to be an acceptable result. We think that another advantage of this technique would be the avoidance of significant hemolysis, which occasionally occurs in the presence of AV valve regurgitation.

The size of ASD is an issue. The limit of ASD size by this method is unknown. We think that 20 mm is too large to close directly and could cause dehiscence. This technique should not be recommended for all patients with AVSDs. We had only 1 infant patient, but this technique is thought to be feasible in cases of early primary repair. A possible drawback to this approach is taking the risk of damaging conduction tissue. We think this risk is very small.

In conclusion, the direct closure of ostium primum defect in the repair of AVSD can be performed with low incidences of AV block and residual AVSD as assessed by short-term follow-up. This method could minimize ischemic time and reduce the use of patch materials. Until now, all ostium primum defects could be closed directly. So far we have only had a small number of patients; therefore, further experience and longer follow-up times are necessary to fully assess this method.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Lillehei C.W., Cohen M., Warden H.E., Varco R.L. The direct-vision intracardiac correction of congenital anomalies by controlled cross-circulation: results in thirty-two patients with ventricular septal defects, tetralogy of Fallot, and atrioventricularis communis defects. Surgery 1955;38:11-29.[Medline]
2. Reddy V.M., McElhinney D.B., Brook M.M., Parry A.J., Hanley F.L. Atrioventricular valve function after single patch repair of complete atrioventricular septal defect in infancy: how early should repair be attempted?. J Thorac Cardiovasc Surg 1998;115:1032-1040.[Abstract/Free Full Text]
3. Bogers A.J., Akkersdijk G.P., de Jong P.L., et al. Results of primary two-patch repair of complete atrioventricular septal defect. Eur J Cardiothorac Surg 2000;18:473-479.[Abstract/Free Full Text]
4. Wilcox B.R., Jones D.R., Frantz E.G., et al. Anatomically sound, simplified approach to repair of "complete" atrioventricular septal defect. Ann Thorac Surg 1997;64:487-494.[Abstract/Free Full Text]
5. Nicholson I.A., Numm G.R., Sholler G.F., et al. Simplified single patch technique for the repair of atrioventricular septal defect. J Thorac Cardiovasc Surg 1999;118:642-647.[Abstract/Free Full Text]
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Takashi Miyamoto Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chikada, M. Articles by Ishizawa, A. Search for Related Content PubMed PubMed Citation Articles by Chikada, M. Articles by Ishizawa, A. Related Collections Congenital - cyanotic Related Article