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Ann Thorac Surg 2001;72:432-433
© 2001 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, Children’s Hospital of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI 53201, USA
e-mail: sblitwin{at}chw.org
Chikada and colleagues report direct closure of the small (7 mm to 10 mm) ostium primum defect in 7 consecutive patients with isolated atrioventricular septal defects (AVSDs) (2 incomplete and 5 complete) seen at the National Children’s Hospital (Tokyo) during a recent twenty one month period.
This patient series is unusual in certain respects. Every child had a small atrial defect whereas in a series of 344 patients with incomplete AVSDs seen over forty years at the Mayo Clinic, only 8 (2%) had defects which were small enough to close without a patch. Secondly the patients of Chikada and associates had operations performed at an older age (7 months to 7.1 years). This is in contradistinction to current surgical practice of early primary repair before 4 to 6 months of age to avoid changes in the pulmonary vascular bed and other sequelae of a left to right shunt. Their late repairs probably necessitated palliative pulmonary artery banding in 4 patients with complete AVSDs and may have resulted in the development preoperatively of significant mitral regurgitation in 4 of 7 patients in the total group. Notwithstanding early outcome of direct closure of ostium primum defects was satisfactory with no dehiscence of repairs, heartblock, or significant residual mitral regurgitation.
In comparing the technique of direct closure to the traditional operation of patch closure there should be little if any difference in cross-clamp time. A patch can be placed expeditiously with a continuous suture and many surgeons (and it is my preference) stitch the upper rim of the patch to the septum secundum after releasing the aortic cross clamp (a left ventricular vent prevents left ventricular ejection). It is also safer to tie the few interrupted stitches placed beneath the coronary sinus (when the repair incorporates coronary sinus drainage to the right atrium) with a beating heart [1]. If a stitch is too close to the His Bundle third degree block is observed with the first throw of the tie, and the stitch can be replaced without permanent injury to conductive tissue.
Avoiding the use of patch material with direct tissue closure is of questionable benefit. In theory it might avert hemolysis which occasionally occurs postoperatively when a minor mitral regurgitant jet hits a synthetic patch. This complication would be most unusual in the presence of a small atrial septal defect closed with a small patch; and some surgeons avoid the hemolysis risk by using a tissue patch.
Patch closure of the ostium primum defect is widely used and well tested. There is a low incidence of heartblock; dehiscence is unheard of; and there should be no distortion of the mitral valve annulus. Direct closure of the ostium primum defect may be performed successfully in a small subset of patients with AVSDs, but surgeons should be careful to use it only for small defects.
References
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