Ann Thorac Surg 2002;74:1237-1238
© 2002 The Society of Thoracic Surgeons
Case report
A 30-year follow-up after ventricular septation: the first and the present patient
Koji Nomura, MD*a,
Hiromi Kurosawa, MDa,
Tatsuta Arai, MDa
a Department of Cardiovascular Surgery, The Jikei University School of Medicine, Tokyo, Japan
Accepted for publication May 1, 2002.
* Address reprint requests to Dr Nomura, Department of Cardiovascular Surgery, Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
e-mail: nomura{at}zg7.so-net.ne.jp
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Abstract
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Two patients with double inlet left ventricles were successfully treated by ventricular septation. Patient 1, a 38-year-old woman, underwent operation in 1971. This patient has been a full-time worker. Patient 2, a 2-year-old boy, had a relatively small left ventricle with an estimated volume of 134% of normal value. This patient underwent ventricular septation in 1995. He is now in New York Heart Association class II and enjoying school life.
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Introduction
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Ventricular septation for univentricular heart was begun in 1956 [1]. We present our experience with two long-term survivors.
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Case reports
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Patient 1
In 1971, A 7-year-old girl was admitted to Tokyo Women’s Medical College complaining of severe cyanosis and exercise intolerance. The electrocardiogram showed a complete atrioventricular block. Catheterization revealed a pulmonary stenosis and a pressure gradient of 90 mm Hg. Two well-functioning atrioventricular valves and a single right coronary artery were also detected.
The first operation was performed on April 1971. Under cardiopulmonary bypass, a longitudinal ventriculotomy was made along with the anterior descending coronary artery. There were fine trabeculations in the main chamber which was morphologically left ventricle and a rudimentary right ventricle was recognized in the left anterior with a large subaortic ventricular septal defect. Commissurotomy was made on the pulmonary valve. Enlargement of the ventricular septal defect was carried out by the superior-anterior muscle resection. All stitches were placed inside the left ventricle, making a newly created ventricular septum using a Teflon patch. A permanent pacemaker was implanted at the end of this operation.
Catheterization in 1984 demonstrated an interatrial shunt, a residual ventricular septal defect, and pulmonary stenosis, which were surgically treated in 1996. Because the complete atrioventricular block was treated with a pacemaker, an incision was made on the anterior wall of the main pulmonary artery that contains the main conduction bundle and extended into right ventricle. Residual shunt as a result of the detachment of the patch was found at the superior-posterior corner of the septum and was closed with an oval-shaped pericardial patch. After resection of the right ventricular free wall muscle, a monocusped patch was designed for the enlargement of the right ventricular outflow tract. The patient is working full-time work since the second operation.
Patient 2
Patient 2, a 2-year-old boy was admitted to Jikei University hospital with the diagnosis of double inlet left ventricle, a left-anterior rudimentary right ventricle, two well-functioning atrioventricular valves, and a large subaortic ventricular septal defect. This patient underwent a pulmonary artery banding at the age of 4 months. He had mild cyanosis when crying. The electrocardiogram showed first degree atrioventricular block. Catheterization demonstrated a mild pulmonary hypertension, pulmonary vascular resistance of 2.2 Wood units, and a mild subaortic stenosis with a pressure gradient of 25 mm Hg at the ventricular septal defect. Echocardiography showed a restrictive flow across the ventricular septal defect and a left ventricular end-diastolic volume of 134% of normal value.
On October 1995, ventricular septal defect was enlarged posteroinferiorly under cardiopulmonary bypass. Ventricular septation using a pericardial patch with Dacron reinforcement was carried out. Because of the relatively small ventricle, the septation patch was sutured to divide the main chamber in an attempt to make right ventricle-to-left ventricle volume ratio of 30/70. The patient was uneventfully weaned off the cardiopulmonary bypass in sinus rhythm.
Catheterizations were done at 3 months and 3 years after the operation. Left ventricular end-diastolic volume was 170% at 3 months, 201% at 3 years after operation. The right ventricular end-diastolic volume was 101% at 3 months and 83% at 3 years. Although the right ventricular pressure was slightly elevated at 38/5 mm Hg 3 years after the operation, the patient’s subsequent course has been satisfactory.
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Comment
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There have been numerous accounts in the literature describing encouraging results in patients with double-inlet left ventricle [2, 3]. But little is known about "long-term survivors" after this procedure. Arai and colleagues [4] reported a successful ventricular septation in 1973. This patient, who is now 37-year-old, has been a full-time worker and, to our knowledge, is considered to be the longest survivor. The patients we studied were operated on in 1971 and in 1995, respectively. During the two decades between the two patients, many aspects of cardiac surgery have dramatically progressed. Surgical technique, anesthesia, myocardial protection, and postoperative management have become more sophisticated. Despite the lack of conventional management, septation provided excellent long-term quality of life for Patient 1. Arai and colleagues determined that the size of the septation patch should be decided in the ventricular systolic phase [4].
Patient 2 had a suboptimal left ventricle for ventricular septation. Kurosawa and associates [5] reported that more than 170% of the normal value of the ventricle is necessary for septation. Preoperatively, the ventricle was estimated at 134% of normal. The patch was fashioned to divide a single ventricle into a relatively small right ventricle and a relatively large left ventricle. It is also essential that the septation patch be small to avoid systolic deviation to the right ventricle. The right ventricle-to-left ventricle volume ratio was 101/170 mm Hg 3 months after septation, which decreased to 83/200 mm Hg 3 years later. This procedure may contribute to good hemodynamics.
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References
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- McGoon D.C., Danielson G.K., Ritter D.G., Wallace R.B., Maloney J.D., Marcelletti C. Correction of the univentricular heart having two atrioventricular valves. J Thorac Cardiovasc Surg 1977;74:218-226.[Abstract]
- Ebert P.A. Staged partitioning of single ventricle. J Thorac Cardiovasc Surg 1984;88:908-913.[Abstract]
- Kawashima Y., Mori T., Matsuda H., Miyamoto K., Kozuda T., Manabe H. Intraventricular repair of single ventricle associated with transposition of the great arteries. J Thorac Cardiovasc Surg 1976;72:21-27.[Abstract]
- Arai T., Sakakibara S., Ando M., Takao A. Intracardiac repair for single or common ventricle, creation of a straight artificial septum. Singapore Med J 1973;14:187-189.[Medline]
- 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]
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Abstract
Introduction
