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Ann Thorac Surg 2003;75:151-152
© 2003 The Society of Thoracic Surgeons

Invited commentary

^a Cardiac Surgical Associates of North Texas, 1615 Hospital Parkway, Suite 211, Bedford, TX 76022, USA

Dr Caldarone and colleagues presented their series of eighteen patients with complex left ventricular outflow tract obstruction requiring surgical treatment. In their technique, the authors have a relatively short follow-up of 3.1 years (range, 0.1–6.7 years). In 15 of the 18 patients, they obtained good relief of left ventricular outflow tract obstruction; however, in three patients, #4, #9, and #10, residual gradients were apparent either immediately postoperative or were progressive with time. The technique described by the authors emphasizes several important technical points in performing aortoventriculoplasty. First, in performing the septal incision, administration of cardioplegia through the aortic root distends the aortic valve leaflets and avoids injury to the valve. Second, heart block can be a significant complication of aortoventriculoplasty. Several such patients have had previous left ventricular outflow tract resection through a transaortic approach, and injury to the left bundle of His can occur during resection. Subsequent septal resection performed through the right ventricle carries the potential for injury to the right bundle of His with resultant complete heart block. We have highlighted the importance of limiting surgical resection of septal tissue to the left side of the septum and to minimize any resection on the right side [1]. The technical advantage of this is further enhanced by beveling the incision on the left side of the septum to further augment the left ventricular outflow tract over and above that afforded by a simple septal incision and patching with prosthetic material (see Fig 4). A further important technical point proposed by the authors is utilization of a two-suture technique in the region of the trabecular portion of the right ventricle to minimize against residual ventricular septal defect.

Although advocated by Dr Caldarone, we would disagree with primary closure of the right ventricle in selected cases. We feel that augmentation afforded by a patch on the right ventricular outflow tract minimizes against outflow tract obstruction secondary to encringement of the septal patch into the right ventricle.

Early application of aortoventriculoplasty for less complex forms of left ventricular outflow tract obstruction may be appropriate as we better define subsets of patients at risk for recurrent obstruction following transaortic resection of left ventricular outflow tract. Utilizing the technical guidelines set forth in this paper should enable effective resection of tract obstruction with minimal morbidity and mortality.

References

1. Roughneen P.T., DeLeon S.Y., Cetta F., Vitullo D.A., Bell T.J., Quinones J.A., Fisher E.A., Blakeman B., Bakhos M. The modified Konno-Rastan procedure for subaortic stenosis: indications, operative techniques, and results. Ann Thorac Surg 1998;65:1368-1376.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Roughneen, P. T. Search for Related Content PubMed Articles by Roughneen, P. T.