Ann Thorac Surg 2005;80:332-333
© 2005 The Society of Thoracic Surgeons
Case report
Dor Procedure for Left Ventricular Diverticulum With Mitral Regurgitation in an Infant
Ko Yoshizumi, MDa,
Kozo Ishino, MDa,*,
Masaaki Kawada, MDa,
Emi Fujisawa, MDa,
Shin-ichi Ohstuki, MDb,
Shunji Sano, MDa
a Department of Cardiovascular Surgery, Okayama, Japan
b Department of Pediatric Cardiology, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
Accepted for publication December 29, 2003.
* Address reprint requests to Dr Ishino, Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine and Dentistry, 2-5-1, Shikata-cho, Okayama-City 700-8558, Japan (Email: ishino{at}tb3.so-net.ne.jp).
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Abstract
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Congenital left ventricular diverticulum accompanied by MR is a rare abnormality. A 5-month-old female infant with this clinical combination underwent a procedure comprising exclusion of a large diverticulum by using an endoventricular circular patch (Dor procedure). This technique allowed us to avoid restriction of the left ventricular cavity and to improve the orientation of the papillary muscles, thus leading to successful mitral valve repair.
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Introduction
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Congenital left ventricular (LV) diverticulum is usually isolated and very rarely associated with mitral regurgitation (MR). Among 4 reported cases with these lesions [1, 2], the surgical treatment for MR was performed in only 1 patient by valve replacement. Herein, we describe an infant who had a large LV diverticulum and regurgitation of an anatomically normal mitral valve, in whom the LV diverticulum was excluded by the Dor procedure [3] using an endoventricular circular patch, and thus a subsequent mitral valve repair was successful.
A 5-month-old female infant, who had been antenatally diagnosed as having fetal cardiomegaly by ultrasound scan, had recurrent tachypnea, feeding difficulties, and oliguria develop. Chest roentgenogram demonstrated a cardiothoracic ratio of 77%. Echocardiography revealed a large LV diverticulum (51 x 29 mm; Fig 1) arising near the base of the anterior and posterior papillary muscles with a broad ostium extending to the apex of the LV, which compressed the right ventricle. The diameter of the mitral valve was 16 mm (123% of predicted normal). The wall of the diverticulum contracted synchronously with the LV, but its movement was severely hypokinetic. Global LV contractility was preserved. The effective LV volume estimated by the biplane area-length method was 20 mL (89% of normal), and the fractional shortening was 20%. Doppler echocardiography showed blood flowing from the LV to the diverticulum during systole, as well as severe MR through the center of the valve.
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Fig 1. Cross-sectional echocardiogram (apical view) obtained during diastole showing large left ventricular diverticulum. (D = diverticulum; LA = left atrium; LV = left ventricle.)
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The patient was scheduled to undergo an elective operation. A median sternotomy was performed and cardiopulmonary bypass was established by using ascending aorta and bi-caval venous cannulation. After aortic cross clamping and the induction of cardiac arrest, the diverticulum was identified as a flaccid wall. Upon opening the center of the diverticulum, the wall was noted to have obvious musculature, and there was no fibrous tissue or thrombus on the internal surface of the large cavity (Fig 2A). The communication between the LV cavity and the diverticulum was 14 mm in diameter. To preserve LV dimension and shape as much as possible, we decided to perform the Dor procedure [3]. Fourteen pledget-reinforced mattress sutures were placed around the orifice, and the diverticulum was excluded from the left ventricle by the implantation of a circular expanded polytetrafluoroethylene cardiovascular patch (WL Gore & Associates, Flagstaff, AZ) that was 16 mm in diameter (Fig 2B). The wall of the diverticulum was trimmed and its remnant was oversewn to cover the patch. Through the incision on the right side of the left atrium, the mitral valve appeared normal except for dilatation of the annulus and the slightly elongated chordae tendineae on the anterior leaflet. A water-injection test showed a significant mitral insufficiency due to the prolapse in the middle portion of the anterior leaflet. Thus the valve was repaired by the edge-to-edge technique [4] creating a double orifice, and a repeated water-injection test confirmed good competency.
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Fig 2. Intraoperative photographs showing repair of the left ventricular diverticulum. (Left) Musculature of the diverticulum. (Right) Reconstruction of the left ventricle by placement of an expanded polytetrafluoroethylene patch at the location of the communication between the left ventricle and the diverticulum.
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Weaning from cardiopulmonary bypass with low-dose catecholamine support was uneventful, as was the patient’s postoperative clinical course. No anticoagulant therapy was given postoperatively, and no episodes of thromboembolism have occurred. After surgery, echocardiography showed trivial MR, an LV end-diastolic dimension of 38 mm (142% of normal) and fractional shortening of 37%. The calculated LV volume was 32 mL (128% of normal). The patient remains well 1 year postoperatively.
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Comment
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Most infants with an isolated LV diverticulum containing three cardiac layers (endocardium, myocardium, and epicardium) are asymptomatic and require no treatment [5]. The prognosis depends upon the size and progression of the lesion. Only a few patients with this condition who suffered rupture [6] or life-threatening arrhythmias [7] have undergone resections of the diverticula during infancy. The indication for surgery in our patient was decreased LV function and diminished output due to severe MR and ineffective blood flow into the large diverticulum.
Because the mitral valve appeared normal and the diverticulum was located close to both papillary muscles in the present case, we suspected that MR was probably due to involvement of the diverticulum with the papillary muscles. Therefore, the surgical treatment of the diverticulum was conducted to restore the effective volume and geometry of the LV in order to optimize LV as well as mitral valve functions. Although an additional mitral valve repair was necessary after the Dor procedure (endoventricular circular patch plasty) [3], we believe that this technique avoided restriction of the LV cavity and contributed, at least in part, to a successful central double-orifice repair of the mitral valve [4] by improved orientation of the papillary muscles. We left a wall of the diverticulum, which has been reported to be potentially arrhythmogenic [8, 9], to cover the endoventricular patch, therefore careful follow-up is necessary.
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References
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Abstract
Introduction
