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Ann Thorac Surg 2006;81:1450-1454
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

Utilization of Double-Orifice Valve Plasty in Correction of Atrioventricular Septal Defect

Yong-Qiang Lai, MD * , Yi Luo, MD, Chun Zhang, MD, Zhao-Guang Zhang, MD

Division of Cardiac Surgery, Beijing Anzhen Hospital, Capital University of Medical Sciences, Beijing, China

Accepted for publication October 31, 2005.

* Address correspondence to Dr Lai, Division of Cardiac Surgery, Beijing Anzhen Hospital, Capital University of Medical Sciences, 36 Wuluju Chaoyang District, Beijing, 100029 China (Email: yongqianglai{at}yahoo.com).


   Abstract
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 Abstract
Introduction
 Material and Methods
 Results
 Comment
 The Society of Thoracic...
 Acknowledgments
 References
 
BACKGROUND: Atrioventricular valve regurgitation represents the principal indication for reoperation after repair of atrioventricular septal defect. Deciding how to correct atrioventricular valve regurgitation is challenging in some cases because of the complexity of the anatomic features. This report deals with our surgical experience in using a double-orifice valve plasty technique in cases with atrioventricular septal defect.

METHODS: From August 2002 to August 2004, 8 patients underwent double-orifice valve plasty in surgical correction of atrioventricular septal defect. Anatomic types were partial (6 patients), intermediate (1 patient), and complete (1 patient). After the mitral cleft was closed, moderate to severe atrioventricular valve regurgitation was still present in these patients. Double-orifice valve plasty was used in the mitral valve in 7 patients and in the tricuspid valve in 1.

RESULTS: No hospital deaths or postoperative morbidity occurred. The follow-up ranged from 6 months to 30 months (median, 14.4 months). No or trivial atrioventricular valve regurgitation was found in 6 patients and mild atrioventricular valve regurgitation was present in 2.

CONCLUSIONS: Double-orifice valve plasty is an easy and effective additional procedure for children and for adult patients who have moderate or severe atrioventricular valve regurgitation after repair of atrioventricular septal defect.


   Introduction
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 Abstract
 Introduction
Material and Methods
 Results
 Comment
 The Society of Thoracic...
 Acknowledgments
 References
 
Advances in surgical technique and postoperative care have resulted in substantial improvement in the operative mortality and postoperative morbidity after repair of atrioventricular septal defect (AVSD) 1–5]. However, late morbidity and the need for reoperation complicate the medium and long-term results. Atrioventricular valve regurgitation (AVVR) is the principal cause of late morbidity and the main reason of reoperation after correction of AVSD 1, 6–9]. The repair of AVVR is challenging in some cases because of the complexity of the anatomic features responsible for valve regurgitation. Many novel methods have been adopted to solve the problem, but the results are far from satisfactory 10–12].

Double-orifice valve plasty (DOVP) technique has been used in a standardized approach to treat patients with bileaflet prolapse and severe mitral regurgitation. The early and mid-term results are satisfactory 13–15]. Herein we provide a description of the surgical technique and short-term results of DOVP for valve repair in correction of AVSD.


   Material and Methods
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 Material and Methods
Results
 Comment
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 Acknowledgments
 References
 
The study was approved by our institutional review board and individual consent was obtained before operation. From August 2002 to August 2004, 8 patients underwent DOVP during correction of AVSD. All the patients were female and their ages ranged from 15 to 45 years. They presented with partial AVSD (6 patients), intermediate AVSD (1 patient), and complete AVSD (1 patient). Epicardial or transesophageal echocardiography was performed in all patients to assess valve regurgitation during operation. All of the patients were re-examined with transthoracic echocardiography before discharge. Follow-up information regarding clinical status and echocardiographic findings were obtained. The follow-up ranged from 6 to 30 months (average, 14.4 months) (Table 1).


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  		Table 1. Patient Profiles
 
The operation was performed under cardiopulmonary bypass and mild hypothermia. Cold antegrade crystalloid cardioplegic solution was used in all patients. The cardiac defect was approached through a right atriotomy. The ostium primum defect was closed with a fresh autologous pericardial patch. For the patient with complete AVSD, a two-patch method was utilized to correct the anomaly; the ventricular septal defect was closed with a heterologous pericardial patch. The small ventricular septal defect was directly closed in the patient with intermediate AVSD. For patients with partial and intermediate AVSD, the inferior edge of the ostium defect patch was placed on the right side of the interventricular septum with interrupted mattress sutures to avoid changing the anatomic morphology of the mitral valve. Interrupted polypropylene 5-0 sutures (Ethicon, Somerville, NJ) were used to completely close the mitral cleft from the annulus to the leaflet margin. The coronary sinus was routinely left in the left atrium. Intraoperative assessment of AVVR was done with repeat saline distention of the left ventricle. Seven of the patients had moderate or severe mitral regurgitation after closing the mitral cleft, and the regurgitation was central. In order to correct this regurgitation, a double-orifice mitral valve plasty was performed in these patients.

The subvalvular structures including chordae and papillary muscles were inspected with a nerve hook. For patients with AVSD, the mitral regurgitation was usually central, just at the position of the closed cleft and the corresponding posterior leaflet. A stay stitch was placed to approximate the free edges of both leaflets at the site of regurgitation. We used one or two U-shaped 5-0 polypropylene stitches reinforced with small pericardial pledgets. The suture was placed through each leaflet just at the edge turned down to attach to the primary chordae. It was beneficial for the two leaflets to touch during systole and create the largest area of coaptation (Figs 1, 2). Go After the DOVP was created, cold saline injection was repeated again. The symmetry of the two halves of the valve was checked again to avoid postoperative distortion and residual leakage. The two orifices were measured with Hegar dilators (SSR Inc, Oyster, NY); a global valve area of more than 2.5cm2 was considered acceptable for normal-size patients [14].


Figure 1
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  		Fig 1. The cleft of the mitral valve was closed and a double-orifice mitral plasty was performed. The inferior edge of the autologous pericardial patch was fixed on the right side of the ventricular septum.

 

Figure 2
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  		Fig 2. Showing the double-orifice of the mitral valve.

 
For the patient with tricuspid DOVP, the mitral cleft was closed with interrupted polypropylene 5-0 sutures, and forceful injection of saline solution into the left ventricle showed trivial mitral regurgitation. Because part of the septal leaflet of tricuspid valve was absent, transfer of the anterior and posterior leaflets and an annuloplasty with a Carpentier ring (Edwards Lifesciences Inc, Irvine, CA) were performed. Saline injection showed that there was still a severe tricuspid regurgitation. Double-orifice valve plasty was adopted for this patient. The anterior and posterior leaflets were sutured together. At the site of regurgitation, two U-shaped 5-0 polypropylene stitches reinforced with small pericardial pledgets were applied. Saline injection demonstrated mild tricuspid regurgitation.

After weaning from cardiopulmonary bypass, epicardial or transesophageal echocardiography was performed to re-evaluate the valve regurgitation and the valve area.

All of the patients were re-examined with transthoracic echocardiography before discharge. The follow-up ranged from 6 to 30 months (average, 14.4 months). Follow-up information regarding clinical status and echocardiographic findings were obtained (Table 1).


   Results
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 Material and Methods
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Comment
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The intensive care unit courses were uneventful with no hospital deaths or postoperative morbidity. They were extubated within 24 hours after operation.

No or trivial AVVR was found in 6 patients and mild AVVR presented in 2. None of the patients had postoperative mitral or tricuspid stenosis. The valve orifice area ranged from 2.5 cm2 to 3.1 cm2 (2.9 ± 0.3 cm2). The mean diastolic trans-double-orifice valve gradient ranged from 1.2 mm Hg to 5.6 mm Hg (3.2 ± 1.5 mm Hg). No obstruction of the left ventricular outflow tract developed during follow-up period. The peak instantaneous gradient across the left ventricular outlet tract ranged from 0.9 m/s to 1.4 m/s (1.1 ± 0.2 m/s).


   Comment
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 Introduction
 Material and Methods
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 Comment
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 Acknowledgments
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With the advances in surgical techniques and postoperative care, the operative mortality for repair of AVSD has been dramatically decreased 1–5]. Although most AVSD patients receive surgical repair as neonates or young infants in the Western world, in developing countries, some patients are postponed until their child or adult to undergo surgical treatment. Atrioventricular valve regurgitation is still the main reason for postoperative morbidity and reoperation. The incidence of reoperation has not improved significantly. After patients underwent correction of AVSD, freedom from reoperation for AVVR is 74% to 91% at 10 years; moderate to severe left AVVR has been observed postoperatively in 23% at follow-up 1, 4, 7, 8, 16–17]. Freedom from postoperative left AVVR grade III or more was 89% at 5 years and 78% at 10 years after correction of incomplete AVSD [7]. Postoperative left AVVR grade II or more during operation or at hospital discharge is an important risk factor related to late left AVVR reoperation. More attention should be directed toward the correction of moderate to severe AVVR during operation, and better techniques to eliminate late AVVR are needed.

It is a challenge to repair AVVR in some cases because of the complexity of the anatomic mechanism responsible for valve regurgitation. Traditional repair may leave a residual central leak in patients with AVSD. The regurgitation is usually at the position of the closed cleft and the corresponding posterior leaflet. This situation is more serious in children and in adult patients, and they are at higher risk than the neonates because of the development of valve thickening, thereby leaving the potential for central regurgitation problems. This obviously affects the mid-term and long-term results. Some patients with severe valve deformity require valve replacement when they undergo reoperation to resolve AVVR.

Double-orifice valve plasty is an easy and effective method to solve complex regurgitant valve problems. The early and mid-term results are satisfactory 13–15]. Repair of a regurgitant valve is superior to valve replacement with lower hospital mortality, longer survival, better preservation of ventricular function, fewer thromboembolic complications, and reduced risk of endocarditis. Immediate postoperative severe left AVVR has been demonstrated a strong risk factor for early death and reoperation for patients with AVSD [18]. Considering the anatomic features of the mitral valve in patients with AVSD, and the difficulty in correcting a residual central regurgitation with traditional repair methods, we applied DOVP in patients who had moderate or severe valve regurgitation after the cleft was closed. Postoperatively there was no or trivial AVVR in 6 patients and mild AVVR in 2. This method was not used in our neonate and infant patients because of concerns about postoperative stenosis after DOVP. Mace and colleagues [19] reported the creation of double-orifice atrioventricular valves in infant AVSD patients with relatively good results. They also emphasized that mural leaflet shape and subvalvular apparatus characteristics were important determinants of the ability to perform a double-orifice valve repair. This indicates that DOVP can also be used to correct moderate and severe AVVR in infant AVSD patients.

The mitral valve annulus is usually only slightly dilated and some restriction of the valve movement might exist after the mitral cleft was closed in patients with AVSD. In fact, DOVP was mainly used in the presence of a valvular prolapse or restriction, not for an annular dilatation. In this situation, DOVP may be an effective additional tool to correct AVVR. We usual fix the inferior edge of the ostium defect patch on the right side of the interventricular septum with interrupted mattress sutures and directed the coronary sinus to left atrium. This could avoid changing the anatomic morphology of the mitral valve and reducing the mitral ring. We believed it may help to prevent mitral stenosis after applying DOVP. All of the patients had no significant stenosis during the operative evaluation and short-term follow-up. Dehiscence was an important reason for AVVR and reoperation. We usually used one or two U-shaped 5-0 polypropylene stitches reinforced with small pericardial pledgets. The small pericardial pledget can reduce the stitch tension to prevent the suture from dehiscence. Greater stitch tension on the mitral valve was seen in diastole after the Alfieri procedure, and it may at least in theory affect the durability of the procedure [20].

Congenital double-orifice left atrioventricular valve is a rare cardiac lesion that occurs as an isolated anomaly or in association with other cardiac malformations. It is often associated with AVSD; about 7.5% patients with complete AVSD had a double-orifice atrioventricular valve. Double-orifice left atrioventricular valve was regarded as a strong risk factor for surgical correction of AVSD and a significant risk factor for reoperation 16, 19, 21–23]. Congenital double-orifice left atrioventricular valve is often associated with a small mural leaflet and subvalvular structural anomalies such as a parachute subvalvular apparatus or chordal insertions into a papillary muscle. This may contribute to surgical risk factors. Ohta and colleagues [24] found that keeping double-orifice mitral valve intact yielded acceptable midterm results without developing severe dysfunction in the left side atrioventricular valve. We inspected the mural leaflet and subvalvular structure during operation. The mural leaflets were well developed in these children or adult patients and we did not find any abnormalities of chordae or papillary muscles. We used DOVP to correct AVVR. No valve malfunction was found during short-term follow-up; the long-term results still need to be determined.

Left ventricular outflow tract obstruction (LVOTO) was one of the principal causes of late morbidity after repair of AVSD 25–28]. In cases with normally related great arteries, the occurrence of left ventricular outflow tract obstruction was seldom. However, in cases with abnormally related great arteries, the morphology of the ventricular septal defect and the mitral cleft did not resemble that of atrioventricular canal defects; the attachment of the cleft usually produced left ventricular outflow tract obstruction. Mascagni and colleagues [29] recently found that edge-to-edge technique could correct the systolic anterior motion of the mitral valve and solve left ventricular outflow tract obstruction after mitral valve repair. For our patients who received DOVP, the short-term follow-up showed no obstruction of the left ventricular outlet tract.

In conclusion, DOVP is an easy and effective additional procedure for those children and adult patients who have moderate or severe atrioventricular valve regurgitation after repair of AVSD. It may reduce the possibility of reoperation after correction of AVSD in some selected patients.


   The Society of Thoracic Surgeons: Forty-Third Annual Meeting
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 Results
 Comment
 The Society of Thoracic...
Acknowledgments
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Please mark your calendars for the Forty-Third Annual Meeting of The Society of Thoracic Surgeons, to be held in San Diego, California, from January 29-31, 2007. The program will provide in-depth coverage of thoracic surgical topics selected to enhance and broaden the knowledge of cardiothoracic surgeons. Attendees will benefit from traditional Abstract Presentations, as well as Surgical Forums, Breakfast Sessions, Surgical Motion Pictures, and Town Hall Meetings on specific topics.

Advance registration forms, hotel reservation forms, and details regarding transportation arrangements, as well as the complete meeting program, will be mailed to Society members this fall. Also, complete meeting information will be available on the Society's Web site at www.sts.org. Nonmembers who wish to receive information on the Annual Meeting may contact the Society's secretary, Douglas E. Wood.

Douglas E. Wood, MD

Secretary

The Society of Thoracic Surgeons

633 N. Saint Clair St, Suite 2320

Chicago, IL 60611-3658

Telephone: (312) 202-5800

Fax: (312) 202-5801

e-mail: mailto:sts{at}sts.org

website: www.sts.org


   Acknowledgments
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 Material and Methods
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 Comment
 The Society of Thoracic...
 Acknowledgments
References
 
The authors acknowledge Dr Gus J. Vlahakes, Chief, Division of Cardiac Surgery, Massachusetts General Hospital, for reviewing this article.


   References
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 Material and Methods
 Results
 Comment
 The Society of Thoracic...
 Acknowledgments
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  16. Najm HK, Coles JG, Endo M, et al. Complete atrioventricular septal defectsresults of repair, risk factors, and freedom from reoperation. Circulation 1997;96:II311-II315.
  17. Boening A, Scheewe J, Heine K, et al. Long-term results after surgical correction of atrioventricular septal defects Eur J Cardiothorac Surg 2002;22:167-173.[Abstract/Free Full Text]
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  20. Nielsen SL, Timek TA, Lai DT, et al. Edge-to-edge mitral repair tension on the approximating suture and leaflet deformation during acute ischemic mitral regurgitation in the ovine heart Circulation 2001;104:I29-I35.
  21. Nakano T, Kado H, Shiokawa Y, Fukae K. Surgical results of double-orifice left atrioventricular valve associated with atrioventricular septal defects Ann Thorac Surg 2002;73:69-75.[Abstract/Free Full Text]
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