Ann Thorac Surg 2007;83:2181
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Alan G. Magee, FRCP
Department of Pediatric Cardiology, Royal Brompton and Harefield NHS Trust, Sydney St, London, SW3 6NP United Kingdom
(Email: a.magee{at}rbht.nhs.uk).
Zhang and colleagues [1] report their experience of mono-valve patch closure in 27 patients with large ventricular septal defects and significantly elevated pulmonary vascular resistance. All patients had a bi-directional shunt on echocardiogram and a total pulmonary vascular resistance of greater than 10 Wood units (ie, above the range in which closure of such a defect is traditionally believed to be safe). The details of the preoperative hemodynamic assessment are rather brief, and the study would be considerably strengthened by the measurement of pulmonary vascular reactivity in response to 100% oxygen and also to nitric oxide (if available). Although a significant acute fall in pulmonary artery pressure was measured, medium term data from a repeat cardiac catheterization or an echocardiographic estimate of pulmonary artery pressure would have been helpful. Nevertheless, the authors are to be congratulated on impressive results with an early mortality of only 7.4% and a dramatic symptomatic improvement in all survivors extending to the medium term in a population often believed to be inoperable.
The use of a fenestrated patch to prevent acute right ventricular failure in the early postoperative period is not new, and double patch flap techniques have been described allowing some early right to left shunting followed by closure of the flap as the shunt becomes left to right. Such patches were constructed using Dacron (Impra, C. R. Bard, Tempe, AZ) or Goretex (W. L. Gore, Flagstaff, AZ) with a flap of autologous pericardium. The innovation here is the use of a mono-valve made from the noncoronary cusp cut from an aortic homograft into which a tailored fenestration was made. The size of the fenestration was roughly dependent on the size of the patient and the degree of right to left shunting as estimated by the resting arterial oxygen saturation. Although the largest fenestration at 8 mm does seem generous, the valves did seem to perform as intended and at follow-up the majority showed no residual right to left shunt. Providing aortic homografts are not in short supply, this technique would seem to offer hope in the management of large ventricular septal defects in those many parts of the world where presentation is late. This study also reminds us that almost 50 years after the description of Eisenmenger’s syndrome by Paul Wood, there is still so much that we do not know about secondary pulmonary hypertension and that perceived wisdom can often be mistaken.
 |
References
|
|---|
- Zhang B, Wu S, Liang J, et al. Unidirectional monovalve homologous aortic patch for repair of ventricular septal defect with pulmonary hypertension Ann Thorac Surg 2007;83:2176-2181.[Abstract/Free Full Text]
Related Article
-
Unidirectional Monovalve Homologous Aortic Patch for Repair of Ventricular Septal Defect With Pulmonary Hypertension
- , , , , , , and
Ann. Thorac. Surg. 83: 2176-2181.
[Full Text]
Top
References