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Ann Thorac Surg 1996;62:154
© 1996 The Society of Thoracic Surgeons

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Invited Commentary

Invited Commentary

Section of Thoracic and Cardiovascular Surgery, The Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64018, E-mail: pmanning{at}cmh.edu.

See also page 151.

The onset of congestive heart failure in the first months of life in the child with a primum atrial septal defect or partial atrioventricular canal defect places the condition in a subset of this defect posing significant challenges to successful management. The association of one or multiple left-sided obstructive lesions including coarctation, mitral valve anomaly or hypoplasia, left ventricular hypoplasia, and subaortic stenosis as the cause of such a presentation is emphasized by Giamberti and associates and in our series from the Children's Hospital in Boston [1]. The challenges in formulating a surgical approach in these children is well described in this series, and an attempt to use objective criteria, such as mitral valve area, is advocated to assist in management decisions.

Although Giamberti and associates have well demonstrated that a poor outcome is highly correlated with severe mitral hypoplasia, it is difficult to advocate "giving up" on the left ventricle to pursue a single-ventricle algorithm when it is managing to support the full systemic circulation in these children preoperatively (assuming the ductus is closed or shunting only left to right). As has been shown with other anomalies characterized as multiple lesions in series (interrupted aortic arch/ventricular septal defect, for example) better results can often be achieved by an approach designed to perform a more complete repair in a single stage. The patients described in this series typically have some degree of aortic arch hypoplasia associated with the coarctation. Repair of such a defect via sternotomy on bypass is often easier with more complete immediate resolution of obstruction than the subclavian flap technique employed by Giamberti and associates.

Regardless of the initial approach followed, the current series well demonstrates the frequent need for reintervention. This underscores the importance of continued close surveillance of these patients, particularly regarding mitral valve function and subaortic stenosis.

Reference

1. Manning PB, Mayer JE, Sanders SP, et al. Unique features and prognosis of primum ASD presenting in the first year of life. Circulation 1994;90(Suppl 2):30–5.

This Article 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 Author home page(s): Peter B. Manning Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Manning, P. B. Search for Related Content PubMed Articles by Manning, P. B. Related Collections Related Article