Ann Thorac Surg 2002;73:62-63
© 2002 The Society of Thoracic Surgeons
Invited commentary
Tetsuya Kitagawa, MDa
a Department of Cardiovascular Surgery, The University of Tokushima, School of Medicine, 2 Kuramoto, Tokushima 770–8503, Japan
e-mail: kitagawa{at}clin.med.tokushima-u.ac.jp
The management of patients with multiple apical ventricular septal defects remains controversial. It is difficult for most cardiac surgeons to divide coarse right ventricular apical trabeculations or to facilitate accurate identification of the true margins of a solitary defect on the left ventricular side using an atrial approach. The most interesting description of the article by Tsang and associates is the presentation of how to accurately expose a solitary defect through an apical right ventriculotomy in an autopsied specimen. However, to my regret, the autopsied specimen in Figure 4 seems to have midmuscular defects in the anterior septum extending around the moderator and septal bands from the right ventricular aspect. Generally speaking, muscular defects located cranially to the base of the anterior papillary muscle can be successfully seen and closed by dividing the moderator band and lower end of the septal band from an atrial approach; those placed caudally require an apical ventriculotomy. The authors’ approach should be used to repair apical defects only. A limited incision confined to the apex of the right ventricle will be acceptable to most cardiac surgeons in order to avoid a limited apical left ventriculotomy.
Most apical muscular defects have appropriate space between prominent right ventricular trabeculations and extrapolated supposed extension of the interventricular septum as shown in the echocardiogram. A limited apical incision must carefully enter the space between the anterior papillary muscle and the septum by observing the location of the moderator band, the anterior papillary muscle and the anterior descending coronary artery. Dividing muscle trabeculations along the right side of the septum improves exposure and facilitates accurate identification of the true margins of the defect. The lower end of the septal and moderator bands may be safely divided when necessary. Tricuspid function should be carefully assessed and a valvuloplasty performed if tricuspid regurgitation results from distortion and delayed ischemia of the papillary muscle. Care should be taken to avoid damaging the anterior papillary muscle of the tricuspid valve.
Although the eventual outcome of a limited apical right ventriculotomy and any significant differences in late results between limited apical right and left ventriculotomies are uncertain, further follow-up and prudent evaluation with respect to ventricular aneurysm formation, ventricular mechanical and electrical function, tricuspid/mitral valve function, and ventricular arrhythmias will elucidate the utility and validity of this approach. The responsibility of proving the safety and efficacy of the technique lie with those who use it.
Related Article
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Surgical repair of supposedly multiple defects within the apical part of the muscular ventricular septum
- Victor T. Tsang, Tain-Yen Hsia, Robert W.M. Yates, and Robert H. Anderson
Ann. Thorac. Surg. 2002 73: 58-62.
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