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Ann Thorac Surg 2002;73:860-861
© 2002 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, New York Presbyterian Hospital 525, E 68th St, Room F695B, New York, NY 10021, USA
e-mail: jjl2005{at}med.cornell.edu
This important contribution to the surgical literature details the authors’ experience with the use of the Damus-Kaye-Stansel (DKS) procedure for the treatment of patients presenting with systemic ventricular outflow obstruction (SVOO) in the setting of functional single ventricle. While their followup averages only 5 years, the authors demonstrate the safety and durability of this approach. The results are remarkable in the modern context for the authors do not believe in routine staging prior to completion of the Fontan procedure.
We are pleased to find that their results corroborate our own somewhat longer term experience with the DKS procedure. At the San Diego Children’s Hospital, we performed the DKS procedure in 38 patients over a 17 year period. Our median followup was 9.75 years (range: 3 to 18 years) with similar results. In our experience, the DKS procedure was usually performed at the time of the bidirectional cavopulmonary shunt. Since our last report [1], one patient has undergone closure of the anatomic aortic valve and another four patients have undergone annuloplasty/repair of the dilated anatomic pulmonary valve or DKS/sinotubular junction. In no patient was reoperation primarily designed to address abnormalities of the semilunar valves. In each case, reoperation, for completion of the Fontan, replacement of a Rastelli conduit, or Fontan revision, provided an opportunity to address mild to moderate semilunar valve insufficiency. No patient has required semilunar valve replacement. I agree with the authors’ recommendation that a prophylactic DKS procedure should be performed in any patient undergoing palliation for single ventricle when the anatomic substrate predicts the possible later development of SVOO. I believe that a normal pulmonary valve should never be obliterated to prevent pouch formation unless the anatomic aortic valve arises directly from the systemic ventricle and there is no possibility of developing subaortic obstruction. In infants, we favor the Norwood procedure when SVOO is present since the DKS procedure can be associated with late transverse arch obstruction if the procedure is performed during infancy.
While we believe that the DKS procedure is the optimal method for treating systemic ventricular outflow tract obstruction in the setting of functional single ventricle, direct surgical enlargement of the ventricular septal defect/bulboventricular foramen can also be accomplished with reasonable operative morbidity and satisfactory midterm results. While surgical enlargement of the ventricular septal defect can often be carried out through the aortic valve, some patients require a ventriculotomy. In all cases of direct surgical enlargement, there is a risk of permanent complete heart block, recurrence of obstruction and diminished ventricular function. Obviously, direct surgical enlargement of the ventricular septal defect will be required when the patient is not a candidate for the DKS procedure. Interestingly, the DKS procedure may still be possible after prior division of the main pulmonary artery, if the pulmonary valve itself has not been obliterated.
In the final analysis, longer term followup will be necessary to determine the optimal treatment for SVOO when the patient is candidate for either the DKS procedure or direct surgical ventricular septal defect enlargement.
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