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The Journal of Thoracic and Cardiovascular Surgery, Vol 105, 289-295, Copyright © 1993 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
EL Bove, LL Minich, AK Pridjian, FM Lupinetti, AR Snider, M Dick 2d and RH Beekman 3d
Neonates with ventricular septal defect and aortic arch obstruction
frequently have subaortic stenosis resulting from posterior deviation of
the infundibular septum. Because the aortic anulus is often hypoplastic,
making direct resection of the infundibular septum through the standard
transaortic approach difficult, the optimal method of repair is uncertain.
From September 1989 through November 1991, seven patients with ventricular
septal defect, coarctation (n = 4), or interrupted aortic arch (n = 3) and
severe subaortic stenosis underwent repair with use of a technique that
included transatrial resection of the infundibular septum. Their ages
ranged from 5 to 63 days (median 15 days) and weights from 1.3 to 5.4 kg
(mean 3.1 kg). Only one patient was older than 1 month. The systolic and
diastolic ratios of the diameter of the left ventricular outflow tract to
that of the descending aorta were 0.53 +/- 0.09 mm (standard deviation) and
0.73 +/- 0.11, respectively. At operation, the posteriorly displaced
infundibular septum was partially removed through a right atrial approach
by resecting the superior margin of the ventricular septal defect up to the
aortic anulus. The resulting enlarged ventricular septal defect was then
closed with a patch to widen the subaortic area. In each patient the aortic
arch was repaired by direct anastomosis. All patients survived operation;
there was one late death from noncardiac causes 3 months after repair. The
survivors remain well from 3 to 14 months after repair (mean 8 months). All
are in sinus rhythm and none has a residual ventricular septal defect. One
patient underwent successful balloon dilation of a residual aortic arch
gradient late after repair. No patient has significant residual subaortic
stenosis, although one has valvular aortic stenosis. This series suggests
that in neonates with ventricular septal defect and severe subaortic
stenosis resulting from posterior deviation of the infundibular septum,
direct relief can be satisfactorily accomplished from a right atrial
approach. This method provides effective widening of the left ventricular
outflow tract and is superior to palliative techniques or conduit
procedures.
ARTICLES
The management of severe subaortic stenosis, ventricular septal defect, and aortic arch obstruction in the neonate
Department of Surgery, University of Michigan School of Medicine, Ann Arbor.
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