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J Thorac Cardiovasc Surg 2007;133:1326-1328
© 2007 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Discussion

Dr W. Williams (Toronto, Ontario, Canada). Mr. Chairman, I have no conflicts of interest to disclose.

I would like to congratulate Dr Shin’oka and his colleagues for their report of their excellent, very large clinical experience in surgical management of patients with AV discordance. Their analysis focuses on survival and the factors that affect survival. Specifically, they address the important question of whether these patients are better served by an anatomic repair wherein the left ventricle is connected to the systemic circulation, rather than conventional repair in which the morphologic right ventricle remains the systemic ventricle. It’s generally accepted that the right ventricle and its tricuspid valve are poorly suited to support the systemic circulation lifelong. There are, however, rare cases of isolated AV discordance in patients who have no associated lesions and who survive into the seventh and eighth decade of life, perhaps the exceptions that prove that rule.

The majority of patients with AV discordance have major associated lesions. The most prevalent are VSD, PS, or PA, TR, and AV block.

These 4 lesions occur in permutations and combinations, but, of course, any cardiac lesion may occur with AV discordance including single ventricle. In Dr Shin’oka’s series, 21% of their patients had a Fontan operation for single ventricle.

In 1990, Dr Ilbawi reported success with anatomic repair for AV discordance as an alternative to conventional repair. Ilbawi’s contribution of using the left ventricle in the systemic circulation expanded the options for these patients. There are now at least 8 surgical options to manage patients with AV discordance. Whether the more complex anatomic repairs will produce better long-term results remain unknown. I must say I am concerned about combining, in one patient, the well-known late complications of an atrial repair, whether a Mustard or a Senning, and those . . . [Full Text of this Article]

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Outcomes of definitive surgical repair for congenitally corrected transposition of the great arteries or double outlet right ventricle with discordant atrioventricular connections: Risk analyses in 189 patients

Toshiharu Shin’oka, Hiromi Kurosawa, Yasuharu Imai, Mitsuru Aoki, Masakuni Ishiyama, Takahiko Sakamoto, Shinka Miyamoto, Kyoko Hobo, and Yuki Ichihara
J. Thorac. Cardiovasc. Surg. 2007 133: 1318-1328. [Abstract] [Full Text] [PDF]