HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Miyamura, H. Articles by Hayashi, J.-i. Search for Related Content PubMed PubMed Citation Articles by Miyamura, H. Articles by Hayashi, J.-i.

J Thorac Cardiovasc Surg 1994;107:1428-1431
© 1994 Mosby, Inc.

SURGERY FOR CONGENITAL HEART DISEASE

Total circular annuloplasty with absorbable suture for the repair of left atrioventricular valve regurgitation in atrioventricular septal defect

Niigata, Japan

From the Department of Thoracic and Cardiovascular Surgery, Niigata University School of Medicine, Niigata, Japan.

Received for publication Aug. 17, 1993. Accepted for publication Nov. 29, 1993. Address for reprints: Haruo Miyamura, MD, Department of Thoracic and Cardiovascular Surgery, Niigata University School of Medicine, Asahi-machi 1-757, Niigata City, 951, Japan.

Abstract

To obtain a better control of left atrioventricular valve regurgitation, we applied total circular annuloplasty with the use of absorbable sutures to 14 children with atrioventricular septal defect (six complete forms and eight incomplete forms). In the intraoperative period, a good coaptation of the leaflets was achieved and the regurgitation was minimized or disappeared. Follow-up studies with echocardiography for 13 survivors showed a gradual increase of annular size during the postoperative period. Ten patients of the survivor group (77%) maintained good valvular competency in a long-term period. Total circular annuloplasty is a simple and effective procedure to reduce the regurgitation and prevent the annular dilatation during the immediate postoperative period. (J THORAC CARDIOVASC SURG 1994;107:1428-31)

Since Lillehei reported the first successful repair of atrioventricular septal defect (AVSD) in 1955, ¹ many variations and modifications of the surgical technique have been developed, ^2-5 and each technique seems to offer satisfactory results if properly used. Surgical treatment of AVSD consists of the closure of interventricular or interatrial communications along with the creation of two competent nonstenotic atrioventricular valves. Interventricular and interatrial communications can be ordinarily closed with synthetic patch materials, but the reparative procedure of the left atrioventricular (AV) valve has not been well established yet. Minor regurgitation often persists after the operation, and it may worsen with time. To obtain the left AV valve competence, we developed a new technique of total circular annuloplasty with absorbable sutures, and we have used this technique clinically since 1984. ⁶ This article describes the early and late results of this method.

PATIENTS AND METHODS

Between June 1984 and June 1991, 28 patients with AVSD (11 complete forms and 17 incomplete forms) underwent corrective operation at our institution. In the intraoperative period, after the standard corrective procedure, 14 of 28 patients were found to have mild-to-moderate residual left AV valve regurgitation, and total circular annuloplasty technique was added. Studies were done on these 14 patients.

The ages of the 14 patients ranged from 7 months to 10 years (mean age 4.7 years, with seven boys and seven girls). The diagnosis was complete AVSD in six patients (one with an association of tetralogy of Fallot) and incomplete AVSD in eight. Three patients had Down syndrome, and one had Ellis van Creveld syndrome. Ten of these 14 patients had moderate-to-severe AV valve regurgitation before the operation. The operation was done through a median sternotomy in all cases. While the patient was under moderate hypothermic extracorporeal circulation, the aortic root was crossclamped, and the cardiac standstill was obtained with cold cardioplegic solution. Through right atriotomy, morphologic details were examined carefully. In complete AVSD, the interventricular and interatrial communications were closed either by the single patch or the two patch method. In both complete and incomplete forms, the commissure between the left superior and left inferior leaflets (the "mitral cleft") was sutured to sufficiently meet each leaflet by several simple stitches. Care was taken not to make the valvular orifice stenotic. Cold saline solution was injected into the left ventricular cavity to ensure AV valve competency. If the mild regurgitation remained after the extensive suturing of the mitral cleft, total circular annuloplasty was performed. Using an absorbable suture material (4-0 polydioxanone or 4-0 polyglactin suture), we made a single row of continuous sutures on the left AV valve anulus (Fig. 1). On the anterior and lateral aspect of the valve, the suture was placed on the anulus, and on the posterior aspect (inferior leaflet), it was placed just inside of the anulus to avoid possible conduction disturbance. In the septal portion, the suture was placed in the new atrial septum (patch) adjacent to the leaflet. A sized obturator was inserted in the valvular orifice, and the suture was pulled until the adequate orifice diameter was obtained. We consider the standard mitral valve orifice size reported by Rowlatt, Rimoldi, and Lev ⁷ to be the optimum size of the left AV valve (Fig. 2). The suture was tied over the obturator, and valve competence was tested again. If considerable regurgitation remained, an additional constriction of the anulus was made. After this procedure, the regurgitation was usually remarkably reduced or completely gone. The atrial septum was then reconstructed with a pericardial xenograft patch. The aortic clamp was released, and the heart was allowed to beat again. The right atrium was closed, and the extracorporeal circulation was terminated.

View larger version (27K): [in this window] [in a new window]   Fig. 1. Total circular annuloplasty technique. A single row of continuous suture is placed on the anulus. In the posterior portion, the suture line is inside the anulus, and, in the septal portion, it is in the patch. The absorbable suture is tied down on a pledget, which is later secured by nonabsorbable suture. P, Patch for atrial septum; LSL, left superior leaflet; LLL, left lateral leaflet; LIL, left inferior leaflet.

View larger version (26K): [in this window] [in a new window]   Fig. 2. The relation of annular diameter and Rowlatt's standard. Open circles are annular diameter before annuloplasty; closed circles are annular diameter after annuloplasty. The solid line is the mean value of the standard, and the dotted lines indicate 5% level of confidence of this standard.

There was one operative death (7.1%): a patient with complete AVSD and tetralogy of Fallot. This patient died of severe biventricular dysfunction after the prolonged extracorporeal circulation. The other 13 patients survived and had uneventful convalescence. The 13 survivors were followed-up for 1 to 9 years after hospital discharge, and the annular diameter of left AV valve was measured by echocardiography during the follow-up period. The patients' profiles and follow-up data are listed on Table I. One patient with incomplete AVSD (patient No. 8) required mitral valve replacement 3 years after the initial repair for the exacerbation of left AV valve regurgitation. This patient tolerated the second operation well and had no symptoms at the time this article was written; another patient with incomplete AVSD (patient No. 3), although without symptoms, showed progressive annular dilatation with moderate valvular regurgitation, which may necessitate valve replacement in the future. All 13 survivors were in satisfactory condition (New York Heart Association functional class I or II). As is shown in Table I, a gradual increase of the annular diameter was observed in the postoperative course. Assessment by Doppler echocardiography showed that the current regurgitation grade was none-to-mild in 10 patients (77% of survivors) and moderate in two patients (15%).

Left AV valve regurgitation is a troublesome residuum after the corrective operation of AVSD. Pozzi and associates ⁸ reported that 10.9% of the patients during follow-up required reoperation for AV valve incompetence. ⁸ McGrath and Gonzalez-Lavin ⁹ reported that 77% of all reoperations were done for left AV valve incompetence. Even if the regurgitation seemed trivial in the intraoperative period, it sometimes became progressively worse during the immediate postoperative period. We suppose that left AV valve regurgitation, as well as left ventricular dysfunction, right after the cardiac operation induces the increase of left ventricular preload, which results in annular dilatation. This increase makes the valve incompetence even worse. The regurgitation has to be minimized as much as possible to end this vicious cycle. We developed a new technique to repair the left AV valve incompetence and prevent the annular dilatation during the immediate postoperative period by total circular annuloplasty with absorbable suture material. At operation, we often find that the lateral and inferior leaflets of the left AV valve are small or hypoplastic and that they do not join well to anterior or bridging leaflets. The total circular annuloplasty allows a good coaptation of these leaflets. The suture placed in the septal portion may seem unnecessary, but we believe that the major advantage of this procedure lies in the simplicity. Placing a purse-string suture on the anulus takes only a few minutes, and thus far we have recognized no adverse sequelae. Because patients are mostly young children, we used absorbable sutures in this procedure. The usefulness of absorbable suture in pediatric cardiovascular surgery was reported by Myers, Campbell, and Waldhausen ¹⁰ and Chiu and associates. ¹¹ Duran and associates ¹² reported the safety and effectiveness of tricuspid annuloplasty with the use of absorbable suture in animal experiments. In our procedure, the absorbable suture was placed in the valvular anulus in the left side of the heart, and, according to echocardiographic evaluation, no unfavorable tissue reaction, such as granuloma formation or tissue disruption, was observed.

We used two kinds of sutures (polydioxanone and polyglactin), and the clinical data did not show any differences between two suture materials. We therefore believe they were both equally useful in this procedure. As is shown in Table I, our technique does not interfere with the annular growth. Furthermore, our findings showed that, even when sutures were absorbed, the valvular incompetence did not progress in most cases, which indicates the importance of complete control of the valvular competency at the initial repair. Our technique of total circular annuloplasty is simple and effective for repair of left AV valve incompetence in AVSD.

References

1. Lillehei CW, Cohen M, Warden HE, Varco RL. The direct-vision intracardiac correction of congenital anomalies by controlled cross circulation. Surgery 1955;38:11-29. [Medline]
   
2. Kirklin JW, Daugherty GW, Burchell HB, Wood EH. Repair of the partial form of persistent common atrioventricular canal. Ann Surg 1955;142:858-62. [Medline]
   
3. Rastelli GC, Ongley PA, Kirklin JW, McGoon DC. Surgical repair of the complete form of persistent common atrioventricular canal. J THORAC CARDIOVASC SURG 1968;55:299-308. [Medline]
   
4. Rastelli GC, Ongley PA, McGoon DC. Surgical repair of complete atrioventricular canal with anterior common leaflet undivided and unattached to ventricular septum. Mayo Clin Proc 1969;44:335-41. [Medline]
   
5. Carpentier A. Surgical anatomy and management of the mitral component of atrioventricular canal defects. In: Anderson RH, Shinebourne EA, eds. Pediatric cardiology. London: Churchill Livingstone, 1978:477-90.
   
6. Eguchi S, Miyamura H, Kanazawa H. Total circular annuloplasty using absorbable suture for the surgery of endocardial cusion defect [in Japanese]. Geka Shinryo 1985;27:1428-32.
   
7. Rowlatt UF, Rimoldi HJA, Lev M. The quantitative anatomy of the normal child's heart. Pediatr Clin North Am 1963;10:499-588.
   
8. Pozzi M, Rmig J, Fimmers R, Urban AE. Atrioventricular septal defect: analysis of short- and medium-term results. J THORAC CARDIOVASC SURG 1991;101:138-42. [Abstract]
   
9. McGrath LB, Gonzalez-Lavin L. Actuarial survival, freedom from reoperation, and other events after repair of atrioventricular septal defects. J THORAC CARDIOVASC SURG 1987;94:582-90. [Abstract]
   
10. Myers JL, Campbell DB, Waldhausen JA. The use of absorbable monofilament polydioxanone suture in pediatric cardiovascular operations. J THORAC CARDIOVASC SURG 1986;92:771-5. [Abstract]
    
11. Chiu IS, Hung CR, Chao SF, Huang SH, How SW. Growth of the aortic anastomosis in pigs. J THORAC CARDIOVASC SURG 1988;95:112-8. [Abstract]
    
12. Duran CMG, Balasundaram SG, Bianchi S, Herdson P. The vanishing tricuspid annuloplasty. J THORAC CARDIOVASC SURG 1992;104:796-801.[Abstract]
    

This article has been cited by other articles:

				L. Mace, P. Dervanian, L. Houyel, E. Chaillon-Fracchia, D. Piot, V. Lambert, J. Losay, and J.-Y. Neveux Surgically created double-orifice left atrioventricular valve: A valve-sparing repair in selected atrioventricular septal defects J. Thorac. Cardiovasc. Surg., February 1, 2001; 121(2): 0352 - 365. [Abstract] [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Miyamura, H. Articles by Hayashi, J.-i. Search for Related Content PubMed PubMed Citation Articles by Miyamura, H. Articles by Hayashi, J.-i.