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J Thorac Cardiovasc Surg 1997;114:851-853
© 1997 Mosby, Inc.

BRIEF COMMUNICATIONS

AORTIC VALVULOPLASTY FOR AORTIC INSUFFICIENCY ASSOCIATED WITH VENTRICULAR SEPTAL DEFECT

Groningen, The Netherlands

Received for publication March 12, 1997 accepted for publication March 27, 1997. Address for reprints: Tjark Ebels, MD, PhD, Thorax Center, University Hospital Groningen, Hanzeplein 1, Postbus 30.001, 9700 RB Groningen, The Netherlands.

Aortic insufficiency caused by valve prolapse is present in more than 5% of children with ventricular septal defect (VSD). ¹ Treatment of aortic insufficiency in children with VSD is a challenging issue. Aortic valvuloplasty by triangular resection of the prolapsing cusp has been used successfully for the treatment of aortic insufficiency resulting from cusp prolapse in adult patients. ² Aortic valvuloplasty by triangular resection of the prolapsing cusp associated with circular annuloplasty and reinforcement of the aortic wall has been previously described for the treatment of aortic insufficiency in children with VSD. ³ However, a circular annuloplasty that includes the entire anulus has the theoretic disadvantage of reducing annular flexibility and precluding annular growth. This can have an adverse effect in view of the somatic growth of children. ⁴

In this brief communication we report the operations performed in three children with VSD and severe aortic insufficiency resulting from cusp prolapse. Aortic valvuloplasty was done successfully with an isolated triangular resection of the prolapsing cusp without any additional procedure involving the aortic anulus.

Surgical technique and results.

The first child (4 years old) was operated on in 1990, the second (5 years old) in 1991, and the third (3 years old) in 1996. The operations were performed with the use of moderate hypothermia. The ascending aorta and both caval veins were cannulated. Cardioplegic arrest was induced by infusion of crystalloid Bretschneider solution. A right transatrial approach was used to expose the VSD. In one case it was necessary to detach the septal leaflet of the tricuspid valve to obtain an adequate exposure of the VSD. The VSD was closed by means of a glutaraldehyde-fixed pericardial patch with a running 6-0 polypropylene suture (Prolene, Ethicon, Inc., Somerville, N.J.). After closure of the VSD, the aorta was opened with an oblique incision extending toward the noncoronary sinus of Valsalva. After inspection of the aortic valve, a triangular portion of the prolapsing cusp was identified at the site of the nodulus of Arantius (Fig. 1). The basis of the triangle was delimited by two 7-0 polypropylene sutures (Prolene, Ethicon), which were used to test proper coaptation of the cusp before cutting the triangular portion. After the size of the triangle had been determined by the amount of excessive tissue, the triangular portion of the prolapsing cusp was resected. A small extra amount of tissue was left for incorporation into the suture line. The resected margins were approximated by means of four to five single 7-0 polypropylene sutures (Prolene, Ethicon). The sutures were tied on the aortic side to prevent the knots from lying on the coaptation side of the cusp. At the end of the procedure the coaptation of the cusps was checked by filling the aortic root with saline solution. The aortotomy was closed with a running 5-0 polypropylene suture (Prolene, Ethicon). After the patients were weaned from cardiopulmonary bypass and before decannulation, the competence of the aortic valve was verified by means of intraoperative epicardial echocardiography. Aortic insufficiency was reduced to a trivial degree in all three patients (Fig. 2). The children were discharged after an uneventful postoperative course. Routine follow-up has shown a stable echocardiographic pattern through the years, with no worsening of the aortic insufficiency.

View larger version (28K): [in this window] [in a new window]   Fig. 1. Draft of the aortic valvuloplasty with triangular resection of the prolapsing cusp. The aortic valve is exposed via an oblique aortotomy. Left, The right coronary cusp is prolapsing. The excessive length of the free edge is identified by placing two 7-0 sutures (see text). Then the triangular resection (gray triangle, with the base on the free edge) is made. Right, After the triangular resection, the free edge of the right coronary cusp is at the same level as the other two cusps. The knots are lying on the aortic side.

View larger version (143K): [in this window] [in a new window]   Fig. 2. Left, Two-dimensional echocardiogram of the aortic root in patient 2. Preoperative image showing a prolapse of the right coronary cusp, with a central defect of coaptation. Right, Two-dimensional echocardiogram of the aortic root in patient 2. Postoperative image showing the realignment of the cusps with proper coaptation.

Treatment of aortic insufficiency resulting from cusp prolapse is required in a small percentage of children with VSD in western Europe. The possible treatments are aortic valve replacement with a prosthetic valve, aortic valve replacement with a pulmonary autograft, or aortic valvuloplasty. Aortic valve replacement with a prosthesis is a cumbersome technique, because anulus enlargement is required to seat an adequately sized prosthesis. In addition, further need for prosthetic replacement can occur as a result of the somatic growth of children. Aortic root replacement with a pulmonary autograft has been described as an effective treatment for congenital aortic insufficiency with good early and late results ⁵ and with growth potential. ⁶ However, aortic root replacement with a pulmonary autograft is a demanding and time-consuming technique. Furthermore, replacement of the entire aortic valve is questionable when only one cusp is diseased. Aortic valvuloplasty with plication of redundant tissue in the prolapsed cusp has recently been reported as the treatment of choice for congenital aortic insufficiency when the aortic valve is tricuspid. ⁷ However, previous studies of aortic valvuloplasty performed with plication have given controversial results. In fact, despite low in-hospital mortality and good initial follow-up results, long-term recurrence of aortic insufficiency is not uncommon with plication ³ in children with VSD and aortic insufficiency. We report three successful cases in which aortic valvuloplasty was performed with an isolated triangular resection of the prolapsing cusp in children with VSD and aortic insufficiency. In these children we did not perform any additional procedure involving the aortic anulus or the aortic wall. The postoperative course of the children was uneventful. Aortic insufficiency was reduced to a trivial degree and has remained stable at echocardiographic follow-up 5 to 6 years after the operations.

Aortic valvuloplasty with an isolated triangular resection of the prolapsing cusp ensures growth potential and leaves the aortic anulus intact. In addition, because the technique is easy, only a few minutes of extra aortic crossclamp time are required to perform it.

We conclude that aortic valvuloplasty with an isolated triangular resection of the prolapsing cusp is an easy and effective technique for the treatment of the aortic insufficiency in children with VSD.

Footnotes

From the Thorax Center^a and Pediatric Cardiology,^b University Hospital Groningen, Groningen, The Netherlands.

References

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This Article 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 Author home page(s): Massimo A. Mariani Tjalling W. Waterbolk Tjark Ebels Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mariani, M. A. Articles by Ebels, T. Search for Related Content PubMed PubMed Citation Articles by Mariani, M. A. Articles by Ebels, T.