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J Thorac Cardiovasc Surg 2007;134:1357-1358
© 2007 The American Association for Thoracic Surgery

Brief Communication

A simple technique of unidirectional valved patch for closure of septal defects

Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi, India.

Received for publication July 17, 2007; accepted for publication August 7, 2007.

^_* Address for reprints: Shiv Kumar Choudhary, MCh, Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi 110029, India. (Email: shivchoudhary{at}hotmail.com).

Delayed presentation and operation for patients with atrial and ventricular septal defects and pulmonary hypertension are not uncommon in the developing world.^1,2 These patients often have a turbulent postoperative course as the result of pulmonary hypertension. To partially overcome this, a wide variety of unidirectional valved patches have been described.^3-5 These serve to achieve a right-to-left shunt to prevent right ventricular failure in the setting of persistently elevated pulmonary artery pressures. We devised a simple technique for creating a unidirectional valved patch.

Clinical Summary

Routine monitoring, anesthesia, and cardiopulmonary bypass techniques are used. After cardioplegic arrest, the right atrium is opened and the atrial or ventricular septal defect is inspected and sized. A patch of knitted polyester fabric (Impra Inc, Tempe, Ariz) to match the width of the defect and approximately 1.5 times longer than the desired length is chosen, and a 4-mm fenestration is made in the patch using a standard aortic punch (Scanlan, St Paul, Minn). The patch is then folded on itself in such a way that after it is folded, the dimensions are adequate for closure of the septal defect. The flap created by the folding of the patch should cover the fenestration (Figure 1). One clip (LT 200 Ethicon Endosurgery, Cincinnati, Ohio) is placed on each side of the patch to hold the flaps together and facilitate suturing. The patch is then sutured to the edges of the septal defect using interrupted or continuous sutures in such a way that the flap lies toward the left ventricular side in patients with a ventricular septal defect and toward the left atrial side in patients with an atrial septal defect. As the sutures approach the clip, they are removed. Once the patch is sutured in place, routine deairing maneuvers are performed and the patient is weaned from cardiopulmonary bypass.

View larger version (15K): [in this window] [in a new window]   Figure 1. Technique of creating a unidirectional valved patch. An appropriately sized Dacron patch is selected (a), and a fenestration is made using an aortic punch. The patch is folded on itself (b) and sutured in place (c) as described in the text.

Discussion

A variety of techniques have been described for the creation of unidirectional valved patches,^3-5 but the techniques are often cumbersome and time-consuming. When the patches are fashioned before cardioplegic arrest and inspection of the defect, the sizing may be inaccurate. If they are fashioned after inspection of the defect, it adds to the cardioplegia time, because most often the fashioning of unidirectional patch requires 2 patches to be sutured. In the technique described here, less than 30 seconds are required for the patch sizing and preparation, thus reducing the cardioplegic arrest time. In contrast with other techniques that require the use of 2 patches (often 1 prosthetic and 1 pericardial patch), only 1 patch is required in this technique. Homografts were used in a recent study,⁵ but they had the disadvantages of limited availability and cost.

The technique described here is simple, easily reproducible, inexpensive, and less time-consuming, and does not require the use of additional material such as pericardium or homografts. It has been demonstrated to be effective in our early experience.

References

1. Health manpower requirements for the achievement of health for all by the year 2000 through primary health care. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser 1985;717:7-92.[Medline]
   
2. Saxena A. Congenital heart disease in India. A status report. Ind J Pediatr 2005;72:595-598.[Medline]
   
3. Novick WM, Sandoval N, Lazorhysynets VV, Castillo V, Baskevitch A, Mo X, et al. Flap valve double patch closure of ventricular septal defects in children with increased pulmonary vascular resistance. Ann Thorac Surg 2005;79:21-28.[Abstract/Free Full Text]
   
4. Zhou Q, Lai Y, Wei H, Song R, Wu Y, Zhang H. Uidirectional valve patch for repair of cardiac septal defects with pulmonary hypertension. Ann Thorac Surg 1995;60:1245-1249.[Abstract/Free Full Text]
   
5. Zhang B, Wu S, Liang J, Zhang G, Jiang G, Zhou M, et al. Unidirectional monovalve homologous aortic patch for repair of ventricular septal defect with pulmonary hypertension. Ann Thorac Surg 2007;83:2176-2181.[Abstract/Free Full Text]
   

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This Article Full Text (PDF) 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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Shiv Kumar Choudhary Sachin Talwar Balram Airan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Choudhary, S. K. Articles by Airan, B. Search for Related Content PubMed Articles by Choudhary, S. K. Articles by Airan, B. Related Collections Congenital - acyanotic