Asian Cardiovasc Thorac Ann 2002;10:31-34
© 2002 Asia Publishing EXchange Pte Ltd
Play Safe: Band the Late Presenting Complete Atrioventricular Canal
Howaida O Al Qethamy, MD,
Saber Aboelnazar, MD,
Khawar Aizaz, MD,
Yahya Al Faraidi, MD
|
Department of Cardiac Surgery Prince Sultan Cardiac Center Riyadh, Saudi Arabia
|
|
|
Saber Aboelnazar, MD Tel: 966 1 479 1000 Ext. 2291 Fax: 966 1 476 0543 email: saberaboelnazar{at}hotmail.com Department of Cardiac Surgery, Prince Sultan Cardiac Center, P.O. Box 7897 (Box No. N-641), Riyadh 11159, Saudi Arabia.
|
 |
ABSTRACT
|
|---|
Primary repair of complete atrioventricular canal in patients who present beyond one year of age carries a high mortality. Between January 1995 and February 2000, 16 patients aged 8 to 24 months (mean, 14.5 months) received pulmonary artery banding at presentation and underwent total correction at 24 to 96 months old (mean, 41.9 months). There was one hospital death (mortality, 6.25%). During a mean follow-up of 10.2 months (range, 6 to 28 months), there was no late death, 13 of the 15 survivors (87%) were in New York Heart Association functional class I, and 2 (13%) were in class III. In patients with complete atrioventricular canal who present late with severe reactive pulmonary hypertension, banding followed by complete repair reduces the risk associated with primary repair.
|
INTRODUCTION
|
|---|
Repair of complete atrioventricular (AV) canal in early infancy is being carried out with excellent results.1 Patients with complete AV canal beyond the first 6 months of life carry a high potential for developing obstructive pulmonary vascular disease. In infants with Down's syndrome, this process is accelerated.2 Patients who present late and those with a low birth weight, multiple ventricular septal defects, and heart failure carry a higher mortality and morbidity for primary repair. Such patients present a surgical challenge, and pulmonary artery (PA) banding at presentation is a safe option.3
|
PATIENTS AND METHODS
|
|---|
From January 1995 to February 2000, 16 patients (9 boys and 7 girls) presented late with a diagnosis of complete AV canal. Mean age at presentation was 14.5 months (range, 8 to 24 months). Most of the patients presented with cardiac murmurs, failure to thrive, and recurrent chest infections; 12 had Down's syndrome (75%). Electrocardiography and chest radiography were performed routinely. Standard right and left cardiac catheterization was carried out in all patients prior to both stages of treatment. Angiographic findings and associated cardiac anomalies are listed in Table 1
. PA banding was undertaken at the time of presentation, through a left thoracotomy via the 4th intercostal space. The pericardium was opened anterior and parallel to the phrenic nerve. The PA was isolated and constricted with nylon tape until the systolic pulmonary arterial pressure distal to the tape was approximately one-third of the systemic pressure, with an arterial oxygen saturation of no less than 75%. Usually, this required a length of tape in millimeters equal to the patient's weight in kilograms plus 20, according to Trusler's law.4 The constriction was made permanent by securing the band to the adventitia of the PA at various intervals with interrupted 5/0 polypropylene sutures.
The final stage of the repair was carried out through a median sternotomy using cardiopulmonary bypass, moderate hypothermia, a single dose of antegrade cold blood cardioplegia (25–30 mL•kg-1), and topical cooling. Repair of the common AV valve with mitral reconstruction was performed using 7/0 polypropylene suture, paying due respect to the valve architecture, which is probably the best way to preserve the competence of the left AV valve during repair. Repair of ventricular septal defect and atrial septal defect was performed by the 2-patch technique, using Gore-Tex (WL Gore, Flagstaff, AZ, USA) and Dacron, respectively. The PA was debanded and reconstructed using an autologous pericardial patch. Postoperatively, the patients stayed in the intensive care unit until stabilization and extubation. Echocardiography was undertaken routinely before discharge to evaluate the repair of ventricular and atrial septal defects, common AV valve reconstruction, and ventricular function.
|
RESULTS
|
|---|
There was no operative death. The duration of banding and band gradients are shown in Table 2. The mean age at total repair was 41.9 months and the mean duration of banding was 27.4 months. There was one hospital death 2 weeks postoperatively from severe sepsis. Operative results and complications are shown in Table 3. All 15 survivors were followed up for a mean period of 10.2 months (range, 6 to 28 months). Follow-up data were obtained from the records of clinical examinations and echocardiographic findings documented at the time of the last visit to the outpatient clinic. Of the 15 survivors, 13 were in New York Heart Association functional class I, and 2 were in class III, of whom one had aortic incompetence and the other had mitral regurgitation.
|
DISCUSSION
|
|---|
Since early primary repair of several simple and complex cardiac malformations became the procedure of choice, PA banding has been largely abandoned in leading cardiac centers. Nevertheless, for some cardiac conditions and under certain circumstances, banding may be the only palliative or therapeutic option to effectively prevent or arrest the development of pulmonary vascular obstructive disease.5 Children with complete AV canal have a rapid progression of pulmonary vascular changes. The primary event initiating pulmonary hypertension in shunt-related pulmonary overcirculation is endothelial cell injury induced by shear stress.6 The metabolic response of the endothelial cells induces a variable cascade that leads to pulmonary vascular obstructive disease.7 Studies on nonsurgical treatment showed that only 54% of patients survived to 6 months of age, 35% to 12 months, 15% to 24 months, and 4% to 5 years of age.8 Primary surgical correction of complete AV canal beyond 9 months of age carries a significant operative mortality of 8% to 17% in various series.9–11 PA banding in this age group results in significant hemodynamic improvement by reducing PA pressure, left-to-right shunting, and pulmonary vascular disease, thereby allowing total repair of complete AV canal at a later stage, with more acceptable mortality and morbidity.12 Technical and conceptual advances have allowed improved survival and reduced mortality after repair of complete AV canal in recent years.13 Residual lesions, such as intracardiac shunt or heart block, have decreased to less than 2%. In this study, one patient needed a permanent pacemaker 3 weeks after repair, due to persistent heart block. On the other hand, the incidence of reoperation for left AV valve regurgitation has decreased less dramatically and is currently between 5% and 10%. Hanley and colleagues14 reported an 8.9% incidence of reoperation for postoperative AV valve regurgitation in 301 patients undergoing surgical repair using a single-patch technique at Boston Children's Hospital between 1972 and 1992. A reoperation rate of 6.3% for residual AV valve regurgitation was reported by Capouya and colleagues15 in their series of 105 patients treated between 1982 and 1990; routine cleft approximation and aggressive use of annuloplasty were the preferred techniques for management of the left AV valve.
In this study, PA banding was performed in all patients who presented late, regardless of Down's syndrome, with the intention of recalling them after 3 to 6 months for total repair. The long delay in correction was partly due to the failure of patients to return, as well as some inadvertent administrative problems. Two patients in this series were found to have mitral or aortic regurgitation at follow-up. Both are being closely followed up, but neither has needed a reoperation so far. Double-patch septal reconstruction with routine cleft closure was the technique of choice in this study. We believe that two-stage repair of the late presenting complete AV canal with reactive pulmonary hypertension is a safe way of avoiding primary repair in these very high-risk cases.
Presented at the 8th Annual Meeting of The Asian Society for Cardiovascular Surgery, Fukuoka, Japan, September 6–8, 2000, and the Joint Meeting of the 12th Scientific Session of the Saudi Heart Association and the 3rd Cardiac Symposium of King Fahad National Guard Hospital, Jeddah, Saudi Arabia, January 23–5, 2001.
|
REFERENCES
|
|---|
-
Yamaki S, Yasui H, Kado H, Yonenaga K, Nakamura Y, Kikuchi T, et al. Pulmonary vascular disease and operative indications in complete atrioventricular canal defect in early infancy. J Thorac Cardiovasc Surg
1993;106: 398–405.[Abstract]
-
Borowski A, Zeuchner M, Schickendantz S, Korb H. Down syndrome as a factor influencing hemodynamic response to pulmonary artery banding. Pediatr Cardiol
1996;17: 375–81.[Medline]
-
Epstein ML, Moller JH, Amplatz K, Nicoloff DM. Pulmonary artery banding in infants with complete atrioventricular canal. J Thorac Cardiovasc Surg
1979; 78:28–31.[Abstract]
-
Albus RA, Trusler GA, Izukawa T, Williams WG. Pulmonary artery banding. J Thorac Cardiovasc Surg
1984; 88:645–53.[Abstract]
-
Stark J. Pulmonary artery banding. In: Stark J, de Leval M, editors. Surgery for congenital heart defects. Philadelphia: Saunders, 1994:259–67.
-
Staub NC, Schultz EL, Albertine KH. Leukocytes and pulmonary microvascular injury. Ann NY Acad Sci
1982; 384:332–43.[Medline]
-
Ilkiw RL, Miller-Hance WC, Nihill MR. The pulmonary circulation. In: Garson A, Bricker JT, McNamara DG, editors. The science and practice of pediatric cardiology. Philadelphia: Lea & Febiger, 1990:360–85.
-
Berger TJ, Blackstone EH, Kirklin JW, Bargeron LM Jr, Hazelrig JB, Turner ME Jr. Survival and probability of cure without and with operation in complete atrioventricular canal. Ann Thorac Surg
1979;27:104–11.[Abstract]
-
Bender HW Jr, Hammon JW Jr, Hubbard SG, Muirhead J, Graham TP. Repair of atrioventricular canal malformation in the first year of life. J Thorac Cardiovasc Surg
1982;84:515–22.[Abstract]
-
Chin AJ, Keane JF, Norwood WI, Castaneda AR. Repair of complete common atrioventricular canal in infancy. J Thorac Cardiovasc Surg
1982;84:437–45.[Abstract]
-
Tweddell JS, Litwin SB, Berger S, Friedberg DZ, Thomas JP, Frommelt PC, et al. Twenty-year experience with repair of complete atrioventricular septal defects. Ann Thorac Surg
1996;62:419–24.[Abstract/Free Full Text]
-
Silverman N, Levitsky S, Fisher E, DuBrow I, Hastreiter A, Scagliotti D. Efficacy of pulmonary artery banding in infants with complete atrioventricular canal. Circulation
1983;68(Suppl II):148–53.[Abstract/Free Full Text]
-
Castaneda AR, Mayer JE Jr, Jonas RA. Repair of complete atrioventricular canal in infancy. World J Surg
1985;9: 590–7.[Medline]
-
Hanley FL, Fenton KN, Jonas RA, Mayer JE, Cook NR, Wernovsky G, et al. Surgical repair of complete atrioventricular canal defects in infancy. Twenty-year trends. J Thorac Cardiovasc Surg
1993;106:387–97.[Abstract]
-
Capouya ER, Laks H, Drinkwater DC Jr, Pearl JM, Milgalter E. Management of the left atrioventricular valve in the repair of complete atrioventricular septal defects. J Thorac Cardiovasc Surg
1992;104:196–203.[Abstract]
This article has been cited by other articles:
|
|
|
|
 
A. F. Corno, E. J. Ladusans, M. Pozzi, and S. Kerr
FloWatch versus conventional pulmonary artery banding.
J. Thorac. Cardiovasc. Surg.,
December 1, 2007;
134(6):
1413 - 1420.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. F. Corno, M. Prosi, P. Fridez, P. Zunino, A. Quarteroni, and L. K. von Segesser
The non-circular shape of FloWatch(R)-PAB prevents the need for pulmonary artery reconstruction after banding.: Computational fluid dynamics and clinical correlations
Eur. J. Cardiothorac. Surg.,
January 1, 2006;
29(1):
93 - 99.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
ABSTRACT
INTRODUCTION
