Asian Cardiovasc Thorac Ann 2002;10:314-317
© 2002 Asia Publishing EXchange Pte Ltd
Tricuspid Valve Detachment for Transatrial Closure of Ventricular Septal Defects
Sajan Koshy, MCh,
Sunil Gopalraj Sumangala, MCh,
Anil Sivadas Radha, DNB1,
Dhinakar Seetharaman, MSc,
Shivaprakasha Krishnanaik, MCh,
Suresh Gururaja Rao, MCh
Division of Pediatric Cardiac Surgery Department of Cardiovascular and Thoracic Surgery
1 Division of Pediatric Cardiology Department of Cardiology Amrita Institute of Medical Sciences and Research Center Cochin, Kerala, India
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For reprint information contact: Suresh Gururaja Rao, MCh Tel: 91 484 33 9080 Fax: 91 484 34 0801 email: sureshgrao{at}aimshospital.org Department of Cardiovascular and Thoracic Surgery, Amrita Institute of Medical Sciences and Research Center, Kochi, Cochin, Kerala 682026, India.
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ABSTRACT
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Tricuspid leaflet detachment improves visualization and accuracy of closure of ventricular septal defects via the transatrial route. Between July 1998 and March 2001, surgical correction was performed in 296 cases of isolated ventricular septal defect, 215 cases of tetralogy of Fallot, and 16 cases of double-outlet right ventricle. Of these, 132 patients (79 with isolated ventricular septal defect, 49 with tetralogy of Fallot, and 4 with double-outlet right ventricle) underwent transatrial repair with temporary detachment of tricuspid leaflets for ventricular septal defect closure. The septal leaflet was detached in most cases, with anterior or posterior leaflets being detached when indicated. Median duration of intensive care was 3.6 days, and median hospital stay was 7 days. There was no incidence of tricuspid regurgitation attributable to leaflet detachment, as confirmed by postoperative echocardiography. Reoperation was not required for a residual defect or tricuspid regurgitation. The benefits of temporary leaflet detachment for transatrial repair of various difficult defects far outweigh the risk of postoperative tricuspid regurgitation.
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INTRODUCTION
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Most types of ventricular septal defect (VSD) can be successfully repaired by approaching through the right atrium across the tricuspid valve. However, chordal attachments, hypertrophy of the ventriculo-infundibular fold, especially in the setting of a grossly hypertrophic and noncompliant right ventricle as often seen in cases of adult tetralogy of Fallot (TOF), and gross aortic override, sometimes obscure the margins of the defect. In the early 1960s, Hudspeth and colleagues1,2 described temporary detachment of tricuspid leaflets to enable better access to the margins of these types of defect. This study reassessed the advantages and safety of tricuspid leaflet detachment to obtain better visualization and improve the accuracy of transatrial repair of congenital lesions such as isolated VSD, TOF and double-outlet right ventricle (DORV) in both adults and children.
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PATIENTS AND METHODS
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Between July 1998 and March 2001, 1900 congenital heart operations were performed in our center, including 296 VSD closures, 215 TOF corrections and 16 DORV repairs. Of these, 132 patients (25%) had transatrial closure of VSD with temporary tricuspid leaflet detachment. An isolated VSD was closed in 79 patients, transatrial intracardiac repairs of TOF and DORV were performed in 49 and 4 patients, respectively. The outcome was retrospectively analyzed with respect to morphology of the defect, leaflets detached, reasons for detachment, incidence of tricuspid regurgitation or residual VSD, and any other problem attributable to leaflet detachment, as determined by echocardiography postoperatively. The age and weight profile can be seen in Table 1
. Mild pulmonary arterial hypertension was present in 3 patients, moderate pulmonary hypertension in 15, and severe pulmonary hypertension in 20. The VSD morphology is described in Table 2.
The heart and great vessels were exposed through a median sternotomy incision. Aortic and bicaval cannulation was used in all patients. The right atrium was opened under cold blood cardioplegic arrest by an incision parallel to the atrioventricular groove. Traction sutures were placed around the edges of the atriotomy and tricuspid annulus. Retractors were positioned to expose the tricuspid valve. The septal leaflet of the tricuspid valve was made taut by grasping its free edge with vascular forceps, and it was detached approximately 1 to 2 mm away from the annulus by making a curved incision parallel to the annulus with a no. 11 blade (Figure 1). When necessary, the incision was extended to the anterior or posterior leaflet as the anatomy dictated. Anterior leaflet detachment was employed in TOF, DORV and perimembranous VSD with outlet extension in bigger children and adults, because a hypertrophic noncompliant right ventricle with gross aortic override and a dilated aortic root precluded visualization of the VSD margins, particularly at the junction of the aortic annulus and the ventriculo-infundibular fold. Similarly, the posterior leaflet was detached in a few cases of inlet and posterior muscular VSD, as the defect was directly under the posterior leaflet. A sling of 5/0 polypropylene suture was placed around the subvalvular apparatus to retract the detached leaflet. The VSD was closed with a Gore-Tex patch (WL Gore, Flagstaff, AZ, USA) using 5/0 continuous polypropylene suture. The parietal band was more clearly visualized and resection was completed after VSD closure when all the VSD sutures could be taken on virgin right ventricular muscle. The leaflet was reattached using 6/0 or 7/0 polypropylene suture including the VSD patch as a sandwich in most cases (Figure 2). Passing the suture through the VSD patch helped to strengthen the suture line and minimize the risk of a residual defect in this area. If there was a muscle rim separating the VSD from the tricuspid annulus, the leaflet was reattached directly. The integrity and competence of the valve were checked by filling the right ventricle with saline via a catheter-tip syringe. Additional procedures were performed as indicated, which included closure of atrial septal defects in 10 patients, patent ductus arteriosus in 11, and additional VSD in 2, and pulmonary arterioplasty in 3. Of the patients with TOF and DORV, all except 5 underwent infundibular resection through a small incision in the ventricular outflow tract; the others had transatrial resection alone. The mean cardiopulmonary bypass and aortic crossclamp times were marginally higher in cases with tricuspid leaflet detachment compared to those without detachment. Total circulatory arrest was utilized in 3 infants with multiple VSD, in whom removal of the venous cannula provided better exposure.
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RESULTS
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Of the 132 patients who underwent transatrial VSD closure with temporary detachment of the tricuspid valve, all had normal sinus rhythm on the day of surgery except 2 with 2:1 atrioventricular block, 2 with atrial ectopics, 2 with atrioventricular dissociation, 7 with nodal rhythm, and 2 with junctional ectopic tachycardia. In 24 patients who required temporary pacing, normal sinus rhythm was restored by the time they were extubated, and none required permanent pacemaker implantation. Mean stay in the intensive care unit was 3.6 days (range, 2 to 6 days), and the median postoperative hospital stay was 7 days (range, 6 to 50 days). There were 4 deaths (3%): a patient with TOF died on the 5th postoperative day due to fulminant sepsis; 2 died of refractory ventricular arrhythmia on the 2nd and 3rd day, the causes of arrhythmia could not be clearly identified; and a patient with VSD and pulmonary hypertension died on the 2nd day, presumably due to pulmonary hypertensive crisis. At the time of discharge, new tricuspid regurgitation was detected by echocardiography in 21 patients: it was mild in 16 (12%) and trivial in 5 (4%); the regurgitation did not appear to be due to detachment but to that usually seen after VSD closure.
The follow-up period ranged from 3 to 30 months (median, 12 months); 92 patients attended follow-up (73% complete). There was no late death during this period, and no patient had a residual VSD. Of the 5 patients found to have trivial tricuspid regurgitation at discharge, none had an increase in the degree of regurgitation. In all 16 patients found to have mild tricuspid regurgitation at discharge, the regurgitation had declined to a trivial level 3 months later. There were 11 patients who had severe pulmonary hypertension preoperatively with mild tricuspid regurgitation; they continued to have mild tricuspid regurgitation without progression during follow-up. None of the patients had new onset tricuspid valve regurgitation. There was no reoperation for residual VSD or tricuspid incompetence. After 3 months, no patient needed decongestive medication. No new arrhythmia was detected during follow-up. The incidence of tricuspid regurgitation was not related to whether the detached leaflet was reattached by the sandwich technique.
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DISCUSSION
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Transatrial repair of VSD requires good exposure of all the margins of the defect, so that complete closure can be performed and residual lesions avoided. The anterosuperior margin is particularly vulnerable because a hypertrophied ventricular-infundibular fold or a dilated and overriding aortic root may obscure it. Chordal attachments crossing the VSD sometimes make accurate closure difficult. Extreme retraction of the tricuspid valve apparatus in these situations might result in damage to the tricuspid subvalvular apparatus and tricuspid regurgitation or postoperative arrhythmias. Inaccuracy in suture placement might lead to residual VSD.
Hudspeth and colleagues1 detached the septal leaflet in a transatrial approach to VSD closure, and subsequently, they reported extension of this technique to total correction of TOF.2 They underscored the exposure of the aortic valve leaflets through this approach, thus minimizing the danger of injuring them while taking sutures in the superior rim of the defect. Although several reports confirmed the safety of the technique, it was not widely followed, possibly because of fear of postoperative tricuspid regurgitation.3–7 An alternative technique of detaching the chordae to improve exposure and reattaching them after closure of the VSD has been described.8 However, we feel that detachment of the leaflet at its annulus is less risky than trying to reattach the delicate chordae, especially in infants. We revisited the old technique and sought wider application of the procedure, particularly in cases with chordae crossing the VSD and those with a noncompliant right ventricle in severe infundibular hypertrophy as seen in adult tetralogy of Fallot. There was no additional risk of tricuspid regurgitation attributable to leaflet detachment, and the leaflet was reattached using a separate continuous suture in all cases. The marginally longer aortic crossclamp and bypass times due to leaflet detachment were not considered to have contributed to postoperative morbidity.
Temporary detachment of tricuspid leaflets improved exposure of the angle between the conal septum, aortic annulus, and the ventriculo-infundibular fold, where sutures could be taken safely and securely, minimizing the incidence of residual VSD. This was particularly helpful in adults with hypertrophic noncompliant right ventricle or extreme aortic dextroposition with ventriculo- infundibular fold hypertrophy or with multiple chordae crossing the VSD. The VSD closure could be performed before parietal band resection, which facilitated taking sutures in virgin right ventricular muscle and safeguarded the aortic valve leaflets. Furthermore, the right ventricular outflow was clearly visualized and parietal band resection could be performed more confidently while safeguarding the VSD patch suture line. These advantages far outweigh the risk of tricuspid regurgitation and could potentially contribute to a reduction of postoperative arrhythmias by reducing retraction of the tricuspid valve. The limitation of the study was that the selection of patients for tricuspid leaflet detachment was at the surgeon’s discretion, depending on the anatomy perceived on the operating table, without objectively defining the indications for employing the technique. Nevertheless, these findings highlight the safety and efficacy of temporary tricuspid leaflet detachment during transatrial closure of various ventricular septal defects.
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REFERENCES
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ABSTRACT
INTRODUCTION
