Asian Cardiovasc Thorac Ann 2005;13:61-64
© 2005 Asia Publishing EXchange Ltd
Surgery for Aortic Insufficiency Associated with Ventricular Septal Defect
Chareonkiat Rergkliang, MD,
Vorawit Chittithavorn, MD,
Apirak Chetpaophan, MD,
Prasert Vasinanukorn, MD
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Prince of Songkla University, Songkhla, Thailand
For reprint information contact: Chareonkiat Rergkliang, MD Tel: 66 74 451 401 Fax: 66 74 429 384 Email: chareonkiat{at}yahoo.com, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Prince of Songkla University, Songkhla 90110, Thailand.
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ABSTRACT
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Aortic valve repair in children is a challenge. We have adopted a technique of single aortic cusp extension with an autologous pericardial strip in patients diagnosed with severe aortic insufficiency (AI) associated with a ventricular septal defect (VSD). The purpose of this study was to report the short-term outcomes. Seven patients were operated on between January 2002 and December 2003. The mean age was 11.28 ± 2.1 years (range 8–14 years). The VSD was closed with a synthetic patch. Aortic cusp extension was performed at the right coronary cusp in 6 patients and the remainder had a non-coronary cusp extension. The mean diastolic arterial pressure increased from 35.71 ± 6.09 to 74.28 ± 7.31 mm Hg after the operation ( p < 0.001). The postoperative grade of AI was trivial in 4 patients, mild in 1 patient and non-existent in 2 patients. The mean follow-up period was 12.85 ± 6.12 months (range 2–20 months). This technique is very effective in patients with severe AI associated with a VSD. However, long-term durability will need to be carefully followed.
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INTRODUCTION
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Aortic insufficiency (AI) associated with a ventricular septal defect (VSD) is relatively common among Asians.1–4 Once it appears, the severity will gradually progress and an aortic valve operation may become necessary.1,3–6 Interest in aortic valve repair as an alternative to replacement has been stimulated,1,6,7 but the unsatisfactory outcome in some patients has usually resulted in re-operation.6,8,9 We have adopted a technique of aortic valve repair by using a single aortic cusp extension with an autologous pericardial strip in patients diagnosed with severe AI associated with VSD, in which the aortic cusp had a severe prolapse, with thickening, retraction, and elongation of the free edge of the prolapsed cusp. The purpose of this study was to review our initial experience and report the short-term outcomes.
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PATIENTS AND METHODS
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From January 2002 to December 2003, 7 patients diagnosed with severe AI associated with VSD, underwent VSD closure and aortic valve repair by single aortic cusp extension with an autologous pericardial strip. The medical records were reviewed and the following data were retrieved: demographic variables, New York Heart Association class (NYHA class), preoperative and postoperative diastolic arterial pressure, type and size of VSD, preoperative and postoperative echocardiographic findings, and short-term follow-up results.
The mean age of patients was 11.28 ± 2.13 years (range 8–14 years). Three patients were male and 4 were female. Two patients were in NYHA class I, 4 patients were in NYHA class II and 1 patient was in NYHA class IV due to severe mitral regurgitation from infective endocarditis. Six patients had a subpulmonic VSD and the other one had a perimembranous VSD. The mean size of the VSD was 12.14 ± 2.91 mm (range 8–15 mm). Two patients had an associated cardiac lesion (1 pulmonic stenosis and 1 severe mitral regurgitation).
Statistical analysis was used for comparing the preoperative and postoperative diastolic arterial pressures, with an unpaired t-test. A p-value of < 0.05 was considered statistically significant. The statistical analysis was carried out using STATA statistical package (version 6.0; College Station, TX, USA).
The operation was performed using a median sternotomy. A piece of pericardium was harvested and treated in glutaraldehyde solution for 10 minutes and then rinsed with normal saline solution. Cardiopulmonary bypass with systemic hypothermia to 30°C was used. Myocardial protection was achieved by injection of cold blood cardioplegia into the coronary artery ostia and coronary sinus. The VSD was closed with a synthetic patch using a transpulmonary artery approach for a subpulmonic VSD and a transatrial approach for a perimembranous VSD. A transverse aortotomy was performed, and the aortic valve was carefully inspected. The autologous pericardium was trimmed into a rectangular strip. The length of pericardial strip was adjusted according to the length of the free edge of the prolapsed cusp. The height of pericardial strip was adjusted to be 2 mm higher than its commissure, usually about 5 to 6 mm in height (Figure 1
). Then, the pericardial strip was sutured to the free edge of the prolapsed cusp using a 6-0 polypropylene suture (Figure 2).
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Figure 1. The pericardial strip. (a) Length of free edge of the prolapsed cusp, (b) Height of strip usually 5 to 6 mm.
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The quality of aortic valve repair was assessed by measuring the diastolic arterial pressure after the operation. Intraoperative transesophageal echocardiography was performed in 1 patient and the remainder had a transthoracic echocardiography before discharge (5 to 7 days after the operation).
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RESULTS
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The mean cardiopulmonary bypass time was 128.14 ± 19.60 min (range 106–159 min) and aortic cross clamp time was 94.71 ± 19.24 min (range 77–132 min). The VSD was closed with a synthetic patch. Aortic cusp extension was performed at the right coronary cusp in 6 patients and 1 patient had a non-coronary cusp extension. The mean preoperative diastolic arterial pressure was 35.71 ± 6.07 mm Hg (range 30–45 mm Hg) and increased to 74.28 ± 7.31 mm Hg (range 65–80 mm Hg) after the operation ( p < 0.001). There was no operative mortality and no serious postoperative complications. Postoperative echocardiography demonstrated a trivial AI in 4 patients, mild in 1 patient and none in 2 patients.
The mean follow-up period was 12.85 ± 6.12 months (range 2–20 months). All of the patients were in NYHA class I, and none of them had a deteriorated AI, as revealed by a subsequent transthoracic echocardiographic study.
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DISCUSSION
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AI associated with VSD has been recognized as a clinical entity for some time.1–4 The mechanism of AI is explained by the lack of continuity between the aortic media, annulus and ventricular septum which renders the aortic sinus and annulus in this region weakened and unsupported. This causes displacement of the aortic annulus and aortic cusp downward and outward into the VSD.1
We found the predominant type of VSD was subpulmonic, which is similar to that of other reports.1–4 However, Brauner and colleagues5 reported that in their series the predominant type of VSD was perimembranous. AI may appear in both subpulmonic and perimembranous VSDs because one boundary of these VSDs is part of the aortic annulus, and therefore the aortic annulus in that region is unsupported.
Early closure of the VSD could completely prevent aortic valve complications. Furthermore, simple VSD closure is sufficient to improve or halt the progression of AI in the majority of patients who have a mild to moderate degree of aortic cusp prolapse.3–5
Once the AI appears, it gradually increases in severity and aortic valve repair should be performed at the time of VSD closure.1,3,4,6,10,11 There are many methods available for aortic valve repair,1,6,12 but unsatisfactory results in some patients have been reported.1,3,6 There are many risk factors for failure, including older age at operation,2 structural defect of aortic valve,6 degree of AI at time of hospital discharge,10 procedure involving the aortic cusp,1 and plication at more than one end of the prolapsed cusp.10
Patients with long-standing disease will have secondary changes in the aortic cusp,1 such as severe prolapse, thickening, retraction of the free edge and elongation of the free edge of the prolapsed cusp. These pathological changes may be an indication for aortic valve replacement. Both mechanical and bioprosthetic replacement may be unsatisfactory in children.13,14 Early degeneration of bioprostheses and the potential risks related to anticoagulation in children have renewed interest in the Ross operation.11,15,16 We do not have experience with this operation, as the homograft is not available in our institute. Furthermore, there was a large discrepancy between the pulmonic annulus and the aortic annulus in our patients, resulting in a more complicated operation.
In patients who have secondary changes in the aortic cusp, VSD closure alone is not sufficient to abolish AI1,3,5 because it is not caused by valve prolapse in isolation, but also by the pathology of the aortic valve. We adopted a technique of aortic valve repair for patients diagnosed with severe AI associated with VSD. Our technique involves lengthening the free edge of the prolapsed cusp, thus increasing the cusp coaptation. From our initial experience, this technique has achieved good early results and no early repair failure in the follow-up period. We advocate this technique because of its reliable outcome, simplicity, and reproducibility.
We also found that the increase in the diastolic arterial pressure after the operation correlated well with the effectiveness of the repair. This finding may be useful for evaluation of the quality of the aortic repair in a situation where intraoperative transesophageal echocardiography is not available.
Concerning the durability of the pericardial extension of the aortic cusp, Grinda and associates17 reported that in patients with aortic cusp extension for rheumatic aortic valve disease, 90% were free from redo valvular surgery at 5 years. A similar result was also reported by Kalangos and associates.18 Duran and associates19 reported the excellent results of aortic valve replacement with freehand glutaraldehyde-treated autologous pericardium. They found freedom from valvular failure was 83.83 ± 8.59% at 5-year follow-up.
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CONCLUSION
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Management of AI associated with VSD remains a challenge. In patients who have severe aortic cusp changes, single aortic cusp extension with an autologous pericardial strip is an alternative technique and achieves good early results. However, midterm and long-term durability should be carefully followed.
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REFERENCES
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ABSTRACT
INTRODUCTION
