Andersons pediatric cardiology 816

FIG.31.48 Techniqueinwhichneitherofthebridgingleafletsiscut
norsutureddirectlytotheventricularseptalcrest.Aninterventricular
patchisinsertedandattachedtotherightsideoftheseptalcrest,
whichisexposedbygentlyretractingthebridgingleafletsoneata
timewitharetractor.Thebridgingleafletsaresandwichedbetween
theinteratrialandinterventricularpatches.

Alltechniqueshavetheirownindicationsandsupporters,andpublicationson
alltechniquesexist.Nosystematictrialhasbeencarriedouttodrawconclusions
ontheirmerits.Publicationbiashasitthatusuallyonlydesirableresultsare
published(Table31.1).Themajoradvantageofthetechniqueusingonlyone
patchistheexcellentexposureoftheentireventricularseptalcrest,sothat
suturingoftheventricularpatchismademucheasier.Themajordisadvantageis
thevalvarsutureline.Friablevalvartissuemighttear.Inaddition,thesutureline
takesupsomevalvartissue,thusenhancingcentralregurgitation.Thesuture
linesalsointroducethedangerofdisruption,particularlyinthesettingof
postoperativeendocarditis.Theattractionofsuturingthebridgingleaflets
directlytotheventricularseptalcrestistheobvioussimplicityoftheprocedure
becauseplacementofthemoredifficultofthetwopatchesiseliminated
entirely.66Intuitively,onemightpresumethatthisstrategycouldresultin


narrowingoftheleftventricularoutflowtract,butinpracticethisdoesnot
happen.67Additionalconcernsaboutdistortionofthevalvarapparatus,
particularlyifthe“scoopedout”septaldefectisdeep,havenotbeenrefuted
becausetechniquesareusedselectively.Whenthedistancebetweenseptalcrest
andvalvarleafletsismorethan12mm,Backerconsidersthisanindicationfora
two-patchtechniqueforfearofvalvardistortion.Midtermresultshavebeen
reportedbyKarlandcolleagues,butlong-termresultsarelargelylacking.68A
personalcommunicationfromthelateBensonWilcox,whowasthefirstto
advocatethispolicy,madeitclearthatheemployedthistechniqueonlyifthe

ventriculardefectwasnottoodeep.
Table31.1
ResultsofSurgicalCorrectioninSelectedSeries
Reference

Maximum
Periodof
Follow-Up
Inclusion
(Years)
Alloperated 1958–
43
partialdefects 2000
Alloperated 1973–
28
defects
1997
Alloperated 1983–
21
partialdefects 2002
Alloperated 1955–
40
partialdefects 1995

DefectType

Welke105
(2007)
Frid96
(2004)

Murashita106
(2004)
ElNadjawi107
(2000)
Guenther97 Alloperated
complete
(1998)
defects

1974–
1995

20

No.of
Operated
Patients
133

Survival
at5
Years
90

Survival
at10
Years
88

Survival Survival

at20
at40
Years
Years
86
78

502

79

77

61

—

61

94

91

91

—

334

94

93

87

76

320

80

78

78

—

Thetissuesofthevalvarleafletsarerarelynormalandareoftendeficient.Itis
illogicalinouropinion,therefore,tofurtherreducetheamountoftissue
availableforrepair.Aboveall,unlessbridgingofoneorbothleafletsisminimal,
wefeelittobeunnecessarywhentheseleafletscaneasilybesuturedtothepatch
withouthavingtobecut.Thechoicebetweenasinglepatchandtwopatches,
therefore,shouldinouropiniondependontheanatomyoftheindividual
bridgingleaflets.Onlywhenbothinferiorandsuperiorleafletsbridgetheseptum
extensivelyisatwo-patchtechniquewarranted.Inallotheranatomicvariantsa
singlepatchcanbeused.Thissinglepatchmustbeincisedtoaccommodateany
leafletthatbridgesextensively(seeFig.31.43).Thus,insteadofemployingone
ortwopatchesdogmatically,ourapproachisnottocutleafletsunlessitproves

impossibletovisualizethelocationofintendedstitches,whichisanunusual
circumstance.
Patchescanbefashionedfromsyntheticmaterialorfromautologousor
xenologouspericardium.Syntheticfabricissturdy,butitssurfaceshouldbe
smoothtopreventhemolysisbyaregurgitantjet.Pericardiumisalwayssmooth
andpliable,soitisourpreferredchoice.Autologouspericardiumshould
probablybetreatedfor5minutesin0.2%glutaraldehydeinordertoprevent
distensionandaneurysmalwidening,specificallyoftheinterventricularpatch.69
Somesurgeonstellusthattheyuseonlyfreshpericardiumandobtainexcellent
results.OurfavoriteoperativetechniqueisillustratedinFigs.31.49to31.56.

FIG.31.49 Intraoperativeimages(throughFig.31.56)fromapatientwith
Downsyndromeaged6months,weighing7.1kgandhavingabody
surfaceareaof0.38m2,elevatedpulmonaryvascularresistance,and
additionalobstructionintheleftventricularoutflowtractproducedby
accessoryvalvartissue.Theseriesshowstheviewoftheatrioventricular
junctionobtainedbythesurgeonworkingthroughtheopenedrightatrium.
Aretractorelevatestherightventricularlateralaspectofthecommon
atrioventricularvalve.Inthisheart,emptyasaresultofcardioplegia,the
valvarleafletsareflaccidlylyinginthejunction.Theleftventricleisonthe
smallside,andthediameteroftheleftpartoftheatrioventricularvalveis
14mm,whichistypicalforthesizeofthepatient.Themuralleaflet,in
keepingwiththesmallishleftventricle,isalsoverysmall,withanangular
annularsizeofapproximately45degrees.Thesuperiorbridgingleaflet
crossestheventricularseptumonlyminimally,typicaloftheso-called
RastelliAconfiguration.Theventricularseptalcrestisbare.