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Eur J Cardiothorac Surg 2004;26:754-761
© 2004 Elsevier Science NL

The left atrioventricular valve in partial atrioventricular septal defect: management strategy and surgical outcome

^a Department of Paediatric Cardiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
^b Department of Cardiac Surgery, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK

Received 22 December 2003; received in revised form 26 April 2004; accepted 14 June 2004.

^* Corresponding author. Address: 318 Edgware Road, London W2 1DY, UK, Tel.: +44-20-7724-5267
e-mail: amira_alhay{at}hotmail.com

Objective: To test the hypothesis that in patients with a partial atrioventricular septal defect (PAVSD) and a competent left atrioventricular valve (LAVV), sutures should be placed across the line of apposition of the superior and inferior bridging leaflets, septal commissure (SC), to prevent the development of regurgitation. Outcome of surgery and risk factors for the need for LAVV reoperation of patients with mild or no LAVV regurgitation (LAVVR) were evaluated. Background: Controversy over management of the LAVV in PAVSD. Method: One hundred and forty seven children with PAVSD underwent surgical repair at the Royal Brompton Hospital between January 1983 and December 1999. Of this group, 21 (16.7%) had LAVVR of sufficient severity to require surgical intervention and were therefore excluded from analysis. The median age and weight at repair of those with mild or no LAVVR was 4.1 years and 15.4 kg. One hundred and eight had normal chromosomes, 13 Down syndrome and five other syndromes. The interatrial communication was closed using a pericardial patch in 62.7% and with synthetic material in the remainder. Intraoperative testing of LAVV competence was undertaken using saline injection into the left ventricle. In 80.9%, sutures were placed across the line of apposition of the left sided superior and inferior bridging leaflets partially to close the SC (sometimes incorrectly named the mitral valve cleft). Result: The overall hospital mortality was 3.2% (95% confidence interval (CI) 1, 8.4%), which did not differ statistically in the last 20 years. No specific risk factors for early death were identified. Eleven patients (8.7%, 95% CI 4.7, 15.4%) required reoperation, 10 for LAVV repair and 1 resection of subaortic stenosis. Univariate analysis of risk factors for LAVV reoperation were low weight, relatively small size LAVV, the presence of a small preoperative interventricular interchordal communication and duration of ventilation. Ten (9.8%) of 102 patients in whom SC was sutured required LAVV reoperation but none for 24 in whom the commissure was left alone. Conclusion: The hypothesis that in the absence of preoperative LAVVR it is necessary to place sutures in the SC has not been proven. We consider that in addition to preoperative cross sectional echocardiographic assessment of LAVVR intraoperative evaluation of LAVV function allows discrimination between those valves where sutures to the septal commissure are necessary and those where the valve can be left undisturbed.

Key Words: Ostium primum atrial septal defect • Partial atrioventricular septal defect • Left atrioventricular valve • Septal commissure

Abbreviations: AVV, atrioventricular valve • CI, confidence interval • DOLAVV, double orifice left atrioventricular valve • LAVV, left atrioventricular valve • LAVV, regurgitation LAVVR • PAVSD, partial atrioventricular septal defect • SC, septal commissure

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