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Eur J Cardiothorac Surg 2003;23:136-137
© 2003 Elsevier Science NL
Letter to the Editor |
Denver Children's Hospital, University of Colorado, Denver, CO, USA
Received 18 September 2002; accepted 27 September 2002.
Key Words: Double outlet right ventricle • Non-committed ventricular septal defect
I thank Dr Jose Caffarena and Dr Gómez-Ullate for their comments on our article on DORV non-committed VSD.
Taussig-Bing and DORV non-committed VSD are surgically very different entities, the DORV non-committed VSD repair being a lot more challenging.
It seems there is a semantic confusion in the definition of perimembranous VSD coming from the vague definition given by many authors using the term subarterial or subaortic VSD to describe perimembranous VSD. When the aorta is far away, it seems that there is difficulty in distinguishing perimembranous VSD from inlet VSD. The definition of the membranous septum is independent from the aortic annulus. It is defined by Anderson [1] as being in contact with the central fibrous body, next to the tricuspid valve. The two specimens shown in our article are true DORV non-committed VSD as stated by authors Bob Anderson and Bob Freedom [2]; the VSD are perimembranous VSD with inlet extension.
The difference with a Taussig-Bing is not due to the nature of the VSD that is also a perimembranous VSD (but with outlet extension) but to a greater distance to the pulmonary valve. As shown by Bob Freedom [2], in Taussig-Bing the VSD is immediately located beneath the pulmonary valve and located above the posterior limb of the trabecula septomarginalis. In DORV non-committed VSD, the VSD is distant from the pulmonary valve and located beneath the posterior limb of the trabecula septomarginalis. True muscular inlet or trabecular VSDs are possible, although we have not found any in our series. As stated by Belli [3], in DORV non-committed VSD, the distance from both arterial annuli should be greater than an aortic annulus diameter. In Taussig-Bing, the distance of the VSD from the pulmonary artery is less than an aortic valve diameter and in DORV non-committed VSD this distance is greater.
One consequence is that the VSDs in DOR non-committed VSD are frequently restrictive which we have never seen in Taussig-Bing. The VSD has to be enlarged anteriorly, as was done in all the cases published. There was no heart block in our series, confirming the perimembranous location of the VSD. I consider that the VSD depicted by Barbero-Marcial [4] as muscular VSD are in fact mostly true perimembranous VSD. Notice also that an AVSD defect is in contact with the tricuspid annulus and is a perimembranous VSD with inlet extension.
Another difference in Taussig-Bing is the usual overriding of the pulmonary artery that is partly located on the left ventricle (now named DORV-TGA type). In DORV non-committed VSD, the vessels are very clearly 200% on the RV.
In DORV non-committed VSD hearts, there is an association with subpulmonary stenosis which is never the case in Taussig-Bing.
Finally, Taussig-Bing belongs more to the group of TGA VSD and is almost exclusively treated by arterial switch (the Kawashima operation being rarely indicated) and on the contrary, the DORV non-committed VSD can be treated differently by VSD tunnellization to the aorta in favourable forms and by tunnellization to the PA and ASO in the most severe forms.
References
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