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J Thorac Cardiovasc Surg 1997;113:615-616
© 1997 Mosby, Inc.
LETTERS TO THE EDITOR |
Department of Cardiovascular and Pediatric Cardiac Surgery
Marie Lannelongue Hospital and Paris–Sud University
133 avenue de la Résistance
92350 Le Plessis Robinson, France
To the Editor:
We read with interest the recent report by Van Ardsell and colleagues
1 regarding the different treatment options for subaortic stenosis associated with atrioventricular septal defect (AVSD). They pointed out the importance of leaflet augmentation and fibromyectomy to decrease the likelihood of recurrence of subaortic stenosis. We would like to further clarify the technical aspects of leaflet augmentation in AVSD when malattachment of the left superior leaflet is the predominant feature of an associated subaortic stenosis. The authors, when describing this surgical procedure, stated that "the superior bridging leaflet is detached from the anterior portion of the septal crest extending to the region just to the left of the left ventricular outflow tract" and that "the increased mitral aortic separation is excised." The left superior leaflet is thus detached at two different boundaries of the left ventricular outflow tract: (1) the septal insertion of the valvular leaflet and (2) the aorta–left atrioventricular (AV) valve continuity.
Leaflet augmentation with detachment of the valvular leaflet from the septal crest was first reported by Lappen and colleagues 2 and subsequently by DeLeon and colleagues 3 in a patient in whom subaortic stenosis recurred after the surgical correction of a partial AVSD. The anatomic concepts leading to that treatment option were emphasized by Chang and Becker 4 in Rastelli type A AVSD. Today, this procedure gains increased interest 5 owing to the failure of more simple options that did not address the pathoanatomic features of the subaortic area in AVSD.
The importance of aorta–left AV valve continuity in the pathogenesis of a subaortic stenosis was underlined by Ebels and coworkers 6 in their description of the "atrial fold." These authors proposed a sham repair with either an enlargement of this anatomic region using a diamond-shaped patch or a resection of the atrial fold in case of an associated left AV valve replacement. Moreover, patch insertion at this level associated with a left AV valve replacement avoids postoperative subaortic stenosis in AVSD. 7
Keeping these important anatomic concepts in mind, we used leaflet augmentation in a 12-year-old girl who had been referred to our institution for native subaortic stenosis associated with an AVSD. Leaflet augmentation was accomplished by extending the detachment of the superior leaflet from the septal crest into the aorta–left AV valve continuity (Fig. 1). 8 The young girl was still doing well 2 years later, without subaortic stenosis, with a moderate stenosis at the aortic level and a mild "mitral" insufficiency. Since this report, we observed, immediately after correction of a partial AVSD in a 3-year-old girl without Down syndrome, the occurrence of a subaortic stenosis with a systolic left ventricle–ascending aorta gradient of 37 mm Hg. One year later, a color-coded echocardiographic study revealed the progressive increase of the left ventricular outflow tract obstruction to a systolic gradient of 80 mm Hg. Using the same operative procedure associated with a fibromyectomy, we completely relieved the subaortic stenosis. The "mitral" valve repair included a cleft closure and an annuloplasty. Today, 2 years later, there is no recurrence of the left ventricular outflow tract obstruction or of the left AV valve insufficiency.
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12/8/78750
References
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