HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Glen Van Arsdell Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Van Arsdell, G. Articles by Freedom, R. M. Search for Related Content PubMed Articles by Van Arsdell, G. Articles by Freedom, R. M.

J Thorac Cardiovasc Surg 1997;113:616-617
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Atrioventricular septal defect with subaortic stenosis: Extended valvular detachment and leaflet augmentation

Hospital for Sick Children, Toronto, Canada
University of Toronto
Toronto, Ontario, Canada

Reply to the Editor:

Macé and colleagues correctly infer that left atrioventricular (AV) valve augmentation in patients having atrioventricular septal defects (AVSDs) and subaortic stenosis may not be inconsequential. These are often redo operations that limit the potential for use of autologous pericardium. Other materials may have less longevity. Stress at the suture line might also cause disruption.

Detachment of the left superior leaflet, only from the septal crest, followed by leaflet augmentation effectively converts the anterior portion of the defect to a Rastelli type C lesion. ¹ This is a lower risk procedure that has its place in the treatment of AVSDs and outlet narrowing.

Patients with AVSDs having recurrent subaortic stenosis are a particular challenge. The outflow angle may be a marker for risk of subaortic stenosis. The outflow angle is defined by the angle created between the plane of the outlet septum and the plane of the closed left-sided anterior leaflet apparatus. ² Normal hearts have an angle approaching 90 degrees. The outflow angle in AVSDs varies but can be as small as zero degrees or approach normal. A narrow angle demonstrates an elongated outflow tract. This is a substrate for development of subaortic stenosis. ³ We hypothesize that an increase in the outflow angle may lessen the incidence of recurrent subaortic stenosis. The largest effective increase in the outflow angle is achieved by detaching the left superior bridging leaflet from the septal crest and extending the incision anteriorly and laterally to include excision of the increased aorta–left AV valve continuity. This area is then generously augmented with a patch. A subaortic myectomy is also performed.

Because of the risk for the combined approach we perform standard subaortic resection and myectomy as a first line of treatment. Leaflet augmentation with subaortic myectomy or modified valve-sparing aortoventriculoplasty ⁴ is performed only in the event of recurrence and if the topography of the left ventricular outflow tract is significantly elongated and narrow.

12/8/78751

References

1. Starr A, Hovaguimian H. Surgical repair of subaortic stenosis in atrioventricular canal defects. J Thorac Cardiovasc Surg 1994;108:373-6.[Abstract/Free Full Text]
   
2. Van Arsdell GS, Williams WG, Boutin C, Trusler GA, Coles JG, Rebeyka IM, et al. Subaortic stenosis in the spectrum of atrioventricular septal defects: solutions may be complex and palliative. J Thorac Cardiovasc Surg 1995;110:1534-42.[Abstract/Free Full Text]
   
3. Gewillig M, Daenen W, Dumoulin M, Van Der Hanwaert L. Rheologic genesis of discrete subvalvular aortic stenosis: a Doppler echocardiographic study. J Am Coll Cardiol 1992;19:181-824.
   
4. Kirklin JW, Barratt-Boyes BG, editors. Cardiac surgery. New York: John Wiley, 1986:971-1012.
   

This article has been cited by other articles:

				A. T. Gurbuz, W. M. Novick, C. A. Pierce, and D. C. Watson Left ventricular outflow tract obstruction after partial atrioventricular septal defect repair Ann. Thorac. Surg., November 1, 1999; 68(5): 1723 - 1726. [Abstract] [Full Text] [PDF]

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Glen Van Arsdell Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Van Arsdell, G. Articles by Freedom, R. M. Search for Related Content PubMed Articles by Van Arsdell, G. Articles by Freedom, R. M.