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J Thorac Cardiovasc Surg 1997;113:617-618
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Is left ventricular outflow tract obstruction really relieved on long-term follow-up?

Second Department of Surgery
Faculty of Medicine
Kagoshima University
8-35-1 Sakuragaoka
Kagoshima City, Japan

To the Editor:

Luciani and associates ¹ report good results in their article titled "One-Stage Repair of Interrupted Aortic Arch, Ventricular Septal Defect, and Subaortic Obstruction in the Neonate: A Novel Approach." However, I am unsure about the long-term results.

I treated a baby girl, not a neonate, who had a simple ventricular septal defect (VSD) associated with infundibular posterior malalignment, which caused only a 30 mm Hg pressure gradient through the left ventricular outflow tract (LVOT). Preoperative echocardiographic examination showed that she had a large perimembranous VSD with a mild pressure gradient between the left ventricle and ascending aorta, which resulted from posterior malalignment of the infundibular septum to the LVOT. Cardiac catheterization showed that the right ventricular/left ventricular pressure ratio was 0.9 and the pressure gradient through the LVOT was only 30 mm Hg. Cardiac angiography also showed that the infundibular septum significantly deviated to the LVOT and the ascending aorta was relatively small (6 mm).

The patient was treated with catecholamines for cardiac failure caused by pulmonary hypertension, but her respiratory distress progressed. Because of her low weight (2850 gm) and mild pressure gradient through the LVOT (30 mm Hg), we merely closed the VSD through the right atrium after inducing cardiac arrest with a crystalloid cardioplegic solution when she was 2 months of age. On closure of the VSD, a Dacron patch was attached with interrupted 5-0 polypropylene sutures. Stay sutures placed on the infundibular side of the VSD were inserted from the left side of the conal septum to the upper margin of the VSD. Moreover, we used as small a patch as possible for closure of the VSD to prevent protrusion of the patch into the LVOT and to pull the conal septum toward the right ventricular side.

The baby's postoperative course was uneventful. No pressure gradient in the LVOT was found, and the protrusion of the infundibular septum into the LVOT was completely repaired, as revealed by the echocardiographic examination before her discharge. However, follow-up echocardiography showed that the subaortic stenosis, which caused a pressure gradient of 30 mm Hg, had recurred 1 year after the operation. This gradient gradually increased because of the development of subaortic stenosis associated with hypertrophy of the conal septum at the left ventricular side. Three years after the operation, cardiac catheterization was performed and the pressure gradient was found to be 80 mm Hg. Consequently, I think that the hypertrophic subaortic muscle will need to be resected in the near future.

With Bove and colleagues, ² I now believe that when the infundibular septum malaligns with the LVOT, resulting in subaortic stenosis, the septum should be resected, with care taken to avoid injuring the aortic valve at the initial operation. This should be done even if the cardiac anomaly is complex and the pressure gradient is mild.

12/8/78757

References

1. Luciani GB, Ackerman RJ, Chang AC, Wells WJ, Starnes VA. One-stage repair of interrupted aortic arch, ventricular septal defect, and subaortic obstruction in the neonate: a novel approach. J Thorac Cardiovasc Surg 1996;111:348-58.[Abstract/Free Full Text]
   
2. Bove EL, Minich LL, Pfidjian AK, et al. The management of severe subaortic stenosis, ventricular septal defect, and aortic arch obstruction in the neonate. J Thorac Cardiovasc Surg 1993;105:289-96.[Abstract]
   

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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kouichi Hisatomi Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hisatomi, K. Search for Related Content PubMed PubMed Citation Articles by Hisatomi, K.