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J Thorac Cardiovasc Surg 1998;115:733
© 1998 Mosby, Inc.

LETTERS TO THE EDITOR

New valid technique for ventricular septal defect associated with aortic regurgitation

^a To the Editor:

We read with great interest the article by Yacoub and associates ¹ concerning the ideal means of total repair of ventricular septal defect (VSD) associated with prolapse of the aortic cusp through a transaortic approach alone. The authors appear to recognize that current operative procedures, which have been considered essentially definitive, leave much room for improvement. In supplemental discussion, they raise questions concerning the validity of direct closure of the VSD just beneath the pulmonary valve and the necessity for plication of the prolapsed sinus of Valsalva for mild aortic regurgitation (AR). On the basis of our own experience, we support the use of their new technique.

Concerning the method of VSD closure in the conal area, especially with a large subpulmonary VSD, Spencer and associates ² suggested that direct closure produced a downward displacement of the aortic anulus and destruction of its commissural support. Kawashima and colleagues ³ also suggested that it seemed dangerous to approximate the pulmonic ring to the lower margin of the defect, because doing so might result in subsequent tearing of the tissue and recurrence of the defect. Following their suggestions, we also performed patch closure for this type of VSD. However, since 1995 we have performed direct closure in five patients with a subpulmonary type of VSD with mild AR. We inserted an interrupted 4-0 or 5-0 polypropylene suture with a pledget from the lower margin of the VSD to the pulmonary ring to increase protrusion of the prolapsed cusp by pushing it back and to improve coaptation of the aortic cusp through the pulmonary artery. As a result, the prolapsing aortic cusp and mild AR disappeared and no anatomic changes in either the aortic or pulmonic anulus were found on follow-up echocardiography. Furthermore, postoperative murmur, which appears sometimes to result from the use of a patch, was detected in none of the patients.

Recently, the incidence of moderate or more severe AR associated with this type of VSD has markedly decreased, because patients are immediately referred for closure of the VSD when progression of prolapse of the aortic cusp or the occurrence of AR is detected. Consequently, the number of patients needing valvuloplasty has decreased. However, the problem of degeneration of the repaired aortic valve has been considered on long-term follow-up for patients who have undergone excessive valvuloplasty for AR. To prevent direct excessive manipulation of the cusps to the repair, we ⁴ have also used aortoplasty (plication of the aorta) to achieve protrusion of the cusp when coaptation is not improved after plication of the prolapsed cusp. Taking into consideration the long-term results, Yacoub's plication maneuver also seems likely to improve coaptation of the cusps without the need to touch them, especially in patients with moderate or severe AR.

Second Department of Surgery^aPediatric Department^bFaculty of Medicine
Kagoshima University8-35-1 Sakuragaoka, Kagoshima 890, Japan References

1. Yacoub MH, Khan H, Stavri G, Shinebourne E, Radley-Smith R. Anatomic correction of the syndrome of prolapsing right coronary aortic cusp, dilatation of the sinus of Valsalva, and ventricular septal defect. J Thorac Cardiovasc Surg 1997;113:253-61. [Abstract/Free Full Text]
   
2. Spencer FC, Doyle EF, Danilowicz DA, Bahnson HT, Weldon CS. Long-term evaluation of aortic valvuloplasty for aortic insufficiency and ventricular septal defect. J Thorac Cardiovasc Surg 1973;65:15-31.[Medline]
   
3. Kawashima Y, Danno M, Shimizu Y, et al. Ventricular septal defect associated with aortic insufficiency. Circulation 1973;47:1057-64.[Abstract/Free Full Text]
   
4. Hisatomi K, Isomura T, Sato T, et al. Aortoplasty for aortic regurgitation with ventricular septal defect. J Thorac Cardiovasc Surg 1994;108:396-7.[Free Full Text]
   

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): Akira Taira Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hisatomi, K. Articles by Moriyama, Y. Search for Related Content PubMed PubMed Citation Articles by Hisatomi, K. Articles by Moriyama, Y.