J Thorac Cardiovasc Surg 1998;115:733-734
© 1998 Mosby, Inc.
New valid technique for ventricular septal defect associated with aortic regurgitation
Professor Sir Magdi H. Yacoub
Reply to the Editor:
,
Yukinori Moriyama, MDaMy colleagues and I read with interest the comments by Hisatomi and his colleagues. We agree that direct closure of the ventricular septal defect in this syndrome does not produce abnormal displacement of the aortic anulus, "destruction of the commissural support," or any undue tension on the lower margin of the defect. The reason is that one of the basic abnormalities in the syndrome is the presence of excessive redundant tissue produced by dilatation of the aortic sinus, which results in downward and outward displacement of the anulus into the right ventricle. Direct closure of the defect combined with plication of the sinus, as described in our article (J Thorac Cardiovasc Surg 1997;113:253-61), corrects these abnormalities. In contrast, insertion of patches will add to the redundant tissue and does not restore the position of the aortic anulus and cusp to treat or prevent subsequent aortic regurgitation. With regard to the choice of a transaortic or transpulmonary approach, we believe that the transaortic approach offers many advantages, which include the capacity to plicate the thin part of the dilated sinus and accurately attach the crest of the ventricular septum and anulus to the edge of the normal aortic media, below the coronary orifice. In addition, the aortic valve can be assessed and any additional procedures to restore competence can be considered. In this regard, we agree fully with Hisatomi and colleagues that earlier operation obviates the need for aortic valvuloplasty and that maneuvers designed to avoid direct operations on the cusp are preferable. With the widespread use of echocardiography and the distinct and easily detectable echocardiographic features of the syndrome, it should be possible to diagnose and correct the defect before the development of secondary changes in the cusps.
Cardiothoracic SurgeonImperial College School of MedicineNational Heart & Lung InstituteDovehouse St., London SW3 6LY, United Kingdom
