after AV Canal Repair: When and How To Intervene
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1 Left Atrioventricular Valve Regurgitation after AV Canal Repair: When and How To Intervene Thomas L Spray, M.D. Chief, Cardiothoracic Surgery Alice Langdon Warner Endowed Chair The Children s Hospital of Philadelphia Professor of Surgery The University of Pennsylvania School of Medicine
2 What are we to do when the irresistible i force of the need to offer clinical advice meets with the immovable object of flawed evidence? All we can do is our best: give the advice, but alert the advisees to the flaws in the evidence on which it is based. Oxford Centre for Evidence Based Medicine
3 Limitations of Evidence: Retrospective observational case series Multiple surgical strategies Small sample sizes Lack of contemporaneous controls Expert opinion
4 Complete AVSD: Dfii Deficiency of fh the atrioventricular i septum with iha common atrioventricular junction guarded by a common atrioventricular valve, in the setting of biventricular atrioventricular connections. In most cases the valve guarding the common atrioventricular junction consists of five leaflets: superior (or anterior) and inferior (or posterior) bridging leaflets, which override the interventricular septum and have chordal attachments to both ventricles, a left mural leaflet, a right mural, and a right ihtantero-lateral lt lleaflet. flt There is an interatrial communication (primum component) between the inferior margin of the atrial septum and the atrial surface of the common atrioventricular valve, and a large interventricular i communication i (ventricular component) between the crest of the inter-ventricular septum and the ventricular surface of the common valve. The left atrioventricular valve is not a mitral valve. The zone of apposition i between the bridging i leaflets is not a cleft. Shuhaiber et al Eur J Cardio-thorac Surg 35 (2009)
5 Surgical loptions for Complete AVSD: Single patch repair Two patch repair Modified single patch repair Closure of cleft
6 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair Division bridging leaflet
7 Suture patch to ventricular septum
8 Suspension of leaflets from patch
9 Closure of Cleft
10 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair Placement of VSD Patch
11 Closure of Cleft
12 Placement of ASD Patch
13
14 Issues: Why is left AV valve reoperation needed (performed)? How often is reoperation needed (performed)? What are the predictors of reoperation? What techniques can be utilized for reoperation? What are the results of reoperation?
15 Issues: Why is left AV valve reoperation needed (performed)? How often is reoperation needed (performed)? What are the predictors of reoperation? What techniques can be utilized for reoperation? What are the results of reoperation?
16 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair
17 Indications for Left AV Valve Reoperation: Severe left AV valve regurgitation Left ventricular dilatation or dysfunction Symptomatic heart failure/growth hfailure Pl Pulmonary hypertension All of these can be difficult to quantify, thus the indications for reoperation likely vary greatly between practitioners and institutions
18 Issues: Why is left AV valve reoperation needed (performed)? How often is reoperation needed (performed)? What are the predictors of reoperation? What techniques can be utilized for reoperation? What are the results of reoperation?
19 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair Freedom from reoperation 82.5% at 10 years 88.5% of reoperations for LAVV patients Multiple surgeons Two patch technique in 91.6% Cleft not closed
20 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair Freedom from LAVV reoperation 91% at 2 years 88% at 6 years 75% at 10 years patients ts Multiple surgeons
21 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair patients Single surgeon Single patch technique with cleft closure
22 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair patients Single surgeon Single patch technique with cleft closure
23 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair Freedom from LAVV reoperation 94% at 1 year 89% at 3 years 89% at 5 years patients Multiple surgeons Two patch technique in 84.5% Complete cleft closure in 89%
24 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair Freedom from LAVV reoperation 98% at 1 year 95% at 3 years 94% at 5 years patients Single surgeon Two patch technique in all Complete cleft closure in 92%
25 patients Multiple surgeons Two patch and modified single patch Closure of cleft variable
26 Issues: Why is left AV valve reoperation needed (performed)? How often is reoperation needed (performed)? What are the predictors of reoperation? What techniques can be utilized for reoperation? What are the results of reoperation?
27 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair
28 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair
29 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair
30
31
32 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair patients Single surgeon Two patch technique in all Complete cleft closure since1987
33 Issues: Why is left AV valve reoperation needed (performed)? How often is reoperation needed (performed)? What are the predictors of reoperation? What techniques can be utilized for reoperation? What are the results of reoperation?
34 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair
35 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
36
37 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair Edge-to edge approximation of leaflets to create double orifice LAVV
38 not be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Left Atrioventricular Valve Reoperation after AVSD Repair Pericardial patch extension of left AV valve leaflet
39 Issues: Why is left AV valve reoperation needed (performed)? How often is reoperation needed (performed)? What are the predictors of reoperation? What techniques can be utilized for reoperation? What are the results of reoperation?
40 Freedom from Second Left AV Valve Reoperation No differences in freedom from second left AV valve reoperation for the three types of operative technique; pericardial patch repair, conventional repair or valve replacement
41 Between 1972 and 2007, 50 patients underwent reoperation after AVSD repair. The indication was left AV valve regurgitation in 41 patients, left AV valve stenosis in 1 and a variety of less common indications. The median interval from initial repair to reoperation was 15 months. Valve repair was performed in 21 and valve replacement in 21 with no early mortality.
42 again.overall Survival after Reoperation The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it
43 Freedom from Second Left AV Valve Reoperation
44 Between 1977 and 2008, 28 patients underwent reoperation after complete AVSD repair. The indication was left AV valve regurgitation in 25 patients. The median interval from initial repair to reoperation was 24 months. Valve repair was possible in 23 and valve replacement in 2.
45 Freedom from Second dleft ftavv Valve Reoperation The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
46 Event-free Survival after Reoperation The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
47 Summary: By 10 years after initial repair, at least 10-15% of patients with complete AVSD will have undergone left AV valve reoperation, most often for regurgitation. g The most significant predictors of reoperation are patient factors, especially a structural abnormality of the left AV Valve. Choice of surgical technique (single patch vs. two patch vs. modified single patch) does not affect the risk of reoperation.
48 Summary: Failure (inability) to completely close the cleft likely increases the risk of reoperation. At reoperation, the left AV valve can often be repaired, usually by cleft closure or annuloplasty, with good early results. However, there is a significant likelihood of additional left AV interventions and late mortality, even after a successful reoperation, even if valve is replaced. These outcomes are remarkably consistent across multiple institutions, bth but have improved only slightly lihtl over the last ttwo decades. d
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