Surgical Treatment for Atrioventricular Septal Defect. Masakazu Nakao Consultant, Paediatric Cardiothoracic Surgery

Transcription

1 Surgical Treatment for Atrioventricular Septal Defect Masakazu Nakao Consultant, Paediatric Cardiothoracic Surgery 1

2 History Rastelli classification (Rastelli) Pulmonary artery banding (Muller & Dammann) Detail anatomy of the bundle of His in AVSD (Lev) Modified single patch repair of AVSD (Wilcox) Today Intracardiac repair of AVSD using cross-circulation(lillehei) Single patch repair of AVSD (Maloney, Gerbode) Modified Australian single patch repair of AVSD championed (Nunn) Two patch repair of AVSD (Trusler) 2

3 3 Partial AVSD

4 Indications Symptomatic mitral regugitation Congestive heart failure Otherwise, same as ASD Operate electively in most of patients Operate as soon as medical treatment fails for heart failure 4

5 Surgical Treatment - Overview Corrective Repair of partial AVSD Closure of atrial septal defect Repair of mitral valve cleft 5

6 Surgical Treatment mitral valve repair a. Simple commissuroplasty b. Shortening of chordae c. Shortening of chordae (completed) d. Local annuloplasty for central imcompetence Adopted from Pacifico AD. Atrio-ventricular septal defect: Surgery for congenital heart defect, third edition. Eds. Stark JF, et al. John Wiley & Sons, 2006:

7 Surgical Treatment Valve Orifice Size BSA (m 2 ) MITRAL TRICUSPID AORTIC PULMONARY BSA (m 2 ) Table in actual use in KKH, modified from Rawlett UF, et al. The quantitative anatomy of the normal child s heart. Pediatr Clin North Am 1963;10:499 7

8 Surgical Treatment - Closure of Atrial Septal Defect Stay on TV till away from septum 2. Avoid AV node 3. Coronary sinus is safe or keep CS on the left side Adopted from Pacifico AD. Atrio-ventricular septal defect: Surgery for congenital heart defect, third edition. Eds. Stark JF, et al. John Wiley & Sons, 2006:

9 Short-Term Mortality Early mortality 0~2% Dilated heart, significant mitral regurgitation are risk factors 9

10 Long-Term Mortality Possible risk factors Younger age (<1.5yo) Preoperative significant MR Survival adopted from Bowman JL, et al. Should repair of partial atrioventricular septal defect be delayed until later in childhood? Am J Cardiol 2014;114:

11 Short-Term Morbidities Residual leak Mitral regurgitation 3% Complete heart eart block 2% LVOTO due to elongated LVOT 3% 11

12 Long-Term Morbidities Over 249 patients Survival-free of reoperation curve adopted from Bowman JL, et al. Should repair of partial atrioventricular septal defect be delayed until later in childhood? Am J Cardiol 2014;114: Reoperation details adopted from Buratto E, et al. Long-term outcomes of reoperations following repair of partial atrioventricular septal defect. Eur J Cardiothorac Surg 2016;50:

13 13 Complete AVSD

14 Indications Failure to thrive Recurrent chest infection Congestive heart failure 1970s ~ early 1980s: Autopsy and clinical study revealed the high risk after the first year - 65% of untreated patients die by 1 year, 85% by 2 years and 96% by 5 years. Operate as soon as medical treatment fails < 6 months for Trisomy 21 < 1 year for others 14

15 Contraindication Eisenmenger Syndrome Predominant right-to-left shunt PVR > 8 Wood units/m 2 If PVR study shows a good response to pulmonary vasodilators, some may be apt for surgery. 15

16 Surgical Treatment - Overview Palliative - Pulmonary artery banding Corrective Single patch repair Two patch repair Modified single patch repair 16

17 Surgical Treatment - Palliative Pulmonary artery banding Previously employed as a two-stage strategy Should be avoided unless left with no choice - increase AV valve regurgitation - carries high mortality 15~25% 17

18 Surgical Treatment Corrective Corrective Single patch repair Two patch repair Modified single patch repair 18

19 Surgical Treatment General Consideration Conduction AV valve Closure of ventricular component Closure of atrial component 19

20 Surgical Treatment General Consideration Conduction stay on the right side AV valve Closure of ventricular component Closure of atrial component Adopted from Pacifico AD. Atrio-ventricular septal defect: Surgery for congenital heart defect, third edition. Eds. Stark JF, et al. John Wiley & Sons, 2006:

21 Surgical Treatment General consideration Conduction AV valve more to the left Closure of ventricular component Closure of atrial component Adopted from Pacifico AD. Atrio-ventricular septal defect: Surgery for congenital heart defect, third edition. Eds. Stark JF, et al. John Wiley & Sons, 2006:

22 Surgical Treatment Single patch repair Adopted from Pacifico AD. Atrio-ventricular septal defect: Surgery for congenital heart defect, third edition. Eds. Stark JF, et al. John Wiley & Sons, 2006:

23 Surgical Treatment Two patch repair Stay on the right side 2. Patch can be boat-shape 3. Height aims to be lower than annular level 4. Too short patch will cause leak at the edge 23 Adopted from Dekel H, et al. Repair of Atrioventricular Septal Defects: The 2-Patch Sandwich Technique. Operative techniques in thoracic and cardiovascular surgery 2015;20(1):63-74

24 Patch meets the annulus on the right side of crest 2. Suture line avoid edge of crest and AV node to the right side 24 Adopted from Dekel H, et al. Repair of Atrioventricular Septal Defects: The 2-Patch Sandwich Technique. Operative techniques in thoracic and cardiovascular surgery 2015;20(1):63-74

25 Mattress suture touch the annulus 2. Keep mattress suture not too wide - become crumpled and shortened 25 Adopted from Dekel H, et al. Repair of Atrioventricular Septal Defects: The 2-Patch Sandwich Technique. Operative techniques in thoracic and cardiovascular surgery 2015;20(1):63-74

26 1. Give more to the left 2. Location of the chordae can be used as a guide 3. Lesser and greater curvature of patch meet annulus Adopted from Dekel H, et al. Repair of Atrioventricular Septal Defects: The 2-Patch Sandwich Technique. Operative techniques in thoracic and cardiovascular surgery 2015;20(1):63-74

27 1 1. Sometimes gap between RSL and RIL is big - pull RSL and RIL equally to zone of apposition and paste to septal patch 27 Adopted from Dekel H, et al. Repair of Atrioventricular Septal Defects: The 2-Patch Sandwich Technique. Operative techniques in thoracic and cardiovascular surgery 2015;20(1):63-74

28 Surgical Treatment Modified single patch Drawing is exaggerated, need closer stitches 2. Some people take eptfe/dacron strip before autologous pericardium 3. Nunn suggested length to be 70%, some 80% of annular diameter 1 28 Adopted from Clarke A, et al. The simplified single patch repair of complete atrioventricular septal defect. Operative techniques in thoracic and cardiovascular surgery 2004;9(3):

29 1 1. Well away to the right side of AV node - floor of CS is safe area 29 Adopted from Clarke A, et al. The simplified single patch repair of complete atrioventricular septal defect. Operative techniques in thoracic and cardiovascular surgery 2004;9(3):

30 Short-Term Mortality Modified from Backer CL, Mavroudis C. Atrioventricular canal defects: Pediatric cardiac surgery, fourth edition. Eds. Mavroudis C, Backer CL, Wiley-Blackwell, 2013:

31 Short-Term Mortality St. Louis JD, et al. Contemporary outcomes of complete atrioventricular septal defect repair: Analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. J Thorac Cardiovasc Surg 2014;148:

32 Long-Term Mortality Modified from Backer CL, Mavroudis C. Atrioventricular canal defects: Pediatric cardiac surgery, fourth edition. Eds. Mavroudis C, Backer CL, Wiley-Blackwell, 2013:

33 Short-Term Morbidities Residual leak Complete heart bock Left AV valve regurgitation Right AV valve regurgitation LVOTO due to elongated LVOT 33

34 Short-Term Morbidities Modified from Backer CL, Mavroudis C. Atrioventricular canal defects: Pediatric cardiac surgery, fourth edition. Eds. Mavroudis C, Backer CL, Wiley-Blackwell, 2013:

35 Short-Term Morbidities St. Louis JD, et al. Contemporary outcomes of complete atrioventricular septal defect repair: Analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. J Thorac Cardiovasc Surg 2014;148:

36 Long-Term Morbidities LAVVR is an independent risk factor for Mortality Ginde S, et al. Long-term outcomes after surgical repair of complete atrioventricular septal defect. J Thorac Cardiovasc Surg 2015;150:

37 Conclusion AVSD represents a wide spectrum of intracardiac anomalies Partial AVSD are treated much like ASD. Complete AVSD should undergo operative repair in early period of life. Postoperative management centers on proactive treatment of pulmonary hypertension. 37

38 Further Reading 1. Hoohenkerk GJF, et al. More than 30 years experience with surgical correction of atrioventricular septal defects. Ann Thorac Surg 2010;90: Kaza AK, et al. Surgical interventions for atrioventricular septal defect subtypes: The pediatric heart network experience. Ann Thorac Surg 2011;92: St. Louis JD, et al. Contemporary outcomes of complete atrioventricular septal defect repair: Analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. J Thorac Cardiovasc Surg 2014;148: Ginde S, et al. Long-term outcomes after surgical repair of complete atrioventricular septal defect. J Thorac Cardiovasc Surg 2015;150:

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