Ventricular Septal Defect Associated with Aortic Regurgitation

Transcription

1 Ventricular Septal Defect Associated with Aortic Regurgitation Kouichi Hisatomi, M.D., Kenichi Kosuga, M.D., Tadashi somura, M.D., Haruo Akagawa, M.D., Kiroku Ohishi, M.D., and Michihiro Koga, M.D. ABSTRACT The effectiveness of aortic valvuloplasty and the indications for aortic valve were examined in 76 patients with ventricular septal defect associated with aortic regurgitation. Results of this study indicate aortic regurgitation is associated with rapid deterioration and that aortic valvuloplasty should be performed as soon as aortic regurgitation is detected. The data also suggest that aortoplasty is indicated if aortic valvuloplasty alone is inadequate for coaptation of the aortic cusps with thickening. A number of surgical techniques have been used to treat ventricular septal defect (VSD) associated with aortic regurgitation (AR) with varying degree of success. Tatsun0 and co-workers [1] reported that in patients with AR with no prolapse of the aortic sinus noted during preoperative angiography, AR generally did not improve after closure of VSD alone. t might be assumed that the congenital anomalies of the valve commissure and severe deformity of the cusp are reflected in these results. Successful surgical procedures were reported by Gallamella and colleagues [] in 1960, and subsequent modifications were reported by Starr and co-workers [3], Spencer and associates [4], Plauth and colleagues [S], and Trusler and co-workers [6]. n 1971, Trusler and colleagues [6] described a repair of the plicated valve cusp using pledgets between the intraaortic and extraaortic walls and forming the hood of the commissure with Dacron sheets. Similarly in 1981, Yokoyama and colleagues (71 designed a method of simultaneous plication and plasty of the commissures by means of a composite hood graft. The site of plication was determined after the nodules of Arantius had been lifted and attached. When the commissure seemed to be fragile and thin, apposition sutures of Teflon felt by suspension method were used. Despite the evolution of these techniques and improvement in results, the technique of choice for patients with this problem is unclear. Therefore, the present study was undertaken to evaluate the effectiveness of aortic valvuloplasty and to determine the diagnostic From the Second Department of Surgery, Kurumc University School of Medicine, Kurume, Fukuoka, 830, Japan. Accepted for publication June 1, 1986 Address reprint requests to Dr. Hisatomi, Second Department of Surgery, Kurume University School of Medicine, Kurumc, Fukuoka, 830, Japan. indications for aortic valve. Because our patients had only slight anatomical changes of the valve without prolapse of the aortic sinus, we conducted a detailed intraoperative observation of the aortic valvular lesion before selecting the appropriate operative maneuvers. Patients and Methods Seventy-six patients were selected retrospectively for study from a total of 603 operative patients with VSD seen in our department from January, 1966, to March, The selected patients constituted our entire population of AR with a clinical stage of grade 1 + or greater according to the criteria of Sellers and co-workers [8]. Staging classification was determined by preoperative aortic root angiograms [8]: grade 1 + AR was considered a jet from the aorta to the left ventricle; grade + was faint opacification of the left ventricle; grade 3+ was dense opacification; and grade 4+ was when the left ventricle was more densely opacified than the aorta. A summary of the age distribution is shown in Figure 1. Patients ranged in age from to 51 years (mean 15 years). The predominant location of the VSD, using the 1957 classification system of Kirklin and associates [9], was type (defect immediately beneath the pulmonary valve) as shown in Table 1. Postoperative angiography was done if any murmur remained, and echocardiography was performed on all subjects. The interval between treatment and the last postoperative evaluation ranged from 1 to 15 years. A Toshiba sector type scanning echocardiograph (model SSH-11 A) coupled to a Toshiba ultrasonic pulsed Doppler unit (model SDS-OA) was used to determine if there was any improvement in the regurgitant fraction according to the criteria of Sellers and colleagues [8]. The transducer was placed at the second intracostal space over the longitudinal axis of the heart. The resultant image was traced, measured for severity of regurgitation, and placed into one of three categories ranging from mild (presence of regurgitant signal only at subaortic region) to severe (presence of regurgitant signal in the ventricular chamber beyond the anterior mitral leaflet), as shown in Figure. The aortic valvuloplasty and aortoplasty techniques employed are shown in Figure 3. Closure of VSD alone was performed in 17 patients, and aortic valve repairs were performed in 49 patients. Of these operations, 40 were performed using plication or appositioning (i.e., 363 Ann Thorac Surg 43: , Apr 1987

2 364 The Annals of Thoracic Surgery Vol 43 No 4 April 1987 Nvnber Of cases Fig 1. Number of patients arid age at operation. Patients rari~ed iti age from to 51 years, with a nieari of 15 years. aortic valvuloplasty alone); aortoplasty was done as an additional procedure in 9 patients. The other 10 patients needed a prosthetic valve. Pearson product-moment correlation coefficients were used to compare the preoperative and postoperative examination results. Comparisons were made between the preoperative degree of AR and age. Results The location of VSD and site of aortic tension are shown in Table 1. n patients less than 10 years old, there was no correlation between age and the preoperative degree of AR according to the classification of Sellers and colleagues [8] (Fig 4). n addition, no relationship was found between the preoperative New York Heart Association (NYHA) Functional Classification and the shunt rate (Fig 5), although a left-to-right shunt was seen in all patients. Furthermore, pulmonary stenosis was present in 6 patients, bacterial endocarditis in, and bicuspid aortic valve in 1. Based on our ultrasonic pulsed Doppler classification (see Fig ), postoperative improvement after valvuloplasty and aortoplasty was observed in more than 70% of the patients, as shown in Tables and 3. n the 19 Table 1. Location of Ventricular Septa1 Defect and Site of Prolapsed Aortic Valzle Location Site of of VSD' No. of Patients Prolapsed Valve RCC (55) NCC () RCC (4) RCC (10) NNC () NCC () NCC (1) RCC = right coronary cusp; NCC = noncoronary cusp; VSD = ventncular septa1 defect. 'Based on the classificahon of Kirklin and colleagues [9]. patients with preoperative grade 1+ according to the classification of Sellers and colleagues [8], improvement was 89%, and VSD closure alone was demonstrated to be best in this grade. Four operative procedures were used in the 51 patients classified as + and 3 +, and 71% of those undergoing valvuloplasty alone showed improvement, while 100% of those who also underwent aortoplasty showed improvement. The overall rate of improvement with valvuloplasty alone was 65%, whereas that for valvuloplasty combined with aortoplasty was 100%. Four patients underwent reoperation. The age of these patients at the time of the initial operation ranged from 4 to 17 years (Fig 6). All 4 patients were categorized as grade + before the initial operation and underwent aortic valvuloplasty alone. They subsequently exhibited a worsening of AR, necessitating a second procedure. Of these 4 patients, 1 patient died of perforation of the free edge of a bicuspid valve; 1 patient who had plication and apposition during the secondary procedure remained at grade 4 + even though the valve showed marked deformity; and the patients who had valvuloplasty combined with aortoplasty during the second operation showed mixed results: 1 improved, and the other showed no change. Comment The prevalence of subaortic VSD at our center is similar to that reported by Tatsuno and colleagues [lo] for other Asian countries and significantly greater than that reported for other parts of the world [ll]. The majority of persons afflicted with this disorder are children. The most important feature in determining the prognosis is the degree of intolerance in the left ventricle. This feature can be detected by a number of assessment techniques. We used an ultrasonic technique to determine left ventricular function and the postoperative degree of AR. This noninvasive procedure was simple, was found to have a high correlation with the grade of regurgitation as assessed angiographically, and provided useful information concerning AR. Based on our retrospective data using this diagnostic procedure comparing preoperative and postoperative results, aortic valvuloplasty combined with aortoplasty appears to be the operative technique of choice, particularly for patients under 15 years of age. Since 1975 we have used the combined procedure when coaptation of the cusps after aortic valvuloplasty alone did not improve the valvular lesion. The aortoplasty consists of plication of the aortic wall at the level of the commissure; the coaptation is improved because the cusps are protruded. Plauth and associates [5] suggested that in younger patients with mild AR an early closure of VSD and no operation on the valve was a procedure worthy of more extensive clinical trial. f in the clinical course further operative treatment clearly was indicated, closure of the defect by either aortic valvuloplasty or prosthetic of the valve should then be performed. Data presented in this study generally support this concept.

3 365 Hisatomi, Kosuga, somura et al: VSD with Aortic Regurgitation A Fig. The postoperative degree of aortic regurgitation determined by echocardiographic pulsed Doppler technique was classified into three categories: mild (A), the presence of regurgitant signal at subaortic region alone; moderate (B),the presence of regurgitant signal localized between left ventricular outflow tract and free edge of anterior mitral cusp; severe (C), the presence of regurgitant signal in the left ventricular chamber beyond the anterior leaflet. (LA = left atrium; LV = left ventricle.)

4 366 The Annals of Thoracic Surgery Vol 43 No 4 April 1987 Shurt rate(%) plicat ion plicat ion + appositioning stitch rn rn i c 0 ll 1v m NYHA Fig 5. Preoperative shunt rate and New York Heart Association (NYHA) functional class. W plicat ion tappositioning st itch Table. Postoperative mprovement Based on Ultrasonic Pulsed Dowler Results Preoperative Angiographic Class" No. of Operative Procedure Patients Postoperative Resultsb W Fig 3. The three conservative operative methods used. m * VSD closure only + VSD closure only 3+ Aortoplasty Aortoplasty None (16) Mild () None (8) Mild (7) Moderate (5; reoperation in 4) Mild () None (5) Mild (5) Moderate (1) Severe (1) Early death () None () Mild (5) None (3) Moderate (; late death in 1) None () Early death () "Based on the classification of Sellers and colleagues S]. bbased on classification system shown in Figure.

5 367 Hisatomi, Kosuga, somura et al: VSD with Aortic Regurgitation Table 3. Rate of mprovement Based on Postoperative Ultrasonic Pulsed Doppler Results Preoperative Angiographic Class" Operative Procedure mprovement (%)b 33 (1 of 3) 1 71 (15 of 1) Aortoplasty 100 ( of ) (10 of 14) Aortoplasty 100 (7 of 7) V 0 (0 of ) "Based on the classification of Sellers and colleagues [S]. bbased on the classification system shown in Figure. 4ge (Yr) Operation sex 1st operation Reoperation i l 1 year after the frst operatwn 3 years atter the frst Operati Results 6 years atte reoperat.,,, 1 year after reoperation The data suggest an additional guide concerning the age of onset of AR. f the onset occurs in patients under 10 years of age and the grade of AR is more severe than mild, aortic valvuloplasty is unavoidable. We think that this point is crucial to successful treatment. f the severity of AR remains more than mild after aortic valvuloplasty, a second procedure is needed. References 1. Tatsuno K, Konno S, Ando M, et al: Pathogenetic mechanisms of prolapsing aortic valve and aortic regurgitation associated with ventricular septal defect: anatomical, angiographic and surgical considerations. Circulation 48:108, Gallamella JJ, Cruz AB, Heupel WH, et al: Ventricular septal defect with aortic insufficiency: successful surgical correction of both defects using the transaortic approach. Am J Cardiol 5:66, Starr A, Menashe V, Dotter D: Surgical correction of aortic insufficiency associated with ventricular septal defect. Surg Gynecol Obstet 111:71, Spencer F, Doyle E, Danilowicz D, et al: Long-term evaluation of aortic valvuloplasty for aortic insufficiency and ventricular septal defect. J Thorac Cardiovasc Surg 65:15, Plauth WH, Braunwald E, Rockoff SD, et al: Ventricular septal defect and aortic regurgitation. Am J Med 39:55, Trusler G, Moes C, Kidd B: Repair of ventricular septal defect with aortic insufficiency. J Thorac Cardiovasc Surg 66:394, Yokoyama A, Kagawa Y, Kahata 0, et al: [Surgical treatment of aortic regurgitation associated with ventricular septal defect.] Jpn J Thorac Surg 34:581, 1981; Circulation 1:587, 1960 (Jap) 8. Sellers RD, Levy MJ, Amplatz K, et al: Left retrograde cardiography in acquired cardiac disease: technique, indications and interpretations in 700 cases. Am J Cardioll4437, Kirklin JW, Harshbarger HG, Donald DE, et al: Surgical correction of ventricular septal defect: anatomic and technical considerations. J Thorac Cardiovasc Surg 33:45, Tastuno K, Ando M, Takao A, et al: Diagnostic importance of aortography in conal ventricular septal defect. Am Heart J 89:171, Nadas A, Thilenius 0, Lafarge C, et al: Ventricular septal defect with aortic regurgitation: medical and pathologic aspects. Circulation 9:86, 1964 i blcuspld valve years after the frst Operatwn Fig 6. Results in 4 patients who underwent reoperation.