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A technique of aortic valvuloplasty for aortic insufficiency associated with ventricular septal defect
A technique of aortic valvuloplasty for aortic insufficiency associated with ventricular septal defect D. Alton Murphy, M.D., and Norman Poirier, M.D., Montreal, Quebec, Canada
JL he competence of the aortic valve is dependent on three factors: (1) normal support of the aortic leaflets from above (the commissures), (2) normal support at the free edge of the leaflet by apposition in diastole, and (3) normal support from below (conal septum). One or a combination of deficiencies in the above are responsible for aortic insufficiency associated with ventricular septal defect.1 In supracristal ventricular septal defects which are associated with aortic incompetence simple closure with ventricular patch support of the abnormal cusp from below occasionally is enough to prevent the aortic insufficiency.1 More frequently, however, there are abnormalities in the commissures and poor apposition of the free edges. More elaborate procedures are then required to prevent aortic regurgitation. Several methods of repairing the aortic leaflets have been proposed 28 and have afforded some success.8"12 The following account records another method of aortic valvuloplasty which may be useful in patients with similar favorable anatomy. From the Department of Cardiovascular Surgery and the McGill-Montreal Children's Hospital Research Institute, 2300 Tupper Street, Montreal 108, Quebec, Canada. This work was supported by J. C. Edwards Foundation and the Quebec Heart Fund. Received for publication May 22, 1972.
800
Case report The patient, an 8-year-old girl, was known to have an infracristal ventricular septal defect, infundibular pulmonic stenosis, and aortic regurgitation since her first admission to this hospital at the age of 5 years. On physical examination, a precordial systolic thrill was palpated maximally over the second to fourth left intercostal spaces, along the left sternal border. The pulses were collapsing. The blood pressure by sphygmomanometer was 115/50 mm. Hg. There was a harsh Grade 6 of 6 pansystolic murmur maximally heard over the second and third left intercostal spaces, and a soft Grade 2 of 6 blowing diastolic murmur was heard along the left sternal border at the fourth intercostal space. Preoperative cardiac catheterization demonstrated an 85 mm. Hg gradient across the pulmonary infundibulum. The aortic root pressure was 110/50 mm. Hg. Angiography confirmed the diagnosis of infundibular pulmonic stenosis, ventricular septal defect, and moderate aortic insufficiency. Elective repair was performed because of increasing cardiomegaly. Operation. A small transverse aortotomy was made, and the aortic valve was exposed.* There was rotation of the aortic root in a counterclockwise direction so that the right coronary and noncoronary commissures were more anterior than usual. There was prolapse of both right coronary and noncoronary cusps. Centrally, the free edges of these cusps were redundant and thickened. The edges of the valve near the commissures were very thin and were not considered strong ♦Cardiopulmonary bypass with a disposable bubble oxygenator, moderate hypothermia (32° C ) , and topical cardiac hypothermia (Ringer's lactate solution, 4° C.) was used.
Volume 64
Aortic valvuloplasty 8 0 1
Number 5 November, 1972
Fig. 1. RCA, Right coronary artery. enough to plicate in the fashion previously described.3' 8 A single 5-0 silk traction stitch was placed through the nodes of Arantii. By means of a scalpel, the aortotomy was carried downward (Fig. \, A) dividing the commissure between the affected cusps for approximately Vi inch. This left a remnant of commissure on each half of the vertical aortotomy. The redundant cusps were then pulled upward and through the aortotomy so that the free edges were in proper approximation. The vertical aortotomy was closed with interrupted horizontal mattress stitches, including the aortic cusps in the formation of a new commissure (Fig. 1, A). The redundant cusps outside the aortic lumen were then oversewn, including the aortic wall with a continuous stitch. (Fig. 1, B). The aortotomy was closed, and the aortic clamp was temporarily released. Minimal left ventricular vent sump drainage was evident. Infundibulectomy and patch closure of the ventricular septal defect were then carried out. Two weeks postoperatively, the heart size had decreased, and no diastolic murmur was heard. The aortic root pressure was 100/60 mm. Hg, indicating a decrease of 20 mm. Hg in the pulse pressure. Only a tiny whiff of aortic regurgitation could be seen by angiography.
Discussion A number of ingenious techniques for aortic valvuloplasty have been reported.28 The method suggested by Garamella's group,2 which consists of excision of the noncoronary cusp and conversion of the tricuspid valve to a bicuspid valve, was not suitable in this case since there were two valves involved and the aortic root was of
normal caliber. The use of plication stitches on the free edge as suggested by several authors,3'4-6> s if used in this particular valve, probably would not have been successful since the valve substance was so thin. Homografts, as suggested by GonzalezLavin and Barratt-Boyes,5 have been difficult to obtain in this center. In dealing surgically with such a variable lesion, it is comforting to have a number of alternative methods to reconstruct the aortic valve. The method described has given a satisfactory result in a patient in whom there were two incompetent aortic cusps, as well as aortic root rotation. The method is suggested as an alternative procedure in the correction of aortic insufficiency associated with ventricular septal defect. Summary A method of aortic valvuloplasty for aortic insufficiency associated with ventricular septal defect is described. The technique consists of a vertical aortotomy through the affected aortic valve commissures with inclusion of the redundant cusp or cusps in the closure of the aortotomy. REFERENCES 1 Van Praagh, R., and McNamara, J. J.: Anatomic Types of Ventricular Septal Defect With Aortic Insufficiency, Am. Heart J. 75: 604, 1968.
The Journal of
8 0 2 Murphy and Poirier
Thoracic and Cardiovascular Surgery
2 Garamella, J. J., Schmidt, R., Jensen, K. K., and Lynch, M. F.: Clinical Experience With the Biscuspid Operation for Aortic Regurgitation, Ann. Surg. 157: 310, 1963. 3 Spenser, F. C , Bahnson, H. T., and Neill, C. A.: The Treatment of Aortic Regurgitation Associated With a Ventricular Septal Defect, J. THORAC. CARDIOVAS. SURG. 43: 222,
1962.
4 Starr, A., Menashe, V., and Dotter, C : Surgical Correction of Aortic Insufficiency Associated With a Ventricular Septal Defect, Surg. Gynecol. Obstet. 11: 71, 1960. 5 Gonzalez-Lavin, L., and Barratt-Boyes, B. G.: Surgical Considerations in the Treatment of Ventricular Septal Defect Associated With Aortic Valvular Incompetence, J. THORAC. CARDIOVASC. SURG. 57: 422,
1969.
6 Frater, R. W. M.: The Prolapsing Aortic Cusp, Ann. Thorac. Surg. 3: 63, 1967. 7 MuUer, W. H., Warren, W. D., Damman, J. F., Beckwith, J. R., and Wood, J. E.: Surgical Relief of Aortic Insufficiency by Direct Opera-
8
9 10
11 12
tion on the Aortic Valve, Circulation 21:587, 1960. Plauth, W. H., Braunwald, E., Rockoff, S. D., Mason, D. T., and Morrow, A. G.: Ventricular Septal Defect and Aortic Regurgitation, Am. J. Med. 39: 552, 1965. Somerville, J., Brandao, A., and Ross, D. N.: Aortic Regurgitation With Ventricular Septal Defect, Circulation 41: 317, 1970. Hallidie-Smith, K. A., Olsen, E. G. J., Oakley, C. M., Goodwin, J. F., and Cleland, W. P.: Ventricular Septal Defect and Aortic Regurgitation, Thorax 24: 257, 1969. Ellis, F. H., Ongley, P. A., and Kirklin, J. W.: Ventricular Septal Defect With Aortic Valvular Incompetence, Circulation 27: 789, 1963. Dubost, C , d'Allaires, C , Blondeau, P., Piwnica, A., and Padeano, J. R.: Les Communications interventriculaires avec Insuffisanse Aortique, Arch. Mai. Coeur 56: 665, 1963.
JL he competence of the aortic valve is dependent on three factors: (1) normal support of the aortic leaflets from above (the commissures), (2) normal support at the free edge of the leaflet by apposition in diastole, and (3) normal support from below (conal septum). One or a combination of deficiencies in the above are responsible for aortic insufficiency associated with ventricular septal defect.1 In supracristal ventricular septal defects which are associated with aortic incompetence simple closure with ventricular patch support of the abnormal cusp from below occasionally is enough to prevent the aortic insufficiency.1 More frequently, however, there are abnormalities in the commissures and poor apposition of the free edges. More elaborate procedures are then required to prevent aortic regurgitation. Several methods of repairing the aortic leaflets have been proposed 28 and have afforded some success.8"12 The following account records another method of aortic valvuloplasty which may be useful in patients with similar favorable anatomy. From the Department of Cardiovascular Surgery and the McGill-Montreal Children's Hospital Research Institute, 2300 Tupper Street, Montreal 108, Quebec, Canada. This work was supported by J. C. Edwards Foundation and the Quebec Heart Fund. Received for publication May 22, 1972.
800
Case report The patient, an 8-year-old girl, was known to have an infracristal ventricular septal defect, infundibular pulmonic stenosis, and aortic regurgitation since her first admission to this hospital at the age of 5 years. On physical examination, a precordial systolic thrill was palpated maximally over the second to fourth left intercostal spaces, along the left sternal border. The pulses were collapsing. The blood pressure by sphygmomanometer was 115/50 mm. Hg. There was a harsh Grade 6 of 6 pansystolic murmur maximally heard over the second and third left intercostal spaces, and a soft Grade 2 of 6 blowing diastolic murmur was heard along the left sternal border at the fourth intercostal space. Preoperative cardiac catheterization demonstrated an 85 mm. Hg gradient across the pulmonary infundibulum. The aortic root pressure was 110/50 mm. Hg. Angiography confirmed the diagnosis of infundibular pulmonic stenosis, ventricular septal defect, and moderate aortic insufficiency. Elective repair was performed because of increasing cardiomegaly. Operation. A small transverse aortotomy was made, and the aortic valve was exposed.* There was rotation of the aortic root in a counterclockwise direction so that the right coronary and noncoronary commissures were more anterior than usual. There was prolapse of both right coronary and noncoronary cusps. Centrally, the free edges of these cusps were redundant and thickened. The edges of the valve near the commissures were very thin and were not considered strong ♦Cardiopulmonary bypass with a disposable bubble oxygenator, moderate hypothermia (32° C ) , and topical cardiac hypothermia (Ringer's lactate solution, 4° C.) was used.
Volume 64
Aortic valvuloplasty 8 0 1
Number 5 November, 1972
Fig. 1. RCA, Right coronary artery. enough to plicate in the fashion previously described.3' 8 A single 5-0 silk traction stitch was placed through the nodes of Arantii. By means of a scalpel, the aortotomy was carried downward (Fig. \, A) dividing the commissure between the affected cusps for approximately Vi inch. This left a remnant of commissure on each half of the vertical aortotomy. The redundant cusps were then pulled upward and through the aortotomy so that the free edges were in proper approximation. The vertical aortotomy was closed with interrupted horizontal mattress stitches, including the aortic cusps in the formation of a new commissure (Fig. 1, A). The redundant cusps outside the aortic lumen were then oversewn, including the aortic wall with a continuous stitch. (Fig. 1, B). The aortotomy was closed, and the aortic clamp was temporarily released. Minimal left ventricular vent sump drainage was evident. Infundibulectomy and patch closure of the ventricular septal defect were then carried out. Two weeks postoperatively, the heart size had decreased, and no diastolic murmur was heard. The aortic root pressure was 100/60 mm. Hg, indicating a decrease of 20 mm. Hg in the pulse pressure. Only a tiny whiff of aortic regurgitation could be seen by angiography.
Discussion A number of ingenious techniques for aortic valvuloplasty have been reported.28 The method suggested by Garamella's group,2 which consists of excision of the noncoronary cusp and conversion of the tricuspid valve to a bicuspid valve, was not suitable in this case since there were two valves involved and the aortic root was of
normal caliber. The use of plication stitches on the free edge as suggested by several authors,3'4-6> s if used in this particular valve, probably would not have been successful since the valve substance was so thin. Homografts, as suggested by GonzalezLavin and Barratt-Boyes,5 have been difficult to obtain in this center. In dealing surgically with such a variable lesion, it is comforting to have a number of alternative methods to reconstruct the aortic valve. The method described has given a satisfactory result in a patient in whom there were two incompetent aortic cusps, as well as aortic root rotation. The method is suggested as an alternative procedure in the correction of aortic insufficiency associated with ventricular septal defect. Summary A method of aortic valvuloplasty for aortic insufficiency associated with ventricular septal defect is described. The technique consists of a vertical aortotomy through the affected aortic valve commissures with inclusion of the redundant cusp or cusps in the closure of the aortotomy. REFERENCES 1 Van Praagh, R., and McNamara, J. J.: Anatomic Types of Ventricular Septal Defect With Aortic Insufficiency, Am. Heart J. 75: 604, 1968.
The Journal of
8 0 2 Murphy and Poirier
Thoracic and Cardiovascular Surgery
2 Garamella, J. J., Schmidt, R., Jensen, K. K., and Lynch, M. F.: Clinical Experience With the Biscuspid Operation for Aortic Regurgitation, Ann. Surg. 157: 310, 1963. 3 Spenser, F. C , Bahnson, H. T., and Neill, C. A.: The Treatment of Aortic Regurgitation Associated With a Ventricular Septal Defect, J. THORAC. CARDIOVAS. SURG. 43: 222,
1962.
4 Starr, A., Menashe, V., and Dotter, C : Surgical Correction of Aortic Insufficiency Associated With a Ventricular Septal Defect, Surg. Gynecol. Obstet. 11: 71, 1960. 5 Gonzalez-Lavin, L., and Barratt-Boyes, B. G.: Surgical Considerations in the Treatment of Ventricular Septal Defect Associated With Aortic Valvular Incompetence, J. THORAC. CARDIOVASC. SURG. 57: 422,
1969.
6 Frater, R. W. M.: The Prolapsing Aortic Cusp, Ann. Thorac. Surg. 3: 63, 1967. 7 MuUer, W. H., Warren, W. D., Damman, J. F., Beckwith, J. R., and Wood, J. E.: Surgical Relief of Aortic Insufficiency by Direct Opera-
8
9 10
11 12
tion on the Aortic Valve, Circulation 21:587, 1960. Plauth, W. H., Braunwald, E., Rockoff, S. D., Mason, D. T., and Morrow, A. G.: Ventricular Septal Defect and Aortic Regurgitation, Am. J. Med. 39: 552, 1965. Somerville, J., Brandao, A., and Ross, D. N.: Aortic Regurgitation With Ventricular Septal Defect, Circulation 41: 317, 1970. Hallidie-Smith, K. A., Olsen, E. G. J., Oakley, C. M., Goodwin, J. F., and Cleland, W. P.: Ventricular Septal Defect and Aortic Regurgitation, Thorax 24: 257, 1969. Ellis, F. H., Ongley, P. A., and Kirklin, J. W.: Ventricular Septal Defect With Aortic Valvular Incompetence, Circulation 27: 789, 1963. Dubost, C , d'Allaires, C , Blondeau, P., Piwnica, A., and Padeano, J. R.: Les Communications interventriculaires avec Insuffisanse Aortique, Arch. Mai. Coeur 56: 665, 1963.