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Evolution of aortic regurgitation following simple patch closure of doubly committed subarterial ventricular septal defect
Evolution of Aortic Regurgitation Following Simple Patch Closure of Doubly Committed Subarterial Ventricular Septal Defect Hideshi Tomita, MD, Yoshio Arakaki, MD, Yasuo Ono, MD, Osamu Yamada, MD, Shinya Tsukano, MD, Toshikatsu Yagihara, MD, and Shigeyuki Echigo, MD We reviewed the Doppler echocardiographic findings of the aortic valve and associated aortic regurgitation (AR) in 55 patients who underwent patch closure of doubly committed subarterial ventricular septal defect (VSD). The maximal diameter of the VSD measured >5 mm, whereas the postoperative follow-up interval was >5 years. Twenty-three patients underwent closure before they developed aortic cusp prolapse or AR (group A). In 15 patients the VSD was closed when aortic cusp prolapse was recognized, but AR was absent (group B). Aortic cusp prolapse with AR was detected before clo-
sure in a further 15 patients (group C). Of 8 patients with no AR before closure, AR was detected during follow-up in 6 group A and in 2 group B patients. In group C, AR resolved after surgery in 4 patients, whereas AR grade improved in a further 8 patients and remained unchanged in 3. Although residual AR was more frequent in patients with aortic cusp prolapse and AR before closure, it was silent and asymptomatic. 䊚2000 by Excerpta Medica, Inc. (Am J Cardiol 2000;86:540 –542)
arly surgical intervention to prevent progressive aortic regurgitation (AR) is frequently recomE mended for a doubly committed subarterial ventricular
was repeated at least once a year. (5) The interval after surgery was ⱖ5 years. AR was graded according to the level the narrow jet reached by Doppler echocardiography: trivial, for just beneath the aortic valve; slight, if confined to the left ventricular outflow tract; and slight-moderate, if the jet reached the level of the anterior mitral leaflet. Concern about potential pulmonary vascular disease or the presence of other anomalies such as a persistent ductus arteriosus or mitral regurgitation led to 23 patients undergoing closure before they developed aortic cusp prolapse or AR (Table I, case 1 through 23, group A). The VSD was closed in 15 patients when aortic cusp prolapse was recognized but without AR (Table I, cases 24 through 38, group B). Aortic cusp prolapse with AR was detected by Doppler echocardiography before closure in a further 15 patients (Table II, group C), although no patient in this group had a diastolic heart murmur suggesting AR. All data are expressed as mean ⫾ SD. Statistical comparisons between the 3 groups were done by 1-way analysis of variance or the Kruskal-Wallis test, and post hoc examinations were performed by the Scheffe´’s F test using StatView 4.5 software (Abacus Concepts, Berkeley, California).
septal defect (VSD) once it is complicated by aortic cusp prolapse.1– 8 This strategy is based on angiographic data suggesting that aortic cusp prolapse and AR often progress concurrently.3,8,9 –12 Recently, aortic cusp prolapse and AR were first recognized by Doppler echocardiography in the absence of symptoms and a diastolic murmur.8,13,14 Because there are few data on the natural history or postoperative prognosis of such silent AR,15 we reviewed the outcome after simple patch closure of doubly committed subarterial VSDs. Subjects and methods: In a retrospective study, we reviewed the Doppler echocardiographic findings of the aortic valve and associated AR in patients who fulfilled the following criteria. (1) Patients who underwent patch closure of a doubly committed subarterial VSD without an associated procedure on the aortic valve from 1985 to 1994 at the National Cardiovascular Center. (2) The maximal diameter of the VSD measured ⱖ5 mm at surgery (in this measurement, the aortic valve was removed from the VSD if it was prolapsed). (3) Aortic valve morphology and AR were evaluated before and after patch closure of the VSD by Doppler echocardiography using a Toshiba SSH 65A, SSH 160A (Toshiba, Tokyo, Japan), or Power Vision. (4) Doppler echocardiography From the Department of Pediatrics and Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan. Manuscript received January 7, 2000; revised manuscript received and accepted March 20, 2000. Address for reprints: Hideshi Tomita, MD, Department of Pediatrics, National Cardiovascular Center, 5–7-1 Fujishirodai, Suita, Osaka 565– 8565, Japan.
540
©2000 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 86 September 1, 2000
RESULTS Age at VSD patch closure was significantly different between the 3 groups. The follow-up interval in group C was slightly shorter than in groups A and B, and patients in group A at last follow-up were younger than those in groups B and C. There was no significant difference in VSD diameter (Table III). In group A, trivial or slight AR was detected during follow-up in 6 patients (26.1%) (Table I and Figure 1). No group A patient, including those who developed AR, had any 0002-9149/00/$–see front matter PII S0002-9149(00)01009-2
TABLE I Group A and B Patients Age (mo)
F/U (yrs)
Last F/U (yrs)
Diameter (mm)
AR
Onset (yrs)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
5 7 7 12 13 13 14 15 15 16 18 19 20 20 21 26 26 28 32 35 38 50 79
9 6 7 10 6 13 6 11 12 13 12 10 5 12 7 11 12 10 10 13 7 6 11
9 7 8 11 7 14 7 12 13 14 14 12 7 14 9 13 14 12 13 16 10 10 18
8 12 7 9 11 10 9 10 10 10 9 9 14 8 8 8 11 11 13 8 8 11 17
0 0 0 0 tr 0 sl 0 tr 0 tr 0 0 tr 0 0 0 0 tr 0 0 0 0
— — — — 3 — 1 — 3 — 12 — — 1 — — — — 1 — — — —
24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
31 48 51 56 59 60 71 87 99 108 135 149 161 189 198
13 6 14 8 10 10 6 5 13 13 11 10 6 12 11
16 10 18 13 15 15 12 12 21 22 22 22 19 28 28
10 7 13 8 7 8 13 9 11 16 13 9 10 10 18
0 0 0 0 sl-m 0 0 0 0 0 0 tr 0 0 0
— — — — 4 — — — — — — 10 — — —
Case
developed trivial or slight-moderate AR after closure (Table I and Figure 1). In group C, 9 patients (60.0%) underwent VSD closure immediately after diagnosis of AR, whereas the VSD was closed 1 to 6 years after detection of AR in 6 patients (40.0%). During the interval, AR progressed from trivial or slight to slight-moderate in only 2 patients (cases 10 and 13). AR disappeared after simple VSD closure and never recurred during follow-up in 4 patients (26.7%) with trivial or slight AR. In 8 patients (53.3%) with slight-moderate or slight AR, it improved to slight or trivial after surgery. In 3 patients (20.0%) with trivial, slight, or slight-moderate AR, it remained unchanged (Table II and Figure 1). No patient in any group had an increase in the degree of AR that was detected after surgery. No morphologic change in the aortic valve was seen during follow-up at any stage. Although the risk of trivial or slight AR was highest in group C, there was no difference among the 3 groups as to the risk of slight-moderate AR. Furthermore, no patient with Doppler AR in this study had a diastolic murmur or symptoms either before or after surgery.
DISCUSSION
In this retrospective study we surveyed the evolution of AR after simple patch closure of a doubly committed subarterial VSD. Because some Doppler echocardiographic TABLE II Group C Patients studies suggest an age-related inAR crease in the incidence of an AR Age F/U Last F/U Diameter Before signal in structurally normal hearts in Case (mo) (yrs) (yrs) (mm) (yrs) F/U adults,16 –19 the follow-up interval and the age at the last follow-up 1 23 9 16 12 sl (0) 0 2 26 7 16 8 sl (0) tr could influence the incidence of AR 3 27 11 16 8 tr (0) tr during the follow-up period. Age at 4 28 10 16 12 sl (0) 0 VSD closure differed significantly 5 29 5 16 12 sl (0) tr between the 3 groups. The interval to 6 32 10 17 10 sl (0) tr follow-up for group C was slightly 7 35 6 17 11 tr (0) 0 8 46 5 18 11 sl (1) tr shorter than for groups A and B, and 9 62 6 19 10 sl (1) 0 group A patients at the last follow-up 10 63 5 19 8 sl-m (5) sl were younger than group B and C 11 76 5 20 13 sl (3) tr patients. Consequently, the incidence 12 81 5 21 16 sl (4) tr 13 94 5 22 8 sl-m (6) sl of AR in group A may have been 14 117 14 24 10 sl (0) sl underestimated compared with that 15 146 9 26 15 sl-m (0) sl-m in groups B and C if an age-related Explanations and abbreviations as in Table I. occurrence existed in this age group. In contrast to a previous report,15 silent (trivial or slight) AR was detected after simple deformity of the aortic valve. All group B patients had typical right coronary cusp prolapse. Although no AR patch closure of a doubly committed subarterial VSD was detected before VSD closure, 2 patients (13.3%) in patients without either AR or right coronary cusp Age ⫽ age at VSD closure; Diameter ⫽ maximal diameter of VSD; Last F/U ⫽ age at last follow-up; Onset of AR ⫽ years after VSD closure; tr ⫽ trivial; sl ⫽ slight; sl-m ⫽ slight-moderate.
CONGENITAL HEART DISEASE/AORTIC REGURGITATION AFTER VSD CLOSURE
541
defect. Anatomical, angiographic and surgical considerations. Circulation 1973;48:1028 –1037. 2. Spencer FC, Doyle EF, Danilowwicz DA, Bahnson Group A Group B Group C p HT, Weldon CS. Long-term evaluation of aortic valvuloplasty for aortic insufficiency and ventricular septal (n ⫽ 23) (n ⫽ 15) (n ⫽ 15) Value defect. J Thorac Cardiovasc Surg 1973;65:15–31. Age at VSD closure 5–79 (23 ⫾ 16) 31–198 (100 ⫾ 54) 23–146 (59 ⫾ 38) ⬍0.01 3. Momma K, Toyama K, Takao A, Ando M, Nakazawa M, Hirosawa K, Imai Y. Natural history of sub(mo) arterial infundibular ventricular septal defect. Am Follow-up interval 5–13 (10 ⫾ 3) 5–14 (10 ⫾ 3) 5–14 (7 ⫾ 3) ⬍0.05 Heart J 1984;108:1312–1317. (yrs) 4. Ando M, Takao A. Pathological anatomy of ventricular Age at last follow-up 7–18 (11 ⫾ 3) 10–28 (18 ⫾ 5) 16–26 (19 ⫾ 3) ⬍0.01 septal defect associated with aortic valve prolapse and (yrs) regurgitation. Heart Vessels 1986;2:117–126. Diameter of VSD 7–17 (10 ⫾ 2) 7–18 (11 ⫾ 3) 8–16 (11 ⫾ 3) NS 5. Leung MP, Beerman LB, Siewers RD, Bahnson HT, (mm) Zuberbuhler JR. Long-term follow-up after aortic valvuloplasty and defect closure in ventricular septal defect with aortic regurgitation. Am J Cardiol 1987;60: 890 – 894. 6. Tohyama K, Satomi G, Momma K. Aortic valve prolapse and aortic regurgitation associated with subpulmonic ventricular septal defect. Am J Cardiol 1997; 79:1285–1289. 7. Yacoub MH, Khan H, Stavri G, Shinebourne E, Radley-Smith R. Anatomic correction of the syndrome of prolapsing right coronary aortic cusp, dilatation of the sinus of valsalva, and ventricular septal defect. J Thorac Cardiovasc Surg 1997;113:253–261. 8. Komai H, Naito Y, Fujiwara K, Noguchi Y, Nishimura Y, Uemura S. Surgical strategy for doubly committed subarterial ventricular septal defect with aortic cusp prolapse. Ann Thorac Surg 1997;64:1146 –1149. 9. Sakakibara S. Experiences with congenital anomalies of the heart in Japan. J Thorac Cardiovasc Surg 1974; FIGURE 1. Fate of AR before and after patch closure of VSD in each group. sl-m ⴝ 68:189 –195. slight-moderate. 10. Tatsuno K, Ando M, Takao A, Hatsune K, Konno S. Diagnostic importance of aortography in conal ventricular septal defect. Am Heart J 1975;89:171–177. prolapse before surgery. One patient, who had a right 11. Lue HC. Is subpulmonic ventricular septal defect an Oriental disease? In: Lue Takao A, eds. Subpulmonic Ventricular Septal Defect. Tokyo: Springercoronary cusp prolapse without AR, developed slight- HC, Verlag, 1986:3– 8. moderate AR 4 years after surgery. AR disappeared in 12. Rhodes LA, Keane JF, Keane JP, Fellows KE, Jonas RA, Castaneda AR, 4 patients (26.7%) and improved in 8 (53.3%) in Nadas AS. Long follow-up (to 43 years) of ventricular septal defect with audible regurgitation. Am J Cardiol 1990;66:340 –345. group C after VSD closure. Thus, although silent AR aortic 13. Craig BG, Smallhorn JF, Burrows P, Trusler GA, Rowe RD. Cross-sectional was more frequent in cases complicated by AR and echocardiography in the evaluation of aoric valve prolapse associated with right coronary cusp prolapse before surgery, the inci- ventricular septal defect. Am Heart J 1986;112:800 – 807. Schmidt KG, Cassidy SC, Silverman NH, Stargen P. Doubly committed dence of residual AR worse than slight-moderate did 14. subarterial ventricular septal defects: echocardiographic features and surgical not differ between the 3 groups. No examples of AR implications. J Am Coll Cardiol 1988;12:1538 –1546. Sim EK, Grignani RT, Wong ML, Quek SC, Wong JC, Yip WC, Lee CN. progression were observed during follow-up. We con- 15. Outcome of surgical closure of doubly committed subarterial ventricular septal clude that surgery for doubly committed subarterial defect. Ann Thorac Surg 1999;67:736 –738. VSD does not necessarily prevent the onset or pro- 16. Yoshida K, Yoshikawa J, Shakudo M, Akasaka T, Jyo Y, Takao S, Shiratori K, Koizumi K, Okumachi F, Kato H, et al. Color Doppler evaluation of valvular gression of AR. regurgitation in normal subjects. Circulation 1988;78:840 – 847. 17. Choong CY, Abascal VM, Weyman J, Levine RA, Gentile F, Thomas JD, AE. Prevalence of valvular regurgitation by Doppler echocardiography Acknowledgment: We thank Peter M. Olley, MD, Weyman in patients with structurally normal hearts by two-dimensional echocardiography. Professor of Pediatrics, University of Alberta, for his Am Heart J 1989;117:636 – 642. 18. Klein AL, Burstow DJ, Tajik AJ, Zachariah PK, Taliercio CP, Taylor CL, advice on language. Bailey KR, Seward JB. Age-related prevalence of valvular regurgitation in normal subjects: a comprehensive color flow examination of 118 volunteers. J Am Soc Echo 1990;3:54 – 63. 19. Singh JP, Evans JC, Levy D, Larson MG, Freed LA, Fuller DL, Lehman B, 1. Tatsuno K, Konno S, Ando M, Sakakibara S. Pathogenetic mechanism of Benjamin EJ. Prevalence and clinical determinants of mitral, tricuspid, and aortic prolapsing aortic valve and aortic regurgitation associated with ventricular septal regurgitation (the Framingham Heart Study). Am J Cardiol 1999;83:897–902.
TABLE III Summary of Characteristics of the Three Groups
542 THE AMERICAN JOURNAL OF CARDIOLOGY姞
VOL. 86
SEPTEMBER 1, 2000
sure in a further 15 patients (group C). Of 8 patients with no AR before closure, AR was detected during follow-up in 6 group A and in 2 group B patients. In group C, AR resolved after surgery in 4 patients, whereas AR grade improved in a further 8 patients and remained unchanged in 3. Although residual AR was more frequent in patients with aortic cusp prolapse and AR before closure, it was silent and asymptomatic. 䊚2000 by Excerpta Medica, Inc. (Am J Cardiol 2000;86:540 –542)
arly surgical intervention to prevent progressive aortic regurgitation (AR) is frequently recomE mended for a doubly committed subarterial ventricular
was repeated at least once a year. (5) The interval after surgery was ⱖ5 years. AR was graded according to the level the narrow jet reached by Doppler echocardiography: trivial, for just beneath the aortic valve; slight, if confined to the left ventricular outflow tract; and slight-moderate, if the jet reached the level of the anterior mitral leaflet. Concern about potential pulmonary vascular disease or the presence of other anomalies such as a persistent ductus arteriosus or mitral regurgitation led to 23 patients undergoing closure before they developed aortic cusp prolapse or AR (Table I, case 1 through 23, group A). The VSD was closed in 15 patients when aortic cusp prolapse was recognized but without AR (Table I, cases 24 through 38, group B). Aortic cusp prolapse with AR was detected by Doppler echocardiography before closure in a further 15 patients (Table II, group C), although no patient in this group had a diastolic heart murmur suggesting AR. All data are expressed as mean ⫾ SD. Statistical comparisons between the 3 groups were done by 1-way analysis of variance or the Kruskal-Wallis test, and post hoc examinations were performed by the Scheffe´’s F test using StatView 4.5 software (Abacus Concepts, Berkeley, California).
septal defect (VSD) once it is complicated by aortic cusp prolapse.1– 8 This strategy is based on angiographic data suggesting that aortic cusp prolapse and AR often progress concurrently.3,8,9 –12 Recently, aortic cusp prolapse and AR were first recognized by Doppler echocardiography in the absence of symptoms and a diastolic murmur.8,13,14 Because there are few data on the natural history or postoperative prognosis of such silent AR,15 we reviewed the outcome after simple patch closure of doubly committed subarterial VSDs. Subjects and methods: In a retrospective study, we reviewed the Doppler echocardiographic findings of the aortic valve and associated AR in patients who fulfilled the following criteria. (1) Patients who underwent patch closure of a doubly committed subarterial VSD without an associated procedure on the aortic valve from 1985 to 1994 at the National Cardiovascular Center. (2) The maximal diameter of the VSD measured ⱖ5 mm at surgery (in this measurement, the aortic valve was removed from the VSD if it was prolapsed). (3) Aortic valve morphology and AR were evaluated before and after patch closure of the VSD by Doppler echocardiography using a Toshiba SSH 65A, SSH 160A (Toshiba, Tokyo, Japan), or Power Vision. (4) Doppler echocardiography From the Department of Pediatrics and Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan. Manuscript received January 7, 2000; revised manuscript received and accepted March 20, 2000. Address for reprints: Hideshi Tomita, MD, Department of Pediatrics, National Cardiovascular Center, 5–7-1 Fujishirodai, Suita, Osaka 565– 8565, Japan.
540
©2000 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 86 September 1, 2000
RESULTS Age at VSD patch closure was significantly different between the 3 groups. The follow-up interval in group C was slightly shorter than in groups A and B, and patients in group A at last follow-up were younger than those in groups B and C. There was no significant difference in VSD diameter (Table III). In group A, trivial or slight AR was detected during follow-up in 6 patients (26.1%) (Table I and Figure 1). No group A patient, including those who developed AR, had any 0002-9149/00/$–see front matter PII S0002-9149(00)01009-2
TABLE I Group A and B Patients Age (mo)
F/U (yrs)
Last F/U (yrs)
Diameter (mm)
AR
Onset (yrs)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
5 7 7 12 13 13 14 15 15 16 18 19 20 20 21 26 26 28 32 35 38 50 79
9 6 7 10 6 13 6 11 12 13 12 10 5 12 7 11 12 10 10 13 7 6 11
9 7 8 11 7 14 7 12 13 14 14 12 7 14 9 13 14 12 13 16 10 10 18
8 12 7 9 11 10 9 10 10 10 9 9 14 8 8 8 11 11 13 8 8 11 17
0 0 0 0 tr 0 sl 0 tr 0 tr 0 0 tr 0 0 0 0 tr 0 0 0 0
— — — — 3 — 1 — 3 — 12 — — 1 — — — — 1 — — — —
24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
31 48 51 56 59 60 71 87 99 108 135 149 161 189 198
13 6 14 8 10 10 6 5 13 13 11 10 6 12 11
16 10 18 13 15 15 12 12 21 22 22 22 19 28 28
10 7 13 8 7 8 13 9 11 16 13 9 10 10 18
0 0 0 0 sl-m 0 0 0 0 0 0 tr 0 0 0
— — — — 4 — — — — — — 10 — — —
Case
developed trivial or slight-moderate AR after closure (Table I and Figure 1). In group C, 9 patients (60.0%) underwent VSD closure immediately after diagnosis of AR, whereas the VSD was closed 1 to 6 years after detection of AR in 6 patients (40.0%). During the interval, AR progressed from trivial or slight to slight-moderate in only 2 patients (cases 10 and 13). AR disappeared after simple VSD closure and never recurred during follow-up in 4 patients (26.7%) with trivial or slight AR. In 8 patients (53.3%) with slight-moderate or slight AR, it improved to slight or trivial after surgery. In 3 patients (20.0%) with trivial, slight, or slight-moderate AR, it remained unchanged (Table II and Figure 1). No patient in any group had an increase in the degree of AR that was detected after surgery. No morphologic change in the aortic valve was seen during follow-up at any stage. Although the risk of trivial or slight AR was highest in group C, there was no difference among the 3 groups as to the risk of slight-moderate AR. Furthermore, no patient with Doppler AR in this study had a diastolic murmur or symptoms either before or after surgery.
DISCUSSION
In this retrospective study we surveyed the evolution of AR after simple patch closure of a doubly committed subarterial VSD. Because some Doppler echocardiographic TABLE II Group C Patients studies suggest an age-related inAR crease in the incidence of an AR Age F/U Last F/U Diameter Before signal in structurally normal hearts in Case (mo) (yrs) (yrs) (mm) (yrs) F/U adults,16 –19 the follow-up interval and the age at the last follow-up 1 23 9 16 12 sl (0) 0 2 26 7 16 8 sl (0) tr could influence the incidence of AR 3 27 11 16 8 tr (0) tr during the follow-up period. Age at 4 28 10 16 12 sl (0) 0 VSD closure differed significantly 5 29 5 16 12 sl (0) tr between the 3 groups. The interval to 6 32 10 17 10 sl (0) tr follow-up for group C was slightly 7 35 6 17 11 tr (0) 0 8 46 5 18 11 sl (1) tr shorter than for groups A and B, and 9 62 6 19 10 sl (1) 0 group A patients at the last follow-up 10 63 5 19 8 sl-m (5) sl were younger than group B and C 11 76 5 20 13 sl (3) tr patients. Consequently, the incidence 12 81 5 21 16 sl (4) tr 13 94 5 22 8 sl-m (6) sl of AR in group A may have been 14 117 14 24 10 sl (0) sl underestimated compared with that 15 146 9 26 15 sl-m (0) sl-m in groups B and C if an age-related Explanations and abbreviations as in Table I. occurrence existed in this age group. In contrast to a previous report,15 silent (trivial or slight) AR was detected after simple deformity of the aortic valve. All group B patients had typical right coronary cusp prolapse. Although no AR patch closure of a doubly committed subarterial VSD was detected before VSD closure, 2 patients (13.3%) in patients without either AR or right coronary cusp Age ⫽ age at VSD closure; Diameter ⫽ maximal diameter of VSD; Last F/U ⫽ age at last follow-up; Onset of AR ⫽ years after VSD closure; tr ⫽ trivial; sl ⫽ slight; sl-m ⫽ slight-moderate.
CONGENITAL HEART DISEASE/AORTIC REGURGITATION AFTER VSD CLOSURE
541
defect. Anatomical, angiographic and surgical considerations. Circulation 1973;48:1028 –1037. 2. Spencer FC, Doyle EF, Danilowwicz DA, Bahnson Group A Group B Group C p HT, Weldon CS. Long-term evaluation of aortic valvuloplasty for aortic insufficiency and ventricular septal (n ⫽ 23) (n ⫽ 15) (n ⫽ 15) Value defect. J Thorac Cardiovasc Surg 1973;65:15–31. Age at VSD closure 5–79 (23 ⫾ 16) 31–198 (100 ⫾ 54) 23–146 (59 ⫾ 38) ⬍0.01 3. Momma K, Toyama K, Takao A, Ando M, Nakazawa M, Hirosawa K, Imai Y. Natural history of sub(mo) arterial infundibular ventricular septal defect. Am Follow-up interval 5–13 (10 ⫾ 3) 5–14 (10 ⫾ 3) 5–14 (7 ⫾ 3) ⬍0.05 Heart J 1984;108:1312–1317. (yrs) 4. Ando M, Takao A. Pathological anatomy of ventricular Age at last follow-up 7–18 (11 ⫾ 3) 10–28 (18 ⫾ 5) 16–26 (19 ⫾ 3) ⬍0.01 septal defect associated with aortic valve prolapse and (yrs) regurgitation. Heart Vessels 1986;2:117–126. Diameter of VSD 7–17 (10 ⫾ 2) 7–18 (11 ⫾ 3) 8–16 (11 ⫾ 3) NS 5. Leung MP, Beerman LB, Siewers RD, Bahnson HT, (mm) Zuberbuhler JR. Long-term follow-up after aortic valvuloplasty and defect closure in ventricular septal defect with aortic regurgitation. Am J Cardiol 1987;60: 890 – 894. 6. Tohyama K, Satomi G, Momma K. Aortic valve prolapse and aortic regurgitation associated with subpulmonic ventricular septal defect. Am J Cardiol 1997; 79:1285–1289. 7. Yacoub MH, Khan H, Stavri G, Shinebourne E, Radley-Smith R. Anatomic correction of the syndrome of prolapsing right coronary aortic cusp, dilatation of the sinus of valsalva, and ventricular septal defect. J Thorac Cardiovasc Surg 1997;113:253–261. 8. Komai H, Naito Y, Fujiwara K, Noguchi Y, Nishimura Y, Uemura S. Surgical strategy for doubly committed subarterial ventricular septal defect with aortic cusp prolapse. Ann Thorac Surg 1997;64:1146 –1149. 9. Sakakibara S. Experiences with congenital anomalies of the heart in Japan. J Thorac Cardiovasc Surg 1974; FIGURE 1. Fate of AR before and after patch closure of VSD in each group. sl-m ⴝ 68:189 –195. slight-moderate. 10. Tatsuno K, Ando M, Takao A, Hatsune K, Konno S. Diagnostic importance of aortography in conal ventricular septal defect. Am Heart J 1975;89:171–177. prolapse before surgery. One patient, who had a right 11. Lue HC. Is subpulmonic ventricular septal defect an Oriental disease? In: Lue Takao A, eds. Subpulmonic Ventricular Septal Defect. Tokyo: Springercoronary cusp prolapse without AR, developed slight- HC, Verlag, 1986:3– 8. moderate AR 4 years after surgery. AR disappeared in 12. Rhodes LA, Keane JF, Keane JP, Fellows KE, Jonas RA, Castaneda AR, 4 patients (26.7%) and improved in 8 (53.3%) in Nadas AS. Long follow-up (to 43 years) of ventricular septal defect with audible regurgitation. Am J Cardiol 1990;66:340 –345. group C after VSD closure. Thus, although silent AR aortic 13. Craig BG, Smallhorn JF, Burrows P, Trusler GA, Rowe RD. Cross-sectional was more frequent in cases complicated by AR and echocardiography in the evaluation of aoric valve prolapse associated with right coronary cusp prolapse before surgery, the inci- ventricular septal defect. Am Heart J 1986;112:800 – 807. Schmidt KG, Cassidy SC, Silverman NH, Stargen P. Doubly committed dence of residual AR worse than slight-moderate did 14. subarterial ventricular septal defects: echocardiographic features and surgical not differ between the 3 groups. No examples of AR implications. J Am Coll Cardiol 1988;12:1538 –1546. Sim EK, Grignani RT, Wong ML, Quek SC, Wong JC, Yip WC, Lee CN. progression were observed during follow-up. We con- 15. Outcome of surgical closure of doubly committed subarterial ventricular septal clude that surgery for doubly committed subarterial defect. Ann Thorac Surg 1999;67:736 –738. VSD does not necessarily prevent the onset or pro- 16. Yoshida K, Yoshikawa J, Shakudo M, Akasaka T, Jyo Y, Takao S, Shiratori K, Koizumi K, Okumachi F, Kato H, et al. Color Doppler evaluation of valvular gression of AR. regurgitation in normal subjects. Circulation 1988;78:840 – 847. 17. Choong CY, Abascal VM, Weyman J, Levine RA, Gentile F, Thomas JD, AE. Prevalence of valvular regurgitation by Doppler echocardiography Acknowledgment: We thank Peter M. Olley, MD, Weyman in patients with structurally normal hearts by two-dimensional echocardiography. Professor of Pediatrics, University of Alberta, for his Am Heart J 1989;117:636 – 642. 18. Klein AL, Burstow DJ, Tajik AJ, Zachariah PK, Taliercio CP, Taylor CL, advice on language. Bailey KR, Seward JB. Age-related prevalence of valvular regurgitation in normal subjects: a comprehensive color flow examination of 118 volunteers. J Am Soc Echo 1990;3:54 – 63. 19. Singh JP, Evans JC, Levy D, Larson MG, Freed LA, Fuller DL, Lehman B, 1. Tatsuno K, Konno S, Ando M, Sakakibara S. Pathogenetic mechanism of Benjamin EJ. Prevalence and clinical determinants of mitral, tricuspid, and aortic prolapsing aortic valve and aortic regurgitation associated with ventricular septal regurgitation (the Framingham Heart Study). Am J Cardiol 1999;83:897–902.
TABLE III Summary of Characteristics of the Three Groups
542 THE AMERICAN JOURNAL OF CARDIOLOGY姞
VOL. 86
SEPTEMBER 1, 2000