Ann Thorac Surg 2003;76:1073-1077
© 2003 The Society of Thoracic Surgeons
Original article: cardiovascular
Liberal use of tricuspid valve detachment for transatrial ventricular septal defect closure
Ryo Aeba, MDa*,
Toshiyuki Katogi, MDa,
Kenichi Hashizume, MDa,
Kiyoshi Koizumi, MDa,
Yoshimi Iino, MDa,
Mitsuharu Mori, MDa,
Ryohei Yozu, MDa
a Division of Cardiovascular Surgery, Keio University, Tokyo, Japan
Accepted for publication April 21, 2003.
* Address reprint requests to Dr Aeba, Division of Cardiovascular Surgery, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan.
e-mail: aeba{at}sc.itc.keio.ac.jp
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Abstract
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BACKGROUND: Although temporary tricuspid valve detachment is useful for improved visualization of ventricular septal defect through right atriotomy, liberal use of this adjunct is not widely supported, mainly because of concerns about iatrogenic complications such as heart blocks and tricuspid valve dysfunction. The objective of this study was to determine whether liberal use of this adjunct can improve operative outcome.
METHODS: Between January1997 and March 2002, trans-atrial closure of isolated ventricular septal defect (conoventricular or canal type) was performed in 87 consecutive patients. Tricuspid valve detachment was used in 4 out of 44 patients (prudent-use group) and 19 out of 43 patients (liberal-use group) in the first and second half of this period, respectively (p = 0.0002). Patient demographics and use of other surgical and cardiopulmonary bypass techniques remained virtually unchanged during this period.
RESULTS: In the prudent-use group, there was one operative death with prolonged bypass time and one residual defect that required reoperation; neither of these patients underwent tricuspid valve detachment. All other patients (both groups) were free from mortality and clinically significant complications, including heart block, tricuspid regurgitation, and residual defect. The liberal-use group had shorter cardiopulmonary bypass time than the prudent-use group (59 ± 14 vs 67 ± 22 minutes, p = 0.037).
CONCLUSIONS: Tricuspid valve detachment should be used liberally for moderate- or even low-difficulty exposure of ventricular septal defect, regardless of patient background, because it is a safe and effective adjunct that can improve speed, programmability, reproducibility, and reliability.
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Introduction
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Clinical application of temporary tricuspid valve detachment (TVD) for complete visualization of ventricular septal defect (VSD) through right atriotomy is not new. In 1961, Hudsepeth and associates [1] first described this adjunct. Its surgical advantage is obvious, as it allows complete visualization of all margins of the VSD [2–6], helping to minimize the incidence of residual VSD. However, TVD requires additional operative time for incision and repair of the valve apparatus, and carries potential risk of iatrogenic complications such as tricuspid dysfunction and heart blocks.
Questions remain regarding the advantages of TVD in VSD closure, and many surgeons are reluctant to use TVD liberally [4, 7]. Because effects of TVD on surgical outcome are largely affected by the criteria for its use, simple comparison between patients repaired with and without TVD may underestimate these effects. A better way to clarify the role of TVD is to compare different surgical policies regarding indications of TVD, but there have been no reports of such comparisons. At Keio University Hospital, use of TVD has increased during the last 5 years, although patient demographics and use of other surgical and cardiopulmonary bypass techniques have remained virtually unchanged. This allowed us to analyze effects of TVD using a highly homogeneous cohort. The objective of this study was to determine whether liberal use of TVD can improve operative outcome.
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Material and methods
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Patients
We retrospectively examined the reports of all consecutive patients operated on at Keio University Hospital between January 1997 and March 2002 who met the following criteria: VSD was the primary cardiac lesion; VSD was either conoventricular or canal type; and VSD was closed through right atriotomy and the tricuspid valve. Criteria for exclusion from this survey were as follows: partial sternotomy access; anatomical type of VSD other than conoventricular or canal type (eg, muscular or conus); multiple VSD; and VSD(s) associated with a more complex cardiac lesion such as tetralogy of Fallot, aortic arch obstruction, transposition of the great arteries, or total anomalous pulmonary venous connection. There were 87 subjects, consisting of 32 (36.8%) male and 55 (63.2%) female patients, and mean follow-up time was 34.0 ± 17.6 months (range, 0.2 to 68.4 months). Median age at operation was 7.9 months (range, 2 to 197 months), and median body weight was 6.2 kg (range, 3.0 to 53.9 kg). A total of 25 patients (28.7%) had Down's syndrome.
The use of TVD for better visualization of VSD was at the discretion of the surgeon, but increased experience with TVD and excellent outcomes resulted in general trend towards gradual increase in TVD use in this series. All surgeries were done or supervised by one of the two surgeons. (R.A. or T.K.), and there were no significant intersurgeon differences in frequency in TVD use. The patient cohort was divided into two chronological groups, which represented two different surgical strategies regarding liberality of TVD use (Table 1).
The prudent-use group (n = 44) consisted of patients who were operated on before January 2000; TVD was used with low frequency (n = 4, 9.1%). In contrast, the liberal-use group (n = 43) consisted of patients who were operated on after January 2000; TVD was used with higher frequency (n = 19, 44.2%). The difference in use of TVD between these two groups was statistically significant (p = 0.0002).
Operative procedures
Normothermic cardiopulmonary bypass was established after aortic and bicaval cannulation, followed by aortic cross-clamping and delivery of antegrade cardioplegic solution. The right atriotomy was parallel to the atrioventricular groove. A patch of expanded polytetrafluoroethylene patch (Cardiovascular Patch, W. L. Gore and Associates Co, Flagstaff, AZ) was tailored and secured with a running suture technique using a 5-0 or 6-0 double-armed polypropylene suture. For reinforcement, an autologous pericardial strip was attached to the suture at the base of the tricuspid septal leaflet. Modified ultrafiltration was used after termination of cardiopulmonary bypass.
The operative technique of TVD consisted of two separate procedures. In leaflet detachment [1], which was performed in 20 patients, a parallel incision was made in the annulus in the septal leaflet, starting from the inferior aspect and extending to the superior aspect, to avoid incidental injury to the aortic valve adjacent to the anterior-septal commissure of the tricuspid valve. When necessary, this incision was extended to the anterior leaflet beyond the anterior-septal commissure. To minimize mechanical stress from retraction on the atrioventricular node (which could cause blunt tears), the most inferior end was slightly extended toward the 2 O'clock direction, resulting in a hockey-stick-shaped incision in the leaflet (Fig 1).
One or two traction suture(s) was passed through the incision to facilitate VSD exposure. After the patch was inserted and secured by this incision, the incision in the leaflet was closed with several simple interrupted or running sutures of 6-0 or 7-0 polypropylene. In chordae detachment [8], which was performed in 3 patients, the major chordae, which were atypically attached to the anterior VSD rim and supported the septal or anterior leaflets, was divided at the end nearest the myocardium. After the patch was secured, the chordae were resuspended to the original site or the patch surface.
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Fig 1. (A) Schematic illustration of tricuspid valve detachment. The leaflet incision was inferiorly extended apart from the annulus. An extension to the anterior leaflet may be used when necessary. (B) One or two traction sutures are used for complete visualization of the ventricular septal defect. (C) The patch is inserted through the leaflet incision, and secured using a running suture technique. An autologous pericardial strip is used for reinforcement of the annulus, followed by leaflet incision repair.
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Data acquisition and statistical analysis
Medical and surgical records of all patients were reviewed. Follow-up information, regarding current activity level, medications, and perceived complications, was obtained from the consulting physicians or parents of the patient. Postoperative follow-up echocardiography with color-flow mapping was performed for all patients 3 weeks to 6 months after the operation.
Statistical analysis was performed using the SPSS program for Windows (SPSS Inc, Chicago, IL). Quantitative variables with and without normal distribution were expressed as the mean ± the standard deviation of the mean and as the median and range, respectively. Comparison between the two groups for quantitative variables with and without normal distribution was performed using the nonpaired Student's t test and the Mann-Whitney u test, respectively. Differences in categorical variables between the two groups were analyzed using Fisher's exact test. Statistical significance was designated as a p value less than 0.05.
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Results
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One operative death occurred in the prudent-use group, in a 4-month-old patient without TVD. This patient had Down's syndrome, exhibited severe pulmonary congestion preoperatively, and had a conoventricular-type VSD with canal extension. There were many chordae attached to the VSD rim of this patient, and this interfered with placement of sutures and securing of the patch, resulting in prolonged operative time (aortic cross-clamping time, 66 minutes; cardiopulmonary bypass time, 114 minutes). Postoperative recovery was complicated by low output due to left ventricular dysfunction, and the patient died on the 5th postoperative day.
Another patient with Down's syndrome (5 months old) developed pulmonary arterial hypertension crisis on the 2nd postoperative day. This was successfully treated with nitric oxide inhalation (duration, 7 days).
Cardiopulmonary bypass time was significantly longer for patients with TVD than for patients without TVD (70 ± 21 vs 60 ± 18 minutes, p = 0.030); overall mean was 63 ± 19 minutes. Aortic cross-clamp time was also significantly longer for patients with TVD than for patients without TVD (40 ± 14 vs 31 ± 11 minutes, p = 0.004); overall mean was 34 ± 13 minutes. However, the liberal-use group had shorter cardiopulmonary bypass time than the prudent-use group, overall (59 ± 14 vs 67 ± 22 minutes, p = 0.037) (Table 1), and in both TVD subgroups: patients with TVD, 64 ± 12 versus 101 ± 27 minutes, p = 0.0002; patients without TVD, 55 ± 14 versus 64 ± 19 minutes, p = 0.047 (Fig 2).
Four patients (9.1%) in the prudent-use group had prolonged (> 100 minutes) cardiopulmonary bypass time, whereas no patients in the liberal-use group had prolonged cardiopulmonary bypass time.
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Fig 2. Comparison of cardiopulmonary bypass time between the liberal- and prudent-use groups. Error bar indicates SD. TVD(+) = patient with tricuspid valve detachment; TVD(-) = patient without tricuspid valve detachment. p = 0.037, 0.0002, and 0.047 for overall, TVD(+), and TVD(-) patients, respectively.
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No high-degree atrioventricular blocks developed. At follow-up echocardiography (Table 2),
tricuspid valve function was not obstructed in any patients. Tricuspid regurgitation was categorized as absent or trivial in 70 patients (80.5%), mild in 16 patients (18.2%), and moderate in 1 patient (1.1%). No patients underwent reoperation to correct tricuspid regurgitation. Residual VSD was either absent or trivial in all but 1 patient (prudent-use group), whose moderate defect was initially repaired without TVD and was reoperated on 14 months later using TVD. At this patient's reoperation, the cranial half of the original defect was largely patent, and was closed using a new patch. There was no significant difference in degree of tricuspid regurgitation or residual VSD between patients with and without TVD.
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Comment
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Opinions vary among surgeons regarding usefulness of TVD as an adjunctive for transatrial closure of VSD. Consequently, its frequency of use varies widely, from never being used to always being used [4]. TVD allows complete visualization of VSD at the cost of destroying valve architecture, and skepticism involves the balance between this benefit and the potential risks of complications.
There have been several reports suggesting that TVD does not impair tricuspid valve function or increase the risk of heart block [3–5], but there are some differences in surgical details between those studies and the present study. In the present series, an autologous pericardial strip was used for reinforcement of the tricuspid septal annulus, regardless of use of TVD, and this may have contributed to preservation of valve competence. Although association of Down's syndrome raises concerns about tricuspid regurgitation after TVD, due to residual systolic hypertension in the right ventricle [3], the present results indicate that TVD does not increase risk of this complication in Down's syndrome patients. An incision completely parallel to the tricuspid annulus may cause atrioventricular node injury, due to mechanical stress or incidental tear with retraction of the incised leaflet. The hockey stick–shaped incision used in the present patients may have helped prevent this serious complication. An incision restricted to the anterior leaflet can help avoid this complication [6], but it carries a risk of incidental injury of the aortic valve or the sinus of Valsalva.
Tricuspid valve detachment requires additional time for incision and resuturing during cardiopulmonary bypass and aortic cross-clamping. Reports indicate that TVD is associated with normal [5] or increased [4] operative time. However, it can be argued that simple comparison of operative times in a cohort between patients with and without TVD is not necessarily meaningful, because the effect of TVD on operative time can be greatly affected by the criteria for its use. In the prudent-use strategy, VSD visualization without TVD is often difficult, and time-saving effects from preservation of the tricuspid valve may be offset or even counterbalanced by the longer time required to close the VSD. It is more meaningful to compare different surgical policies regarding the frequency with which TVD is used. To the best of our knowledge, the present study is the first in which this approach has been used. In the present study, the liberal-use strategy actually made clinically crucial operative times more short than long in the aggregate despite a short-time consumptive nature of TVD procedure itself. No patients in the liberal-use group had an aortic cross-clamping time exceeding 60 minutes. This implies that liberal use of TVD can improve programmability, reproducibility, and reliability of VSD closure. This is beneficial, especially for patients with severely ill preoperative status.
More importantly, nonuse of TVD may result in incomplete visualization and incomplete closure of the VSD, or excessive traction of the tricuspid valve apparatus in an effort to optimize visualization, leading to tricuspid regurgitation or heart blocks. Whereas not statistically significant, the present finding that the only patient who underwent reoperation for residual VSD was in the prudent-use group and underwent initial repair without TVD is consistent with the findings of Gaynor and associates [5].
The present study has some limitations. The first concern is study design. TVD is not necessary in all patients undergoing transatrial VSD closure. The cut-off point for use of TVD has not been clearly quantitatively determined, and liberality of TVD use is defined only by frequency of use. Consequently, it is not feasible to conduct a prospective randomized comparison study of two different surgical policies regarding liberality of TVD use. Thus, the present study is necessarily a historical comparison, which carries a potential bias. However, other than the increased frequency of TVD, use of surgical and cardiopulmonary bypass techniques remained virtually unchanged during the study period, and we believe this contributes to the reliability of the present results. Second, the present study lacks long-term follow-up, especially for growth and competence of the tricuspid valve. Bol-Raap and associates [4] reported that, after TVD, echocardiography showed the tricuspid valve to be completely or almost completely competent, both immediately after repair and an average of 2.0 years after repair. This suggests that, in the present series, tricuspid valve function will remain satisfactory and uncomplicated in the long term, but follow-up is mandatory.
We conclude that TVD should be liberally used for moderate- and even low-difficulty VSD exposure, regardless of preoperative clinical status, age, patient size, or presence of Down's syndrome. TVD can improve speed, programmability, reproducibility, and reliability of VSD closure, without iatrogenic complications.
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Acknowledgments
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The authors give special thanks to Leon Sakuma for drawing the illustrations.
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References
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- Hudspeth A.S., Cordell A.R., Meredith J.H., Johnston F.R., Winston-Salem N.C. An improved transatrial approach to the closure of ventricular septal defects. J Thorac Cardiovasc Surg 1962;43:157-165.
- Frenckner B.P., Olin C.L., Bomfim V., Bjarke B., Wallgren C.G., Bjork V.O. Detachment of the septal tricuspid leaflet during transatrial closure of isolated ventricular septal defect. J Thorac Cardiovasc Surg 1981;82:773-778.[Abstract]
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Abstract
Introduction
