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Atrioventricular Valve Repair in Patients with Functional Single Ventricle
Tomohiro Nakata, Yoshifumi Fujimoto, Keiichi Hirose, Masaki Osaki, Yuko Tosaka, Yujiro Ide, Maiko Tachi, Kisaburo Sakamoto
Shizuoka Children's Hospital, Shizuoka, Japan
BACKGROUND:
There is a paucity of knowledge about systemic atrioventricular valve (AVV) regurgitation in patients with functional single ventricle (fSV), because most studies have focused on the surgical technique, diagnosis, valve anatomy or the surgical stage leading to Fontan completion. The purpose of this study is to evaluate the surgical repair for AVV regurgitation in all patients with fSV.
METHODS:
We performed a retrospective chart review of all consecutive fSV patients who had undergone AVV repair at a tertiary pediatric cardiac center between January 1999 and October 2008. Kaplan-Meier and Cox proportional hazard model were used for statistical analyses.
RESULTS:
We identified 64 fSV patients, including 12 newborns. Median age was 9.5 month (range, 0 day-17 years) and median weight was 9.0 kg (range, 2.5-66.0 kg). The primary diagnosis was heterotaxy in 30 patients, and hypoplastic left heart syndrome (HLHS) in 12. The systemic AVV morphology was common atrioventricular valve in 34 patients, tricuspid valve in 20, mitral valve in 2, and both tricuspid and mitral valves in 8. AVV regurgitation was repaired at palliative stage in 21 patients, at Glenn stage in 29, and at Fontan stage in 14. There was no initial valve replacement during the study period. The major procedures of AVV repair included commissural annuloplasty in 50 patients, closure of commissure or cleft in 32, edge-to-edge repair in 19, De Vega in 8, and chorda shortening or reconstruction in 7. The major concomitant procedures included pulmonary artery angioplasty in 24 patients, bidirectional Glenn in 22, Fontan procedure in 10, repair of total anomalous pulmonary venous return or pulmonary venous obstruction in 10, systemic-to-pulmonary shunt in 8, and Norwood procedure in 5. The mean follow-up period was 36.5 ± 36.7 months, and follow-up was complete in all patients. The overall survival rates after the AVV repair were 76.4% and 70.0% at 1 and 5 years, respectively. Younger age (p = 0.009), lower body weight (p = 0.004), HLHS (p = 0.002), concomitant Norwood procedure (p < 0.001), and palliative stage (p = 0.006) were the risk factors for mortality. Among 64 patients, 20 underwent reoperation for AVV (repairs, 15; replacements, 5), and freedom from reoperation for AVV were 68.2% and 56.0% at 1 and 5 years, respectively. Concomitant systemic-to-pulmonary shunt (p = 0.044) was a risk factor for reoperation. Of the 47 survivors, 37 underwent Fontan completion; 7, Glenn; and 3 is awaiting Glenn. Follow-up cardiac catheterization was performed in 32 patients after Fontan completion, which showed central venous pressure, 12.7 ± 2.3 mmHg; cardiac index, 3.1 ± 0.7 L/min/m2; ejection fraction, 55.4% ± 11.5%; and arterial oxygen saturation, 92.9% ± 5.0%.
CONCLUSIONS:
The midterm results of the surgical repair for AVV regurgitation in fSV patients were favorable. With AVV repair in appropriate timing, cardiac function was maintained effectively. The outcomes of surgical AVV repair in fSV patients at palliative stage, especially in HLHS patients, is not promising, but can be improved.
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