Tricuspid valve detachment in closure of congenital ventricular septal defect

Abstract

From January 1991 through December 2001, 600 patients underwent closure of a perimembranous ventricular septal defect through a right atrial approach at our institution. In 122 of these patients, the operation included temporary detachment of a tricuspid valve septal leaflet from the annulus to allow complete visualization of a perimembranous ventricular septal defect The mean age of the patients at surgery was 4.6 years in those who underwent leaflet detachment and 4.7 years in the 478 patients who did not (P > 0.05). Preoperatively, all patients were in sinus rhythm. Echocardiography showed trivial tricuspid regurgitation in 21 of the patients undergoing detachment and in 39 of the non-detachment patients. There was no difference in bypass time or aortic cross-clamp time between the 2 groups. Postoperatively, 3 patients in the non-detachment group had heart block; all other patients were in sinus rhythm. Echocardiograms on the 7th postoperative day showed small residual ventricular septal defects in none of the patients who underwent valve detachment and in 10 of the non-detachment patients; mild tricuspid regurgitation was present in 12 non-detachment patients only; and trivial tricuspid regurgitation was present in 19 patients who underwent valve detachment and in 29 who did not. There was no hospital death in either group. Long-term follow-up showed no progression of tricuspid regurgitation or tricuspid stenosis. All patients remained in sinus rhythm. This study suggests that tricuspid valve detachment is a safe, effective technique that improves exposure for ventricular septal defect repair and does not adversely affect valve competence.

Fig. 1 The 2 criteria for temporary detachment of the septal leaflet of the tricuspid valve from the annulus are combined in this figure. Abnormal chordal attachments to the septum impair visibility of the superior and posteroinferior margins of the ventricular septal defect (VSD); and the valve is attached to the rim of the VSD, forming an aneurysm and impairing visibility of nearly the entire VSD margin. The 3 arrows indicate a left-to-right ventricular shunt through multiple openings at the mouth of the aneurysm (beneath the septal leaflet). (Illustration by Lee Rose) AL = anterior leaflet; PL = posterior leaflet; SL = septal leaflet

Fig. 2 The septal leaflet of the tricuspid valve has been partially detached from the annulus by an incision made at a distance of 1 to 2 mm from the annulus. Visibility of the ventricular septal defect is greatly improved. (Illustration by Lee Rose) VSD = ventricular septal defect

Fig. 3 The patch closure of the ventricular septal defect has been made through the leaflet incision with use of a continuous suture. When the suture lines approach the 2 ends of the valve incision, the patch is sandwiched between the annulus and the leaflet. (Illustration by Lee Rose)