Selective management of the left ventricular outflow tract for repair of interrupted aortic arch with ventricular septal defect: Management of left ventricular outflow tract obstruction

Abstract

Interrupted aortic arch/ventricular septal defect with posterior malalignment of the infundibular septum can be repaired with low mortality in the neonatal period. Tailored to the degree of subaortic narrowing, resection or incision of the infundibular septum at the time of primary repair was very effective in preventing or prolonging the interval to recurrent left ventricular outflow tract obstruction compared with the published data. However, reoperation for left ventricular outflow tract obstruction, often related to the development of a new and discrete subaortic membrane or valvar stenosis, is still required in a subset of patients.

Primary Complete Repair of Interrupted Aortic Arch with Associated Lesions in Infants

“…The presence of restrictive LVOT greatly complicates patient management owing to its multiple anatomic causes . In the current series, the most common cause of LVOTO was posterior deviation of the infundibular septum, which morphologically led to subaortic stenosis.…”

Improved results after the primary repair of interrupted aortic arch: impact of a new management protocol with isolated cerebral perfusion☆☆☆

“…SAS represents one of the most frequent and haemodynamically important lesions associated with IAA, which occurs in a wide spectrum of changes as far as the type, location and severity is concerned [3,4,6,[17][18][19][20]. Most often, it is caused by hypertrophy and posterior deviation of the connal septum.…”

“…It is, however, difficult to set up exact criteria and indications for intervention under borderline conditions. Different methods of echocardiographic assessment of SAS were proposed; however, none of them is ideal [18][19][20]. From our practice, we think that the subaortic obstruction should be addressed if the diameter of LVOT is less than about 3-4 mm.…”

“…Usually it can be completely excised, but sometimes it is located so close to the aortic valve that the risk of injury to the valve is extremely high. Valvar stenosis and hypoplastic aortic annulus occur less often but, generally, all types of SASs are more common in type B IAA, in the presence of aberrant subclavian artery or bicuspid aortic valve, and in restrictive VSD [6,7,18]. Luciani et al recommended placing the superior part of the VSD patch to the left and to suture it from the left ventricular aspect to the connal septum so as to make the path from the left ventricle to the aorta smoother and without turbulence [19].…”

“…The method requires the use of a valved conduit for reconstruction of the right ventricular to pulmonary artery continuity. Recurrence rate of SAS ranges between 4% and 67% [3,4,5,18,19]. Sell reported 42% incidence of this complication occurring within 3 years after the repair [3].…”