The Surgical Anatomy of Ventricular Septal Defect Part IV: Double Outlet Ventricle

Abstract

In this fourth part of our series of articles concerned with the surgical anatomy of ventricular septal defects (VSDs), we have analyzed the arrangements when both arterial trunks arise from the same ventricle. The essence of these anomalies is that the interventricular communication is an integral part of the circulation. Unless the surgeon constructs an alternative route of exit, closure of this defect would isolate one of the ventricles. The usual surgical approach, therefore, is to patch the hole between the ventricles into one or other of the subarterial outflow tracts. This means that all the components of the ventricular outflow tracts are of potential surgical importance. In hearts with double outlet right ventricle, the VSD can be categorized as being subaortic, subpulmonary, doubly committed, or non-committed. It is also important to determine whether its anatomical borders, as seen from the right ventricle, are in part fibrous or exclusively muscular, so as to establish the location of the atrioventricular conduction axis. It is possible, according to the nature of these borders, to place the defects into one of three groups, perimenbranous, muscular, or doubly committed and juxta-arterial. The size of the defect is another important surgical consideration. Double outlet left ventricle is a significantly more rare malformation, but the rules for determining the disposition of the conducting tissues are the same.

Diagnostic aspects in surgical treatment of Fallot-type DORV (differential diagnosis)

“…From the point of view of a surgeon, the high frequency of the infundibular and mixed type of obstruction of RVOT obstruction in these groups, is of interest to the anatomy of the coronary arteries in this area [12]. Wilcox B. R. et al subdivided abnormalities of the CA observed in these patients into 3 variants [13]. Table 6 presents variants of abnormalities of the coronary arteries, which were found in our study.…”

Repair of double outlet right ventricle with doubly-committed ventricular septal defect

“…It is useful to unify hearts with double outlet right ventricle on the basis of the orientation of the ventricular septal defect relative to the great arteries, and this approach has unequivocal surgical relevance. 4,5 Within and between these subsets, nonetheless, there remains a morphologic spectrum. 6 It is not always very easy to distinguish one pattern from another, such as the subaortic defect from the doubly-committed one, or the subaortic from the non-committed defect.…”

Double-outlet left ventricle: Diagnosis and management

“…• In the presence of a double-outlet ventricle, when both great arteries arise from the same ventricle, interventricular communication via the VSD is an integral part of the circulation [ 16 ]. Closure of the VSD will isolate one ventricle, and the surgeon must create an alternate outfl ow tract for that ventricle [ 16 ].…”

“…Closure of the VSD will isolate one ventricle, and the surgeon must create an alternate outfl ow tract for that ventricle [ 16 ]. A DOLV with two well-developed ventricles and pulmonary stenosis is conventionally treated surgically by VSD closure, closure of the native left ventricle-to-pulmonary outfl ow and placement of a right ventricle-to-pulmonary artery extracardiac conduit (Rastelli repair).…”