SURGICAL-MANAGEMENT OF COMPLETE ATRIOVENTRICULAR SEPTAL-DEFECTS - A 20-YEAR EXPERIENCE

Creation of a competent left atrioventricular valve is a cornerstone i n surgical repair of complete atrioventricular septal defects. To iden tify risk factors for mortality and failure of left atrioventricular v alve repair and to determine the impact of cleft closure on postoperat ive atrioventricular valve function; we retrospectively analyzed hospi tal records of 203 patients between January 1974 and January 1995. Ove rall early mortality,vas 7.9%. Operative mortality decreased significa ntly over the period of the study from 19% (4/21) before 1980 to 3% (2 /67) after 1990 (p = 0.03). Ten-year survival including operative mort ality was 91.3% +/- 0.004% (95% confidence limit): all survivors are i n New York Heart Association class I or II. Preoperative atrioventricu lar valve regurgitation was assessed in 203 patients by angiography or echocardiography and was trivial or mild in 103 (52%), moderate in 82 (41%), and severe in 18 (8%). Left atrioventricular valve cleft was c losed in 93% (189/203) but left alone when valve leaflet tissue was in adequate and closure of the cleft might cause significant stenosis. Re operation for severe postoperative left atrioventricular valve regurgi tation was necessary in eight patients, five of whom initially did not have closure of the cleft and three of whom had cleft closure. Six pa tients had reoperation with annuloplasty and two patients required lef t atrioventricular valve replacement. Five patients survived reoperati on and are currently in New York Heart Association class I or II. On m ost recent evaluation assessed by angiography or echocardiography (a m ean of 59 months after repair), left atrioventricular valve regurgitat ion was trivial or mild in 137 of the 146 survivors (94%) examined; no ne had moderate or severe left atrioventricular valve stenosis. By mul tiple logistic regression analysis, strong risk factors for early deat h and need for reoperation included postoperative pulmonary hypertensi ve crisis, immediate postoperative severe left atrioventricular valve regurgitation, and double-orifice left atrioventricular valve. These r esults indicate that complete atrioventricular septal defects can be r epaired with low mortality and good intermediate to long-term results. Routine approximation of the deft is safe and has a low incidence of reoperation for left atrioventricular valve regurgitation.