CORRECTION OF COMPLETE ATRIOVENTRICULAR SEPTAL-DEFECTS WITH THE DOUBLE-PATCH TECHNIQUE AND CLEFT CLOSURE

Background. Controversy continues to surround determining which is the most beneficial method of complete atrioventricular septal defect rep air, eg, one- versus two-patch repair, closure of mitral cleft, and th e necessity of annuloplasty. Methods. Between January 1988 and Novembe r 1995, 120 patients with complete atrioventricular septal defect unde rwent total correction at the German Heart Institute Berlin. Sixty-nin e of the patients were infants and 51 were children or adolescents. El even patients had previously undergone pulmonary artery banding. One h undred three patients had Down's syndrome. In all 120 patients complet e atrioventricular septal defect repair was performed using the two-pa tch technique. The mitral cleft was closed with interrupted sutures in 119 cases. Results. Thirty-four patients required aggressive treatmen t of postoperative pulmonary hypertensive crises (including nitric oxi de inhalation). There were 12 hospital deaths (10%). Mortality was hig hest in patients with persistently high postoperative pulmonary arteri al pressure (pulmonary artery pressure/systemic artery pressure > 0.6) (7 of 17 patients died; 41%). Associated atrioventricular valve anoma lies, especially dysplastic valve tissue and severe preoperative cardi opulmonary instability necessitating catecholamine support and artific ial ventilation, represented other risk factors. There were six late d eaths (5%); cumulative mortality was 15%. Four patients suffered a com plete heart block and sick sinus node syndrome necessitating pacemaker implantation 1 to 6 months after operation. During the follow-up peri od (3 to 80 months after operation), 7 patients (6.8% of survivors) we re successfully reoperated on after significant mitral valve incompete nce due to an open ''cleft'' (suture failure) developed. Conclusions. Correcting complete atrioventricular septal defect using the two-patch technique, routine cleft closure, and atrial septal incision led to a low incidence of residual mitral valve incompetence. Mortality was pr imarily influenced by severe cardiopulmonary instability and additiona l atrioventricular valve anomalies preoperatively and the persistence of high pulmonary arterial hypertension postoperatively.