Impact of inter-annular bridge
to make better apposition between facing leaflets of atrioventricular regurgitant valves
in functional single ventricle
SAKAMOTO Kisaburo, MURATA Masaya, IDE Yujiro
Mt. FUJI Shizuoka Children’s Hospital
It is hard to control atrioventricular regurgitation on the patients with functional single ventricle, because of their circular or semicircular valves with dysplastic leaflets.
Today, we report novel approach with inter-annular bridge for these difficult groups.
From 2007, we have used this approach mainly for the functionally single ventricle patients with the common atrioventricular valves and the tricuspid valves, that were difficult to control central regurgitation using conventional repair techniques.
The valves mostly had dysplastic and short leaflets and circular form of the valve annulus, difficult to make effective coaptation to reduce central regurgitation.
We have put inter-annular bridges on them to make oval or spindle shaped annulus and better apposition between the facing leaflets apart. This strategy could be effective to reduce the regurgitation and to leave possibility of following repeat repair.
We used this approach on the 10 patients.(mean age 5.8 months old and BW 4.9 kg).
The grade of post-operative regurgitation were 1.3 ( pre-op 2.7) and 8 patients could reach BDG or TCPC, even for these patients were hard to reach their next stages.
This novel approach with inter-annular bridge can bring more functionally single ventricle patients with dysplastic circular valve and central regurgitation to the next stage.
1 : Reproduce preoperative echo findings
The plane of AVV faces rather posterior aspect. Echocardiologists check the AVV condition under beating heart and in situ position. Surgeons check it under cardiac arrest, with the plane of valve being converted from posterior to anterior.
The shape of AVV and ventricular mass including tension-apparatus may be considerably changed. AVV performance including coaptation and regurgitation is affected by these changes. This must result in discrepancy between two findings.
2 : Select potential leaflets,
Remake to get better function and growth-potential
As a dysplastic AV valve has multiple & dysplastic leaflets with different condition, we select potential leaflets and remake them to be better-functioning and to have better growth potential, using resection of disadvantageous basal cords, remaking papillary muscles, cleft closure and so on
Common AV valve has oval-shaped morphology with various opening patterns, and it is easily deformed by slight traction.
3 : Make better apposition between the potential leaflets
Reduce annular size, make better apposition & coaptation between adjoining functioning leaflets.
Closing a severely dysplastic commissure.
Pruning off a severely dysplastic leaflet.
Keeping both capacity of growth and ability for repeat repair, without unnecessary reduction of their annular base.
4 : Multistage repair
using staged annuloplasty theory
5 : “inter-annular bridging annuloplasty”
our new approach, “IAB”
easy to get better apposition of the facing leaflets apart