A word of caution regarding early repair of complete atrioventricular septal defect: Don't let the pendulum swing too far
Year: 2021
Type: article
Abstract: The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. In their terrific paper, Ramgren and colleagues1Ramgren J.J. Nozohoor S. Zindovic I. Gustafsson R. Hakacova N. Sjögren J. Long-term outcome after early repair of complete atrioventricular septal defect in young infants.J Thorac Cardiovasc Surg. 2021; 161: 2145-2153Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar provide an opportunity to learn from their experience treating patients with a complete atrioventricular canal (CAVC) before 3 months of age. Their overall results for all of the CAVCs are excellent: 95% 20-year survival and 6.3% reoperation rate—although their Figure 3 may suggest otherwise? The authors suggest that pulmonary artery (PA) banding is not ideal and complete repair should be performed for these young patients when indicated. We agree with both points. What is not explicitly stated, but implied in their discussion, is that ALL patients with a CAVC should undergo repair before 3 months of age. A naïve practitioner may therefore conclude, when a baby is diagnosed with CAVC, surgery should ensue shortly thereafter even if the patient is otherwise doing well on a reasonable diuretic regimen. Perhaps that is the right next step. To that end, we ask the following:1.The authors had a slightly increased tendency to avoid complete cleft closure in the younger group. What, if any, impact have they seen in the long term?2.The authors use the age cut-off of 3 months, a reasonable one; however, details matter: The authors clearly state that there were 3 neonates, but how many were between 30 and 60 days old and 60-90 days old? What was the median age at repair (outliers can skew mean values)?3.The authors state that 9 of 55 (16%) had severe atrioventricular valve regurgitation; what were the indications for early intervention in the other 80%? Were any “elective”?4.The authors note a mortality hazard ratio of 14.7 with concomitant coarctation repair; they state that their approach is to repair the arch as a newborn but delay CAVC repair until later. We prefer to repair the coarctation and band the PA (the one instance we feel a PA band is helpful). So why don't the authors consider PA banding in this setting? When there is significant atrioventricular valve regurgitation, however, we do address the valve, where we reluctantly resort to a modified single-patch repair; reluctantly, because we worry these same patients are at risk for future left ventricular outflow tract obstruction.5.The authors note that of 19 patients who required 26 left atrioventricular valve–related reoperations, 4 underwent early reoperation and some required multiple. Were any in the younger cohort?6.Finally, regarding right ventricular outflow tract obstruction, of 6 patients with pulmonary atresia, 1 received a Blalock–Taussig shunt. How were the others managed? One among the younger group received complete repair; how did this patient do? Do the authors also advocate for early repair in CAVC with right ventricular outflow tract obstruction? As we have become comfortable with smaller children, “why should we wait?” is a natural question. However, “do we need to operate now?” is equally important. The age for repair could easily swing to newborns, only to be demonstrated inferior in the future. So the question of whether patients with CAVC should be “electively” repaired as early as possible remains of interest to us. We enjoyed this paper and look forward to the author's responses. Long-term outcome after early repair of complete atrioventricular septal defect in young infantsThe Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 6PreviewThe long-term outcome after repair of complete atrioventricular septal defect in young infants is still not fully understood. The objective of this study was to evaluate data after repair for complete atrioventricular septal defect over a 25-year period to assess survival and identify risk factors for left atrioventricular valve–related reoperations. Full-Text PDF Reply: “Early” has a definition and age matters but program attributes matter moreJTCVS OpenVol. 9PreviewEghtesady and colleagues'1 characteristically thoughtful and judicious observations regarding Johansson Ramgren and colleagues'2 report of long-term outcomes after complete repair of complete atrioventricular septal defect (CAVSD) are important for readers to hear and be clear about. The message of these outstanding results should not be interpreted as an endorsement of a therapeutic strategy that eliminates age as a factor in timing of CAVSD repair. To walk away from a reading of the Swedish experience with this lesion with that conclusion would be at best, in the words of our colleagues, naïve. Full-Text PDF Open AccessReply: Nonelective correction of patients with complete atrioventricular septal defect failing medical management is a viable option even in very young infantsJTCVS OpenVol. 9PreviewI thank Miller and coauthors for their comments regarding our recently published paper.1 The congenital cardiac community has continuously searched for the optimal surgical timing and treatment for complete atrioventricular septal defect (CAVSD). Since the regionalization of pediatric cardiac surgery in Sweden almost 3 decades ago, we have used elective surgical correction at 3 to 4 months of age as our clinical standard.2 However, in patients who, despite optimized medical treatment, develop congestive heart failure, we have performed nonelective corrective surgery even before 3 months of age and avoided palliative measures. Full-Text PDF Open Access
Source: JTCVS Open
Institution: Washington University in St. Louis
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,100
OpenAlex ID: W3200717655