Annuloplasty band implantation in adults with partial atrioventricular septal defect: a propensity-matched study

Annuloplasty band implantation in adults with partial atrioventricular septal defect: a... Abstract OBJECTIVES The incidence of recurrent left atrioventricular valve (LAVV) regurgitation is generally high after repair of partial atrioventricular septal defect (AVSD). This study aimed to evaluate the effect of implanting an additional annuloplasty band into the LAVV during partial AVSD repair and to assess the late outcomes of recurrent LAVV regurgitation. METHODS This study enrolled 133 patients who underwent repair of partial AVSD at our institution from January 2005 to December 2015. All patients underwent repair of the ostium primum atrial septal defect and closure of the LAVV cleft; 37 patients underwent additional annuloplasty band implantation. To minimize differences in preoperative data, propensity score matching was used to identify 33 well-matched patient pairs. RESULTS Cardiopulmonary bypass time and aorta cross-clamp time were significantly longer in the band implantation group (P < 0.05). The 2 groups had similar durations of intensive care and hospital stay (P > 0.05). There was 1 in-hospital death in the band implantation group. During follow-up, conduction block occurred in 6 patients in each group. After follow-up of more than 10 years, freedom from late recurrent LAVV regurgitation was 91% in the band implantation group and 57% in the isolated cleft closure group (P < 0.05). In patients with preoperative severe regurgitation and moderate/mild regurgitation, the rates of freedom from recurrent LAVV regurgitation were 85% and 37%, respectively (P < 0.05). CONCLUSIONS In patients with moderate/severe LAVV regurgitation or severe annular dilation, additional band implantation significantly reduces the incidence of recurrent regurgitation and improves long-term outcomes. Adult, Partial atrioventricular septal defect, Left atrioventricular valve repair, Annuloplasty band implantation INTRODUCTION The anatomical characteristics of partial atrioventricular septal defect (AVSD) are the presence of an ostium primum atrial septal defect and a cleft in the anterior leaflet of the left atrioventricular valve (LAVV). Unlike complete AVSD, which is generally corrected during childhood, partial AVSD may not be identified until adulthood [1]. However, studies depicting long-term outcomes after repair of partial AVSD in adults are scarce. Generally, the incidence of late recurrence of LAVV regurgitation is high after repair of partial AVSD, which remains a major indication for reoperation [1]. The optimal surgical technique for LAVV repair during correction of partial AVSD is unclear. Prosthetic annuloplasty band implantation is widely used in mitral valve repair due to degenerative mitral regurgitation, and this could significantly improve long-term outcomes. Yet it is unclear whether additional band implantation in the repair of partial AVSD can reduce the incidence of recurrent LAVV regurgitation and improve late outcomes. Therefore, the aim of this study was to determine whether additional band implantation reduced the late recurrence of LAVV regurgitation in adult patients with partial AVSD. MATERIALS AND METHODS This study was approved by the ethics committee of Zhongshan Hospital. We retrospectively reviewed the clinical and echocardiographic data from all adult patients who underwent repair of partial AVSD at our institution from January 2005 to December 2015. Patients were excluded if they underwent other concomitant heart surgery or had LAVV regurgitation due to other aetiologies. A final total of 133 patients were included in the study. None of the included patients had Down syndrome. The mean age was 38 ± 13 years, and 47 (35%) patients were men. Thirty-one patients had conduction block, and 10 had atrial fibrillation. Ninety-four (71%) patients were asymptomatic or mildly symptomatic [New York Health Association (NYHA) Class I–II]. Diagnosis was established using transthoracic echocardiography. Intraoperative transoesophageal echocardiographic examination was routinely used to evaluate the degree of LAVV regurgitation. Transoesophageal echocardiography was also routinely used postoperatively to examine the repair quality and the residual regurgitation. Repair of the ostium primum atrial septal defect and closure of the LAVV cleft were performed in all patients. Thirty-seven patients underwent additional implantation of an incomplete flexible band into the LAVV after closure of the LAVV cleft. The size of the annuloplasty band was determined by intraoperative measurement of the annulus using a sizer; the median size was 28.5 (interquartile range 28–30). Four kinds of band were used, including Sorin Sovering (62%, 23/37), Edwards Cosgrove (16%, 6/37), Baxter (3%, 1/37) and BalMedic (19%, 7/37). Interrupted horizontal mattress sutures were used to fix the artificial band in place. Other surgical techniques included double-orifice repair in 5 patients (2 in the additional band implantation group and 3 in the isolated cleft closure group) and anterior papillary muscle incision in 3 patients (2 in the additional band implantation group and 1 in the isolated cleft closure group). Annuloplasty of the right atrioventricular valve was also performed in 50 patients to correct right-sided regurgitation. To deal with the absence of randomization and to account for key differences in preoperative data, propensity score matching was used to identify 33 well-matched patient pairs. Late recurrence of LAVV regurgitation was defined as moderate or severe LAVV regurgitation that presented during the follow-up period. Statistical analysis Continuous variables were presented as the mean ± standard deviation, and categorical variables as absolute numbers and percentages. Continuous data were also presented as medians and interquartile ranges. To compare differences between groups, we used the Student’s t-test for continuous variables, and Pearson’s χ2 test or the Fisher’s exact test for categorical variables. The Mann–Whitney U-test was used to compare differences in perioperative data between propensity-matched groups. Survival data were analysed using the Kaplan–Meier analysis with log-rank test. The tests were 2 tailed. Propensity to undergo additional band implantation was calculated using multivariable logistics to model a dichotomous outcome of whether additional band implantation was needed for the 133 patients in the sample. Ten fixed-effect variables (male gender, age, NYHA class, conduction block, degree of LAVV regurgitation, significant annular dilation, left ventricular ejection fraction, left ventricular end-diastolic diameter, left atrial dimension and pulmonary artery systolic pressure) were included in the final model. Patients were matched in a 1:1 nearest neighbour fashion to patients with similar propensity scores; a propensity score difference of less than 0.1 was required for each match. In all tests, a P-value <0.05 was considered statistically significant. Statistical analysis was performed using Stata 12.0 (StataCorp LP, College Station, TX, USA) and SPSS 19.0 (SPSS Inc., Chicago, IL, USA). RESULTS Preoperative profiles of the patients are summarized in Table 1. Patients who underwent additional band implantation were more likely to have a higher NYHA class (P < 0.05) and severe LAVV regurgitation (53% vs 20%, P < 0.05). Patients who underwent additional band implantation also had a significantly larger left atrial dimension (P < 0.05) and significantly higher pulmonary artery systolic pressure (P < 0.05). These inter-group differences indicated that additional band implantation was preferred in patients who had a more advanced stage of LAVV regurgitation. After propensity matching, the baseline characteristics were similar between the band implantation group and the isolated cleft closure group. Propensity-matched baseline profiles and echocardiographic data are summarized in Table 2. Table 1: Clinical characteristics (before propensity matching)   Additional band implantation group (n = 37)  Isolated cleft closure group (n = 96)  P-value  Male, n (%)  9 (24)  38 (40)  0.1  Age (years)  36 ± 14 (33, 25–42)  39 ± 13 (40, 27–50)  0.28  Atrial fibrillation, n (%)  3 (8)  7 (7)  0.87  Hypertension, n (%)  3 (8)  8 (8)  1  Diabetes mellitus, n (%)  0  2 (2)  0.93  Conduction block, n (%)  5 (14)  26 (27)  0.1  NYHA class, n (%)      0.003   I  4 (11)  33 (34)     II  17 (46)  40 (42)     III  13 (35)  20 (21)     IV  3 (8)  3 (3)    LAVV regurgitation, n (%)      0.001   Mild  2 (6)  11 (12)     Moderate  15 (42)  61 (68)     Severe  19 (53)  18 (20)    Significant annular dilation, n (%)  6 (18)  0  <0.001  LVEF (%)  66 ± 5 (66, 64–70)  66 ± 5 (66, 60–69)  0.56  LVESD (mm)  28 ± 6 (28, 25–33)  27 ± 3 (26, 25–28)  0.17  LVEDD (mm)  45 ± 10 (44, 39–48)  42 ± 5 (41, 39–44)  0.09  LAD (mm)  45 ± 11 (42, 37–53)  40 ± 8 (40, 35–45)  0.04  PASP (mm)  59 ± 16 (61, 49–72)  51 ± 14 (49, 42–56)  0.02    Additional band implantation group (n = 37)  Isolated cleft closure group (n = 96)  P-value  Male, n (%)  9 (24)  38 (40)  0.1  Age (years)  36 ± 14 (33, 25–42)  39 ± 13 (40, 27–50)  0.28  Atrial fibrillation, n (%)  3 (8)  7 (7)  0.87  Hypertension, n (%)  3 (8)  8 (8)  1  Diabetes mellitus, n (%)  0  2 (2)  0.93  Conduction block, n (%)  5 (14)  26 (27)  0.1  NYHA class, n (%)      0.003   I  4 (11)  33 (34)     II  17 (46)  40 (42)     III  13 (35)  20 (21)     IV  3 (8)  3 (3)    LAVV regurgitation, n (%)      0.001   Mild  2 (6)  11 (12)     Moderate  15 (42)  61 (68)     Severe  19 (53)  18 (20)    Significant annular dilation, n (%)  6 (18)  0  <0.001  LVEF (%)  66 ± 5 (66, 64–70)  66 ± 5 (66, 60–69)  0.56  LVESD (mm)  28 ± 6 (28, 25–33)  27 ± 3 (26, 25–28)  0.17  LVEDD (mm)  45 ± 10 (44, 39–48)  42 ± 5 (41, 39–44)  0.09  LAD (mm)  45 ± 11 (42, 37–53)  40 ± 8 (40, 35–45)  0.04  PASP (mm)  59 ± 16 (61, 49–72)  51 ± 14 (49, 42–56)  0.02  Continuous data were presented as mean ± standard deviation and median with interquartile range. LAD: left atrial diameter; LAVV: left atrioventricular valve; LVEDD: left ventricular end-diastolic diameter; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic diameter; NYHA: New York Heart Association; PASP: pulmonary artery systolic pressure. Table 2: Clinical characteristics (propensity-matched groups)   Additional band implantation group (n = 33)  Isolated cleft closure group (n = 33)  P-value  Male, n (%)  9 (27)  8 (24)  0.78  Age (years)  36 ± 14 (32, 25–42)  37 ± 14 (33, 23–43)  0.76  Atrial fibrillation, n (%)  2 (6)  1 (3)  1  Hypertension, n (%)  2 (6)  3 (9)  1  Diabetes mellitus, n (%)  0  1 (3)  1  Conduction block, n (%)  5 (15)  7 (21)  0.52  NYHA class, n (%)      0.54   I  3 (9)  5 (15)     II  15 (46)  14 (42)     III  12 (36)  12 (36)     IV  3 (9)  2 (6)    LAVV regurgitation degree, n (%)      0.26   Mild  2 (6)  0     Moderate  14 (42)  23 (70)     Severe  17 (52)  10 (30)    LVEF (%)  66 ± 5 (66, 63–70)  65 ± 6 (67, 60–68)  0.48  LVESD (mm)  28 ± 5 (27.5, 25–32)  27 ± 3 (26, 24–28)  0.69  LVEDD (mm)  43 ± 8 (43.5, 38–48)  42 ± 6 (42, 38–46)  0.66  LAD (mm)  45 ± 11 (42, 37–53)  43 ± 10 (43, 36–47)  0.47  PASP (mmHg)  60 ± 16 (61, 49–72)  54 ± 15 (50, 44–65)  0.23    Additional band implantation group (n = 33)  Isolated cleft closure group (n = 33)  P-value  Male, n (%)  9 (27)  8 (24)  0.78  Age (years)  36 ± 14 (32, 25–42)  37 ± 14 (33, 23–43)  0.76  Atrial fibrillation, n (%)  2 (6)  1 (3)  1  Hypertension, n (%)  2 (6)  3 (9)  1  Diabetes mellitus, n (%)  0  1 (3)  1  Conduction block, n (%)  5 (15)  7 (21)  0.52  NYHA class, n (%)      0.54   I  3 (9)  5 (15)     II  15 (46)  14 (42)     III  12 (36)  12 (36)     IV  3 (9)  2 (6)    LAVV regurgitation degree, n (%)      0.26   Mild  2 (6)  0     Moderate  14 (42)  23 (70)     Severe  17 (52)  10 (30)    LVEF (%)  66 ± 5 (66, 63–70)  65 ± 6 (67, 60–68)  0.48  LVESD (mm)  28 ± 5 (27.5, 25–32)  27 ± 3 (26, 24–28)  0.69  LVEDD (mm)  43 ± 8 (43.5, 38–48)  42 ± 6 (42, 38–46)  0.66  LAD (mm)  45 ± 11 (42, 37–53)  43 ± 10 (43, 36–47)  0.47  PASP (mmHg)  60 ± 16 (61, 49–72)  54 ± 15 (50, 44–65)  0.23  Continuous data were presented as mean ± standard deviation and median with interquartile range. LAD: left atrial diameter; LAVV: left atrioventricular valve; LVEDD: left ventricular end-diastolic diameter; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic diameter; NYHA: New York Heart Association; PASP: pulmonary artery systolic pressure. There were no operative deaths. Perioperative data for propensity-matched groups are presented in Table 3. After propensity matching, patients who underwent additional band implantation had significantly longer cardiopulmonary bypass time (110 ± 28 min vs 82 ± 19 min, P < 0.001) and aortic cross-clamp time (74 ± 20 min vs 50 ± 14 min, P < 0.001). The 2 groups had a similar length of intensive care unit stay (2 ± 1 days vs 2 ± 1 days, P > 0.05) and length of hospital stay (8 ± 4 days vs 7 ± 2 days, P > 0.05). Third-degree atrioventricular block that required implantation of a permanent pacemaker was observed in 1 (3%) patient in the band implantation group and 3 (4%) patients in the isolated cleft closure group (P > 0.05). There was 1 in-hospital death in the additional band implantation group; the cause of death was low cardiac output syndrome postoperatively. No in-hospital deaths occurred in the isolated cleft closure group (P > 0.05). Table 3: Perioperative details (propensity-matched groups)   Additional band implantation group (n = 33)  Isolated cleft closure group (n = 33)  P-value  Cardiopulmonary bypass time (min)  110 ± 28 (105, 95–127)  82 ± 19 (76, 69–91)  <0.001  Aorta cross-clamp time (min)  74 ± 20 (76, 58–89)  50 ± 14 (48, 40–54)  <0.001  Intensive care unit stay (days)  2 ± 1 (1, 1–3)  2 ± 1 (1, 1–2)  0.38  Hospital stay (days)  8 ± 4 (7, 5–11)  7 ± 2 (6, 5–7)  0.21  Residual mild LAVV regurgitation,an (%)  11 (33)  20 (61)  0.62  In-hospital death, n (%)  1 (3)  0  0.32    Additional band implantation group (n = 33)  Isolated cleft closure group (n = 33)  P-value  Cardiopulmonary bypass time (min)  110 ± 28 (105, 95–127)  82 ± 19 (76, 69–91)  <0.001  Aorta cross-clamp time (min)  74 ± 20 (76, 58–89)  50 ± 14 (48, 40–54)  <0.001  Intensive care unit stay (days)  2 ± 1 (1, 1–3)  2 ± 1 (1, 1–2)  0.38  Hospital stay (days)  8 ± 4 (7, 5–11)  7 ± 2 (6, 5–7)  0.21  Residual mild LAVV regurgitation,an (%)  11 (33)  20 (61)  0.62  In-hospital death, n (%)  1 (3)  0  0.32  Continuous data were presented as mean ± SD and median with interquartile range. a Subsequent to separation from cardiopulmonary bypass, residual LAVV regurgitation was assessed using transoesophageal echocardiography. LAVV: left atrioventricular valve. The median follow-up time was 3.5 years (interquartile range 1–6.4 years). There were 2 late deaths in the additional band implantation group; the cause of late death was multiple organ dysfunction syndrome due to acute heart failure in 1 patient, and a non-cardiac reason in the other. There were no late deaths in the isolated cleft closure group. Left ventricular outflow tract obstruction was not observed during follow-up. Follow-up echocardiographic data are listed in Table 4. Survival data are illustrated in Fig. 1. Late recurrent LAVV regurgitation was observed in 1 patient in the matched additional band implantation group, and 9 patients in the matched isolated cleft closure group. Among these 9 patients in the matched isolated cleft closure group, dehiscence of the sutured cleft was found by follow-up transthoracic echocardiography in 2 patients and infective endocarditis was identified in 1 patient. No patient underwent reoperation for recurrent LAVV regurgitation. After at least 10 years of follow-up, the freedom from late recurrent LAVV regurgitation was 91% in the band implantation group and 57% in the isolated cleft closure group (P < 0.05). Table 4: Echocardiographic data during follow-up   Additional band implantation group  Isolated cleft closure group  P-value  LVEF (%)  64 ± 6 (64, 62–69)  67 ± 5 (65, 64–71)  0.2  LVESD (mm)  29 ± 4 (28, 26–32)  29 ± 4 (30, 26–31)  0.93  LVEDD (mm)  44 ± 5 (43, 42–46)  46 ± 4 (46, 43–49)  0.23  LAD (mm)  42 ± 10 (39, 37–44)  37 ± 7 (37, 33–41)  0.1  PASP (mmHg)  42 ± 25 (32, 28–39)  33 ± 6 (32, 30–35)  0.18    Additional band implantation group  Isolated cleft closure group  P-value  LVEF (%)  64 ± 6 (64, 62–69)  67 ± 5 (65, 64–71)  0.2  LVESD (mm)  29 ± 4 (28, 26–32)  29 ± 4 (30, 26–31)  0.93  LVEDD (mm)  44 ± 5 (43, 42–46)  46 ± 4 (46, 43–49)  0.23  LAD (mm)  42 ± 10 (39, 37–44)  37 ± 7 (37, 33–41)  0.1  PASP (mmHg)  42 ± 25 (32, 28–39)  33 ± 6 (32, 30–35)  0.18  LAD: left atrial diameter; LVEDD: left ventricular end-diastolic diameter; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic diameter; PASP: pulmonary artery systolic pressure. Figure 1 View largeDownload slide The Kaplan–Meier survival curves. (A) Over 10 years of follow-up, freedom from recurrent LAVV regurgitation for matched additional band implantation group and isolated cleft closure group were 91% and 57%, respectively (P = 0.02). (B) For all patients, freedom from recurrent LAVV regurgitation was 37% for patients with severe preoperative regurgitation and 85% for patients with moderate/mild preoperative regurgitation (P = 0.002). LAVV: left atrioventricular valve. Figure 1 View largeDownload slide The Kaplan–Meier survival curves. (A) Over 10 years of follow-up, freedom from recurrent LAVV regurgitation for matched additional band implantation group and isolated cleft closure group were 91% and 57%, respectively (P = 0.02). (B) For all patients, freedom from recurrent LAVV regurgitation was 37% for patients with severe preoperative regurgitation and 85% for patients with moderate/mild preoperative regurgitation (P = 0.002). LAVV: left atrioventricular valve. We further examined the durability of LAVV repair according to the degree of preoperative and residual LAVV regurgitation. In patients with severe regurgitation and moderate/mild regurgitation preoperatively, the rates of freedom from recurrent LAVV regurgitation were 37% and 85%, respectively (P < 0.05). In patients with preoperative moderate/mild LAVV regurgitation, isolated cleft closure was still associated with a lower freedom from recurrent LAVV regurgitation compared with those who underwent additional band implantation (62% vs 100%, P = 0.07). DISCUSSION Patients with partial AVSD can remain asymptomatic until adulthood and reportedly begin to experience symptoms from 30–40 years of age [2]. The mean age of patients in our series was 38 ± 13 years; 72% of patients were symptomatic and presented with exertional dyspnoea. Repair of partial AVSD can reportedly be performed safely with good long-term results in adult patients [3–5]. Our study also showed low perioperative and long-term mortality rates in adult patients undergoing repair of partial AVSD. Previous studies have indicated that preoperative LAVV regurgitation is a predictor of postoperative residual regurgitation, and LAVV regurgitation is the main indication for late reoperation [3, 4]. One previous study reported that late recurrent LAVV regurgitation was observed in 23% of patients, and 10% of patients required reoperation to replace the valve [5]. In this study, we also observed a high incidence of recurrent LAVV regurgitation; overall, 15% (10/66) of patients experienced late recurrence of moderate/severe LAVV regurgitation. Although no patient in this study underwent reoperation, reoperation was advised for the patient diagnosed with late infective endocarditis. These findings support the American Heart Association (AHA) statement that adult patients with AVSD often experience late recurrent LAVV regurgitation requiring reoperation [6]. Hence, an active surgical strategy is required to deal with concomitant LAVV regurgitation in patients with partial AVSD to ensure the durability of LAVV repair. The standard surgical technique for partial AVSD is to repair the ostium primum atrial septal defect and to close the LAVV cleft using interrupted sutures [3–5, 7]. However, this might not be enough to correct LAVV regurgitation and improve the regurgitation-associated prognosis in all patients. In past studies, various repair techniques were used to correct LAVV regurgitation. Gatzoulis et al. [4] reported that 12% of patients underwent additional annuloplasty in their patient series, and Bergin et al. [5] performed annuloplasty in 13% of patients. Welke et al. [8] examined long-term outcomes of a population-based cohort over 40 years and found that annuloplasty was increasingly used (from 0% of patients undergoing annuloplasty at the beginning of the study to 34% in the final 10 years). Stulak et al. [9] investigated reoperation after initial repair of partial AVSD and found that severe annular dilation attributed to 23% of all LAVV pathologies. We also observed severe annular dilation in 16% (6/37) of patients who underwent additional band implantation. In the repair of degenerative mitral regurgitation with annular dilation, standardized band or ring implantation is routinely practised to assure the durability of mitral valve repair, which improves late outcomes [10, 11]. Therefore, in adult patients with partial AVSD, especially those with concomitant annular dilation, annuloplasty with band implantation may also reduce the incidence of late recurrent LAVV regurgitation. In this study, we evaluated the late outcomes of additional band implantation in the repair of partial AVSD. In the original cohort, additional band implantation was preferred in symptomatic patients with severe LAVV regurgitation. To account for key differences in preoperative profiles, propensity score matching was used to identify 2 groups with similar baseline data. In the propensity-matched cohort, nearly all patients experienced moderate or severe LAVV regurgitation, and freedom from late recurrent LAVV regurgitation was significantly higher in patients undergoing additional band implantation. Murashita et al. [12] also reported that cleft closure in combination with annuloplasty may improve valvular function during the follow-up period. Therefore, in patients with moderate/severe regurgitation, additional band implantation could significantly reduce the incidence of recurrent LAVV regurgitation and thus improve the late outcomes of adult patients after repair of partial AVSD. Repair of partial AVSD remains challenging due to the anatomy of the congenital anomaly. In partial AVSD, the atrioventricular node is displaced posteroinferiorly from the apex of the triangle of Koch. The atrioventricular node and bundle of His might be harmed during the closure of the atrial septal defect or the annuloplasty band implantation, so conduction block is a common complication of partial AVSD. El-Najdawi et al. [13] found that patients who had suture closure of the LAVV cleft were less likely to have postoperative arrhythmias than patients who did not have closure of the cleft. However, common existing prosthetic bands might not fit due to the posterior displacement of the valve annulus. Furthermore, the free edges of the cleft are free-floating or insert with abnormal short chordae on the ventricular septum [14]. These above-mentioned abnormalities might influence the safety and effects of additional band implantation, resulting in artificial band-related complications and further exacerbating regurgitation. In our series, there was no significant difference between the propensity-matched groups in the incidence of postoperative third-degree atrioventricular block requiring pacemaker implantation. This result shows that compared with isolated cleft closure, additional band implantation was feasible and could be performed safely without increasing the risk of deteriorating conduction block. Most patients underwent isolated cleft closure at our institution. Originally, the decision to perform additional band implantation was made by surgeons according to intraoperative exploration results. After closing the cleft, a repeated saline injection test was performed to evaluate valve function. If isolated cleft closure was not enough to correct regurgitation, an artificial band was considered. In patients with mild or trace regurgitation, cleft closure alone corrected regurgitation in most cases, therefore additional band implantation might not be necessary. A previous study reported that the degree of preoperative LAVV regurgitation predicts postoperative regurgitation [15]. In our series, we also found that freedom from recurrent LAVV regurgitation was significantly lower in patients with severe preoperative regurgitation. In patients with moderate preoperative regurgitation, isolated cleft closure was still associated with lower freedom from recurrent LAVV regurgitation. Therefore, additional band implantation is beneficial for repair durability. Several differences in preoperative clinical profiles were identified between the 2 groups before propensity matching; patients who underwent additional band implantation had a higher NYHA class, larger left atrial dimension and higher pulmonary artery systolic pressure. As the optimal surgical technique to repair LAVV is unclear, these differences might reflect the indications for additional band implantation. In fact, dilation of the left atrium, pulmonary artery hypertension and severe symptoms might be exacerbated by the recurrence of LAVV regurgitation during follow-up, so these patients would benefit from a more durable correction of LAVV regurgitation. Therefore, preoperative heart failure symptoms, echocardiographic indicators and degree of LAVV regurgitation and annular dilation should be taken into consideration when determining the surgical strategy. In patients with concomitant moderate/severe LAVV regurgitation or severe annular dilation, especially those with left atrial dilation and pulmonary artery hypertension, additional band implantation is recommended to decrease the risk of late LAVV regurgitation and improve regurgitation-related late outcomes. CONCLUSION In conclusion, in adult patients with partial AVSD, especially those with moderate/severe LAVV regurgitation or severe annular dilation, additional band implantation can reduce the incidence of late recurrent LAVV regurgitation and improve regurgitation-related long-term outcomes. Funding This work was supported by the National Natural Science Foundation of China [81570422, 81500194 and 81301312], Youth Foundation of Zhongshan Hospital [2015ZSQN48], Talent Training Programme Foundation for the Excellent Youth Supported by Zhongshan Hospital [2015ZSYXQN12] and ‘Chen Guang’ project supported by Shanghai Municipal Education Commission and Shanghai Education Development Foundation [14CG06]. Conflict of interest: none declared. 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Google Scholar CrossRef Search ADS PubMed  11 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP3rd, Fleisher LA et al.   2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation  2014; 129: 87– 8. Google Scholar CrossRef Search ADS PubMed  12 Murashita T, Kubota T, Oba J, Aoki T, Matano J, Yasuda K. Left atrioventricular valve regurgitation after repair of incomplete atrioventricular septal defect. Ann Thorac Surg  2004; 77: 2157– 62. Google Scholar CrossRef Search ADS PubMed  13 El-Najdawi EK, Driscoll DJ, Puga FJ, Dearani JA, Spotts BE, Mahoney DW et al.   Operation for partial atrioventricular septal defect: a forty-year review. J Thorac Cardiovasc Surg  2000; 119: 880– 90. Google Scholar CrossRef Search ADS PubMed  14 Adachi I, Uemura H, McCarthy KP, Ho SY. Surgical anatomy of atrioventricular septal defect. Asian Cardiovasc Thorac Ann  2008; 16: 497– 502. Google Scholar CrossRef Search ADS PubMed  15 Ceithaml EL, Midgley FM, Perry LW. Long-term results after surgical repair of incomplete endocardial cushion defects. Ann Thorac Surg  1989; 48: 413– 6. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

Annuloplasty band implantation in adults with partial atrioventricular septal defect: a propensity-matched study

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Oxford University Press
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© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1569-9293
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1569-9285
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10.1093/icvts/ivx349
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Abstract

Abstract OBJECTIVES The incidence of recurrent left atrioventricular valve (LAVV) regurgitation is generally high after repair of partial atrioventricular septal defect (AVSD). This study aimed to evaluate the effect of implanting an additional annuloplasty band into the LAVV during partial AVSD repair and to assess the late outcomes of recurrent LAVV regurgitation. METHODS This study enrolled 133 patients who underwent repair of partial AVSD at our institution from January 2005 to December 2015. All patients underwent repair of the ostium primum atrial septal defect and closure of the LAVV cleft; 37 patients underwent additional annuloplasty band implantation. To minimize differences in preoperative data, propensity score matching was used to identify 33 well-matched patient pairs. RESULTS Cardiopulmonary bypass time and aorta cross-clamp time were significantly longer in the band implantation group (P < 0.05). The 2 groups had similar durations of intensive care and hospital stay (P > 0.05). There was 1 in-hospital death in the band implantation group. During follow-up, conduction block occurred in 6 patients in each group. After follow-up of more than 10 years, freedom from late recurrent LAVV regurgitation was 91% in the band implantation group and 57% in the isolated cleft closure group (P < 0.05). In patients with preoperative severe regurgitation and moderate/mild regurgitation, the rates of freedom from recurrent LAVV regurgitation were 85% and 37%, respectively (P < 0.05). CONCLUSIONS In patients with moderate/severe LAVV regurgitation or severe annular dilation, additional band implantation significantly reduces the incidence of recurrent regurgitation and improves long-term outcomes. Adult, Partial atrioventricular septal defect, Left atrioventricular valve repair, Annuloplasty band implantation INTRODUCTION The anatomical characteristics of partial atrioventricular septal defect (AVSD) are the presence of an ostium primum atrial septal defect and a cleft in the anterior leaflet of the left atrioventricular valve (LAVV). Unlike complete AVSD, which is generally corrected during childhood, partial AVSD may not be identified until adulthood [1]. However, studies depicting long-term outcomes after repair of partial AVSD in adults are scarce. Generally, the incidence of late recurrence of LAVV regurgitation is high after repair of partial AVSD, which remains a major indication for reoperation [1]. The optimal surgical technique for LAVV repair during correction of partial AVSD is unclear. Prosthetic annuloplasty band implantation is widely used in mitral valve repair due to degenerative mitral regurgitation, and this could significantly improve long-term outcomes. Yet it is unclear whether additional band implantation in the repair of partial AVSD can reduce the incidence of recurrent LAVV regurgitation and improve late outcomes. Therefore, the aim of this study was to determine whether additional band implantation reduced the late recurrence of LAVV regurgitation in adult patients with partial AVSD. MATERIALS AND METHODS This study was approved by the ethics committee of Zhongshan Hospital. We retrospectively reviewed the clinical and echocardiographic data from all adult patients who underwent repair of partial AVSD at our institution from January 2005 to December 2015. Patients were excluded if they underwent other concomitant heart surgery or had LAVV regurgitation due to other aetiologies. A final total of 133 patients were included in the study. None of the included patients had Down syndrome. The mean age was 38 ± 13 years, and 47 (35%) patients were men. Thirty-one patients had conduction block, and 10 had atrial fibrillation. Ninety-four (71%) patients were asymptomatic or mildly symptomatic [New York Health Association (NYHA) Class I–II]. Diagnosis was established using transthoracic echocardiography. Intraoperative transoesophageal echocardiographic examination was routinely used to evaluate the degree of LAVV regurgitation. Transoesophageal echocardiography was also routinely used postoperatively to examine the repair quality and the residual regurgitation. Repair of the ostium primum atrial septal defect and closure of the LAVV cleft were performed in all patients. Thirty-seven patients underwent additional implantation of an incomplete flexible band into the LAVV after closure of the LAVV cleft. The size of the annuloplasty band was determined by intraoperative measurement of the annulus using a sizer; the median size was 28.5 (interquartile range 28–30). Four kinds of band were used, including Sorin Sovering (62%, 23/37), Edwards Cosgrove (16%, 6/37), Baxter (3%, 1/37) and BalMedic (19%, 7/37). Interrupted horizontal mattress sutures were used to fix the artificial band in place. Other surgical techniques included double-orifice repair in 5 patients (2 in the additional band implantation group and 3 in the isolated cleft closure group) and anterior papillary muscle incision in 3 patients (2 in the additional band implantation group and 1 in the isolated cleft closure group). Annuloplasty of the right atrioventricular valve was also performed in 50 patients to correct right-sided regurgitation. To deal with the absence of randomization and to account for key differences in preoperative data, propensity score matching was used to identify 33 well-matched patient pairs. Late recurrence of LAVV regurgitation was defined as moderate or severe LAVV regurgitation that presented during the follow-up period. Statistical analysis Continuous variables were presented as the mean ± standard deviation, and categorical variables as absolute numbers and percentages. Continuous data were also presented as medians and interquartile ranges. To compare differences between groups, we used the Student’s t-test for continuous variables, and Pearson’s χ2 test or the Fisher’s exact test for categorical variables. The Mann–Whitney U-test was used to compare differences in perioperative data between propensity-matched groups. Survival data were analysed using the Kaplan–Meier analysis with log-rank test. The tests were 2 tailed. Propensity to undergo additional band implantation was calculated using multivariable logistics to model a dichotomous outcome of whether additional band implantation was needed for the 133 patients in the sample. Ten fixed-effect variables (male gender, age, NYHA class, conduction block, degree of LAVV regurgitation, significant annular dilation, left ventricular ejection fraction, left ventricular end-diastolic diameter, left atrial dimension and pulmonary artery systolic pressure) were included in the final model. Patients were matched in a 1:1 nearest neighbour fashion to patients with similar propensity scores; a propensity score difference of less than 0.1 was required for each match. In all tests, a P-value <0.05 was considered statistically significant. Statistical analysis was performed using Stata 12.0 (StataCorp LP, College Station, TX, USA) and SPSS 19.0 (SPSS Inc., Chicago, IL, USA). RESULTS Preoperative profiles of the patients are summarized in Table 1. Patients who underwent additional band implantation were more likely to have a higher NYHA class (P < 0.05) and severe LAVV regurgitation (53% vs 20%, P < 0.05). Patients who underwent additional band implantation also had a significantly larger left atrial dimension (P < 0.05) and significantly higher pulmonary artery systolic pressure (P < 0.05). These inter-group differences indicated that additional band implantation was preferred in patients who had a more advanced stage of LAVV regurgitation. After propensity matching, the baseline characteristics were similar between the band implantation group and the isolated cleft closure group. Propensity-matched baseline profiles and echocardiographic data are summarized in Table 2. Table 1: Clinical characteristics (before propensity matching)   Additional band implantation group (n = 37)  Isolated cleft closure group (n = 96)  P-value  Male, n (%)  9 (24)  38 (40)  0.1  Age (years)  36 ± 14 (33, 25–42)  39 ± 13 (40, 27–50)  0.28  Atrial fibrillation, n (%)  3 (8)  7 (7)  0.87  Hypertension, n (%)  3 (8)  8 (8)  1  Diabetes mellitus, n (%)  0  2 (2)  0.93  Conduction block, n (%)  5 (14)  26 (27)  0.1  NYHA class, n (%)      0.003   I  4 (11)  33 (34)     II  17 (46)  40 (42)     III  13 (35)  20 (21)     IV  3 (8)  3 (3)    LAVV regurgitation, n (%)      0.001   Mild  2 (6)  11 (12)     Moderate  15 (42)  61 (68)     Severe  19 (53)  18 (20)    Significant annular dilation, n (%)  6 (18)  0  <0.001  LVEF (%)  66 ± 5 (66, 64–70)  66 ± 5 (66, 60–69)  0.56  LVESD (mm)  28 ± 6 (28, 25–33)  27 ± 3 (26, 25–28)  0.17  LVEDD (mm)  45 ± 10 (44, 39–48)  42 ± 5 (41, 39–44)  0.09  LAD (mm)  45 ± 11 (42, 37–53)  40 ± 8 (40, 35–45)  0.04  PASP (mm)  59 ± 16 (61, 49–72)  51 ± 14 (49, 42–56)  0.02    Additional band implantation group (n = 37)  Isolated cleft closure group (n = 96)  P-value  Male, n (%)  9 (24)  38 (40)  0.1  Age (years)  36 ± 14 (33, 25–42)  39 ± 13 (40, 27–50)  0.28  Atrial fibrillation, n (%)  3 (8)  7 (7)  0.87  Hypertension, n (%)  3 (8)  8 (8)  1  Diabetes mellitus, n (%)  0  2 (2)  0.93  Conduction block, n (%)  5 (14)  26 (27)  0.1  NYHA class, n (%)      0.003   I  4 (11)  33 (34)     II  17 (46)  40 (42)     III  13 (35)  20 (21)     IV  3 (8)  3 (3)    LAVV regurgitation, n (%)      0.001   Mild  2 (6)  11 (12)     Moderate  15 (42)  61 (68)     Severe  19 (53)  18 (20)    Significant annular dilation, n (%)  6 (18)  0  <0.001  LVEF (%)  66 ± 5 (66, 64–70)  66 ± 5 (66, 60–69)  0.56  LVESD (mm)  28 ± 6 (28, 25–33)  27 ± 3 (26, 25–28)  0.17  LVEDD (mm)  45 ± 10 (44, 39–48)  42 ± 5 (41, 39–44)  0.09  LAD (mm)  45 ± 11 (42, 37–53)  40 ± 8 (40, 35–45)  0.04  PASP (mm)  59 ± 16 (61, 49–72)  51 ± 14 (49, 42–56)  0.02  Continuous data were presented as mean ± standard deviation and median with interquartile range. LAD: left atrial diameter; LAVV: left atrioventricular valve; LVEDD: left ventricular end-diastolic diameter; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic diameter; NYHA: New York Heart Association; PASP: pulmonary artery systolic pressure. Table 2: Clinical characteristics (propensity-matched groups)   Additional band implantation group (n = 33)  Isolated cleft closure group (n = 33)  P-value  Male, n (%)  9 (27)  8 (24)  0.78  Age (years)  36 ± 14 (32, 25–42)  37 ± 14 (33, 23–43)  0.76  Atrial fibrillation, n (%)  2 (6)  1 (3)  1  Hypertension, n (%)  2 (6)  3 (9)  1  Diabetes mellitus, n (%)  0  1 (3)  1  Conduction block, n (%)  5 (15)  7 (21)  0.52  NYHA class, n (%)      0.54   I  3 (9)  5 (15)     II  15 (46)  14 (42)     III  12 (36)  12 (36)     IV  3 (9)  2 (6)    LAVV regurgitation degree, n (%)      0.26   Mild  2 (6)  0     Moderate  14 (42)  23 (70)     Severe  17 (52)  10 (30)    LVEF (%)  66 ± 5 (66, 63–70)  65 ± 6 (67, 60–68)  0.48  LVESD (mm)  28 ± 5 (27.5, 25–32)  27 ± 3 (26, 24–28)  0.69  LVEDD (mm)  43 ± 8 (43.5, 38–48)  42 ± 6 (42, 38–46)  0.66  LAD (mm)  45 ± 11 (42, 37–53)  43 ± 10 (43, 36–47)  0.47  PASP (mmHg)  60 ± 16 (61, 49–72)  54 ± 15 (50, 44–65)  0.23    Additional band implantation group (n = 33)  Isolated cleft closure group (n = 33)  P-value  Male, n (%)  9 (27)  8 (24)  0.78  Age (years)  36 ± 14 (32, 25–42)  37 ± 14 (33, 23–43)  0.76  Atrial fibrillation, n (%)  2 (6)  1 (3)  1  Hypertension, n (%)  2 (6)  3 (9)  1  Diabetes mellitus, n (%)  0  1 (3)  1  Conduction block, n (%)  5 (15)  7 (21)  0.52  NYHA class, n (%)      0.54   I  3 (9)  5 (15)     II  15 (46)  14 (42)     III  12 (36)  12 (36)     IV  3 (9)  2 (6)    LAVV regurgitation degree, n (%)      0.26   Mild  2 (6)  0     Moderate  14 (42)  23 (70)     Severe  17 (52)  10 (30)    LVEF (%)  66 ± 5 (66, 63–70)  65 ± 6 (67, 60–68)  0.48  LVESD (mm)  28 ± 5 (27.5, 25–32)  27 ± 3 (26, 24–28)  0.69  LVEDD (mm)  43 ± 8 (43.5, 38–48)  42 ± 6 (42, 38–46)  0.66  LAD (mm)  45 ± 11 (42, 37–53)  43 ± 10 (43, 36–47)  0.47  PASP (mmHg)  60 ± 16 (61, 49–72)  54 ± 15 (50, 44–65)  0.23  Continuous data were presented as mean ± standard deviation and median with interquartile range. LAD: left atrial diameter; LAVV: left atrioventricular valve; LVEDD: left ventricular end-diastolic diameter; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic diameter; NYHA: New York Heart Association; PASP: pulmonary artery systolic pressure. There were no operative deaths. Perioperative data for propensity-matched groups are presented in Table 3. After propensity matching, patients who underwent additional band implantation had significantly longer cardiopulmonary bypass time (110 ± 28 min vs 82 ± 19 min, P < 0.001) and aortic cross-clamp time (74 ± 20 min vs 50 ± 14 min, P < 0.001). The 2 groups had a similar length of intensive care unit stay (2 ± 1 days vs 2 ± 1 days, P > 0.05) and length of hospital stay (8 ± 4 days vs 7 ± 2 days, P > 0.05). Third-degree atrioventricular block that required implantation of a permanent pacemaker was observed in 1 (3%) patient in the band implantation group and 3 (4%) patients in the isolated cleft closure group (P > 0.05). There was 1 in-hospital death in the additional band implantation group; the cause of death was low cardiac output syndrome postoperatively. No in-hospital deaths occurred in the isolated cleft closure group (P > 0.05). Table 3: Perioperative details (propensity-matched groups)   Additional band implantation group (n = 33)  Isolated cleft closure group (n = 33)  P-value  Cardiopulmonary bypass time (min)  110 ± 28 (105, 95–127)  82 ± 19 (76, 69–91)  <0.001  Aorta cross-clamp time (min)  74 ± 20 (76, 58–89)  50 ± 14 (48, 40–54)  <0.001  Intensive care unit stay (days)  2 ± 1 (1, 1–3)  2 ± 1 (1, 1–2)  0.38  Hospital stay (days)  8 ± 4 (7, 5–11)  7 ± 2 (6, 5–7)  0.21  Residual mild LAVV regurgitation,an (%)  11 (33)  20 (61)  0.62  In-hospital death, n (%)  1 (3)  0  0.32    Additional band implantation group (n = 33)  Isolated cleft closure group (n = 33)  P-value  Cardiopulmonary bypass time (min)  110 ± 28 (105, 95–127)  82 ± 19 (76, 69–91)  <0.001  Aorta cross-clamp time (min)  74 ± 20 (76, 58–89)  50 ± 14 (48, 40–54)  <0.001  Intensive care unit stay (days)  2 ± 1 (1, 1–3)  2 ± 1 (1, 1–2)  0.38  Hospital stay (days)  8 ± 4 (7, 5–11)  7 ± 2 (6, 5–7)  0.21  Residual mild LAVV regurgitation,an (%)  11 (33)  20 (61)  0.62  In-hospital death, n (%)  1 (3)  0  0.32  Continuous data were presented as mean ± SD and median with interquartile range. a Subsequent to separation from cardiopulmonary bypass, residual LAVV regurgitation was assessed using transoesophageal echocardiography. LAVV: left atrioventricular valve. The median follow-up time was 3.5 years (interquartile range 1–6.4 years). There were 2 late deaths in the additional band implantation group; the cause of late death was multiple organ dysfunction syndrome due to acute heart failure in 1 patient, and a non-cardiac reason in the other. There were no late deaths in the isolated cleft closure group. Left ventricular outflow tract obstruction was not observed during follow-up. Follow-up echocardiographic data are listed in Table 4. Survival data are illustrated in Fig. 1. Late recurrent LAVV regurgitation was observed in 1 patient in the matched additional band implantation group, and 9 patients in the matched isolated cleft closure group. Among these 9 patients in the matched isolated cleft closure group, dehiscence of the sutured cleft was found by follow-up transthoracic echocardiography in 2 patients and infective endocarditis was identified in 1 patient. No patient underwent reoperation for recurrent LAVV regurgitation. After at least 10 years of follow-up, the freedom from late recurrent LAVV regurgitation was 91% in the band implantation group and 57% in the isolated cleft closure group (P < 0.05). Table 4: Echocardiographic data during follow-up   Additional band implantation group  Isolated cleft closure group  P-value  LVEF (%)  64 ± 6 (64, 62–69)  67 ± 5 (65, 64–71)  0.2  LVESD (mm)  29 ± 4 (28, 26–32)  29 ± 4 (30, 26–31)  0.93  LVEDD (mm)  44 ± 5 (43, 42–46)  46 ± 4 (46, 43–49)  0.23  LAD (mm)  42 ± 10 (39, 37–44)  37 ± 7 (37, 33–41)  0.1  PASP (mmHg)  42 ± 25 (32, 28–39)  33 ± 6 (32, 30–35)  0.18    Additional band implantation group  Isolated cleft closure group  P-value  LVEF (%)  64 ± 6 (64, 62–69)  67 ± 5 (65, 64–71)  0.2  LVESD (mm)  29 ± 4 (28, 26–32)  29 ± 4 (30, 26–31)  0.93  LVEDD (mm)  44 ± 5 (43, 42–46)  46 ± 4 (46, 43–49)  0.23  LAD (mm)  42 ± 10 (39, 37–44)  37 ± 7 (37, 33–41)  0.1  PASP (mmHg)  42 ± 25 (32, 28–39)  33 ± 6 (32, 30–35)  0.18  LAD: left atrial diameter; LVEDD: left ventricular end-diastolic diameter; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic diameter; PASP: pulmonary artery systolic pressure. Figure 1 View largeDownload slide The Kaplan–Meier survival curves. (A) Over 10 years of follow-up, freedom from recurrent LAVV regurgitation for matched additional band implantation group and isolated cleft closure group were 91% and 57%, respectively (P = 0.02). (B) For all patients, freedom from recurrent LAVV regurgitation was 37% for patients with severe preoperative regurgitation and 85% for patients with moderate/mild preoperative regurgitation (P = 0.002). LAVV: left atrioventricular valve. Figure 1 View largeDownload slide The Kaplan–Meier survival curves. (A) Over 10 years of follow-up, freedom from recurrent LAVV regurgitation for matched additional band implantation group and isolated cleft closure group were 91% and 57%, respectively (P = 0.02). (B) For all patients, freedom from recurrent LAVV regurgitation was 37% for patients with severe preoperative regurgitation and 85% for patients with moderate/mild preoperative regurgitation (P = 0.002). LAVV: left atrioventricular valve. We further examined the durability of LAVV repair according to the degree of preoperative and residual LAVV regurgitation. In patients with severe regurgitation and moderate/mild regurgitation preoperatively, the rates of freedom from recurrent LAVV regurgitation were 37% and 85%, respectively (P < 0.05). In patients with preoperative moderate/mild LAVV regurgitation, isolated cleft closure was still associated with a lower freedom from recurrent LAVV regurgitation compared with those who underwent additional band implantation (62% vs 100%, P = 0.07). DISCUSSION Patients with partial AVSD can remain asymptomatic until adulthood and reportedly begin to experience symptoms from 30–40 years of age [2]. The mean age of patients in our series was 38 ± 13 years; 72% of patients were symptomatic and presented with exertional dyspnoea. Repair of partial AVSD can reportedly be performed safely with good long-term results in adult patients [3–5]. Our study also showed low perioperative and long-term mortality rates in adult patients undergoing repair of partial AVSD. Previous studies have indicated that preoperative LAVV regurgitation is a predictor of postoperative residual regurgitation, and LAVV regurgitation is the main indication for late reoperation [3, 4]. One previous study reported that late recurrent LAVV regurgitation was observed in 23% of patients, and 10% of patients required reoperation to replace the valve [5]. In this study, we also observed a high incidence of recurrent LAVV regurgitation; overall, 15% (10/66) of patients experienced late recurrence of moderate/severe LAVV regurgitation. Although no patient in this study underwent reoperation, reoperation was advised for the patient diagnosed with late infective endocarditis. These findings support the American Heart Association (AHA) statement that adult patients with AVSD often experience late recurrent LAVV regurgitation requiring reoperation [6]. Hence, an active surgical strategy is required to deal with concomitant LAVV regurgitation in patients with partial AVSD to ensure the durability of LAVV repair. The standard surgical technique for partial AVSD is to repair the ostium primum atrial septal defect and to close the LAVV cleft using interrupted sutures [3–5, 7]. However, this might not be enough to correct LAVV regurgitation and improve the regurgitation-associated prognosis in all patients. In past studies, various repair techniques were used to correct LAVV regurgitation. Gatzoulis et al. [4] reported that 12% of patients underwent additional annuloplasty in their patient series, and Bergin et al. [5] performed annuloplasty in 13% of patients. Welke et al. [8] examined long-term outcomes of a population-based cohort over 40 years and found that annuloplasty was increasingly used (from 0% of patients undergoing annuloplasty at the beginning of the study to 34% in the final 10 years). Stulak et al. [9] investigated reoperation after initial repair of partial AVSD and found that severe annular dilation attributed to 23% of all LAVV pathologies. We also observed severe annular dilation in 16% (6/37) of patients who underwent additional band implantation. In the repair of degenerative mitral regurgitation with annular dilation, standardized band or ring implantation is routinely practised to assure the durability of mitral valve repair, which improves late outcomes [10, 11]. Therefore, in adult patients with partial AVSD, especially those with concomitant annular dilation, annuloplasty with band implantation may also reduce the incidence of late recurrent LAVV regurgitation. In this study, we evaluated the late outcomes of additional band implantation in the repair of partial AVSD. In the original cohort, additional band implantation was preferred in symptomatic patients with severe LAVV regurgitation. To account for key differences in preoperative profiles, propensity score matching was used to identify 2 groups with similar baseline data. In the propensity-matched cohort, nearly all patients experienced moderate or severe LAVV regurgitation, and freedom from late recurrent LAVV regurgitation was significantly higher in patients undergoing additional band implantation. Murashita et al. [12] also reported that cleft closure in combination with annuloplasty may improve valvular function during the follow-up period. Therefore, in patients with moderate/severe regurgitation, additional band implantation could significantly reduce the incidence of recurrent LAVV regurgitation and thus improve the late outcomes of adult patients after repair of partial AVSD. Repair of partial AVSD remains challenging due to the anatomy of the congenital anomaly. In partial AVSD, the atrioventricular node is displaced posteroinferiorly from the apex of the triangle of Koch. The atrioventricular node and bundle of His might be harmed during the closure of the atrial septal defect or the annuloplasty band implantation, so conduction block is a common complication of partial AVSD. El-Najdawi et al. [13] found that patients who had suture closure of the LAVV cleft were less likely to have postoperative arrhythmias than patients who did not have closure of the cleft. However, common existing prosthetic bands might not fit due to the posterior displacement of the valve annulus. Furthermore, the free edges of the cleft are free-floating or insert with abnormal short chordae on the ventricular septum [14]. These above-mentioned abnormalities might influence the safety and effects of additional band implantation, resulting in artificial band-related complications and further exacerbating regurgitation. In our series, there was no significant difference between the propensity-matched groups in the incidence of postoperative third-degree atrioventricular block requiring pacemaker implantation. This result shows that compared with isolated cleft closure, additional band implantation was feasible and could be performed safely without increasing the risk of deteriorating conduction block. Most patients underwent isolated cleft closure at our institution. Originally, the decision to perform additional band implantation was made by surgeons according to intraoperative exploration results. After closing the cleft, a repeated saline injection test was performed to evaluate valve function. If isolated cleft closure was not enough to correct regurgitation, an artificial band was considered. In patients with mild or trace regurgitation, cleft closure alone corrected regurgitation in most cases, therefore additional band implantation might not be necessary. A previous study reported that the degree of preoperative LAVV regurgitation predicts postoperative regurgitation [15]. In our series, we also found that freedom from recurrent LAVV regurgitation was significantly lower in patients with severe preoperative regurgitation. In patients with moderate preoperative regurgitation, isolated cleft closure was still associated with lower freedom from recurrent LAVV regurgitation. Therefore, additional band implantation is beneficial for repair durability. Several differences in preoperative clinical profiles were identified between the 2 groups before propensity matching; patients who underwent additional band implantation had a higher NYHA class, larger left atrial dimension and higher pulmonary artery systolic pressure. As the optimal surgical technique to repair LAVV is unclear, these differences might reflect the indications for additional band implantation. In fact, dilation of the left atrium, pulmonary artery hypertension and severe symptoms might be exacerbated by the recurrence of LAVV regurgitation during follow-up, so these patients would benefit from a more durable correction of LAVV regurgitation. Therefore, preoperative heart failure symptoms, echocardiographic indicators and degree of LAVV regurgitation and annular dilation should be taken into consideration when determining the surgical strategy. In patients with concomitant moderate/severe LAVV regurgitation or severe annular dilation, especially those with left atrial dilation and pulmonary artery hypertension, additional band implantation is recommended to decrease the risk of late LAVV regurgitation and improve regurgitation-related late outcomes. CONCLUSION In conclusion, in adult patients with partial AVSD, especially those with moderate/severe LAVV regurgitation or severe annular dilation, additional band implantation can reduce the incidence of late recurrent LAVV regurgitation and improve regurgitation-related long-term outcomes. Funding This work was supported by the National Natural Science Foundation of China [81570422, 81500194 and 81301312], Youth Foundation of Zhongshan Hospital [2015ZSQN48], Talent Training Programme Foundation for the Excellent Youth Supported by Zhongshan Hospital [2015ZSYXQN12] and ‘Chen Guang’ project supported by Shanghai Municipal Education Commission and Shanghai Education Development Foundation [14CG06]. Conflict of interest: none declared. 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Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Mar 1, 2018

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