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Commentary: Defining the limits of the modified single-patch technique

  • Carl L. Backer
    Correspondence
    Address for reprints: Carl L. Backer, MD, UK HealthCare Kentucky Children's Hospital, 800 Rose St, C-259, Lexington, KY 40536-0293.
    Affiliations
    Section of Pediatric Cardiothoracic Surgery, UK HealthCare Kentucky Children's Hospital, Lexington, Ky
    Cardiothoracic Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Published:August 28, 2022DOI:https://doi.org/10.1016/j.jtcvs.2022.08.011
      A limitation of the modified single-patch technique is the increased late left AV valve insufficiency in patients with a very deep (>11 mm) VSD. Prior PA banding did not adversely affect outcomes.
      See Article page 411.
      The pediatric cardiac surgery group from Okayama, Japan, has provided for us a review that aids in the understanding of the limitations of the modified single-patch technique.
      • Kobayashi Y.
      • Kasahara S.
      • Sano S.
      • Kotani Y.
      Modified single-patch repair for atrioventricular septal defects results in good functional outcomes in the absence of deep ventricular septal defects.
      The modified single-patch technique is no longer a new operation, having been first described independently by Ben Wilcox from North Carolina in 1997
      • Wilcox B.R.
      • Jones D.R.
      • Frantz E.G.
      • Brink L.W.
      • Henry G.W.
      • Mill M.R.
      • et al.
      Anatomically sound, simplified approach to repair of “complete” atrioventricular septal defect.
      and Graham Nunn from Sydney, Australia, in 1999.
      • Nicholson I.A.
      • Nunn G.R.
      • Sholler G.F.
      • Hawker R.E.
      • Cooper S.G.
      • Lau K.C.
      • et al.
      Simplified single patch technique for the repair of atrioventricular septal defect.
      The operation has been the subject of countless reviews heralding its advantages and results in comparison with the previous standard operation the double-patch technique.
      • Fong L.S.
      • Betts K.
      • Bell D.
      • Konstantinov I.E.
      • Nicholson I.A.
      • Winlaw D.S.
      • et al.
      Complete atrioventricular septal defect repair in Australia: results over 25 years.
      Like any new operation, limitations and previously unforeseen complications tighten the indications for its use.
      The current review evaluates the outcome of complete atrioventricular septal defect (AVSD) repair in 118 patients. Of these patients, 69 had the modified single-patch technique and 49 had a 2-patch technique. The results are very good, with a 10-year follow-up, a 2.5% overall mortality, and only a 7% reoperation rate on the left atrioventricular (AV) valve. In contrast to many other centers, nearly 30% of the patients had a pulmonary artery band before complete repair.
      The important takeaway from this study is that patients with a deep ventricular septal defect, as defined by a depth greater than 11 mm by echocardiogram, had the greatest incidence of moderate or greater left AV valve regurgitation late after the modified single-patch repair. When I was in Chicago, our experience led us to agree with the findings in the review from Okayama and recommend that the 2-patch technique be applied when the ventricular septal defect was larger than 1.5 cm in depth.
      • Backer C.L.
      • Stewart R.D.
      • Mavroudis C.
      What is the best technique for repair of complete atrioventricular canal?.
      It appears that the current review, with more patients and longer follow-up, refines this recommendation to a depth of 11 mm.
      I have previously emphasized the advantages of the modified single-patch technique, which include (1) shorter crossclamp times, (2) shorter bypass times, (3) relatively easy to teach, and (4) in our hands, a low incidence of reoperation for heart block, AV valve insufficiency, or left ventricular outflow tract obstruction.
      • Backer C.L.
      • Stewart R.D.
      • Bailliard F.
      • Kelle A.M.
      • Webb C.L.
      • Mavroudis C.
      Complete atrioventricular canal: comparison of modified single-patch technique with two-patch technique.
      One other interesting conclusion from the analysis from Okayama is that they used pulmonary artery banding in nearly one-third of their patients, and it did not appear to adversely affect their patients' outcomes. This is consistent with the recent review from the Congenital Heart Surgeons' Society, as reported by Devlin and colleagues.
      • Devlin P.J.
      • Jegatheeswaran A.
      • McCrindle B.W.
      • Karamlou T.
      • Blackstone E.H.
      • Williams W.G.
      • et al.
      Pulmonary artery banding in complete atrioventricular septal defect.
      New operations lead to outcomes analysis, which leads to refinement in their application. The limitations of the modified single-patch technique keep becoming clearer. Deep ventricular septal defects are to be avoided, and pulmonary artery banding perhaps should be considered in a larger subset of cases.

      References

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        • Kasahara S.
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        • Kotani Y.
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        • Henry G.W.
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        Anatomically sound, simplified approach to repair of “complete” atrioventricular septal defect.
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        • Nunn G.R.
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        Simplified single patch technique for the repair of atrioventricular septal defect.
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        • Bell D.
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        Complete atrioventricular septal defect repair in Australia: results over 25 years.
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        What is the best technique for repair of complete atrioventricular canal?.
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