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CLINICAL STUDIES

Accessory and anomalous atrioventricular valvar tissue causing outflow tract obstruction

Surgical implications of a heterogeneous and complex problem

Doff B. McElhinney, MD^*, V. Mohan Reddy, MD^*, Norman H. Silverman, MD and Frank L. Hanley, MD^*

^* Division of Cardiothoracic Surgery, University of California, San Francisco, California, USA
Division of Pediatric Cardiology, University of California, San Francisco, California, USA

Manuscript received March 30, 1998; revised manuscript received July 14, 1998, accepted July 29, 1998.

Address for correspondence: V. Mohan Reddy, MD, UCSF Medical Center, 505 Parnassus Avenue, M593, San Francisco, California 94143-0118

Objectives. The purpose of this study was to determine the effect of accessory or anomalous atrioventricular valvar apparatus on relief of outflow tract obstruction.

Background. Outflow tract obstruction due to accessory tissue or anomalous attachments of the atrioventricular valvar apparatus is an unusual but well-recognized problem. In addition to obstruction, anomalous attachments of the atrioventricular valvar apparatus may interfere with procedures to relieve outflow tract obstruction or perform outflow tract reconstruction.

Methods. Since 1992, we have operated on 21 patients (median age 4 years) with systemic (n = 13), pulmonary (n = 5) or bilateral (n = 3) outflow tract obstruction due to accessory atrioventricular valvar tissue and/or anomalous attachments of the subvalvar apparatus. Primary diagnoses were isolated obstruction of the systemic outflow tract or aortic arch (n = 7), transposition complexes (n = 6), previously repaired atrioventricular septal defect (n = 3), functionally single ventricle (n = 3) and ventricular septal defect with pulmonary outflow obstruction (n = 2). Outflow tract gradients ranged from 20–110 mm Hg (median 58 mm Hg).

Results. Complete relief of obstruction due to atrioventricular valvar anomalies was possible in 14 patients. In six patients, the planned procedure either had to be modified or only partial relief of the obstruction was achieved. In the remaining patient, who had borderline functionally single ventricle heart disease (unbalanced atrioventricular septal defect) and systemic outflow obstruction due to accessory and functional valvar apparatus, support was withdrawn because the parents refused univentricular palliation and the valvar anomalies precluded a Ross-Konno procedure. There were two early deaths. At follow-up ranging from 1 to 66 months (median 27 months), there was one death, and there has been no recurrence of outflow tract obstruction or residual atrioventricular valvar tissue.

Conclusions. Outflow tract obstruction caused by accessory or anomalous atrioventricular valvar structures is an uncommon and heterogeneous group of conditions that can have significant surgical implications. In the majority of cases, tailoring of surgical techniques will permit complete relief of obstruction. However, such anomalies may limit standard surgical options and necessitate an innovative approach in some patients.

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