The left ventricular outflow tract in atrioventricular septal defect revisited: Surgical considerations regarding preservation of aortic valve integrity in the perspective of anatomic observations

Objective: The anatomy of the left ventricular outflow tract in hearts with atrioventricular septal defect has been widely investigated, but controversies remain regarding detailed aspects of left ventricular outflow tract anatomy in the perspective of operative techniques to either prevent or relieve outflow tract obstruction. Methods: We investigated 29 postmortem hearts with an atrioventricular septal defect. Measurements were taken of the circumferences and of the widths of the components that make up the outflow tract, that is, the interventricular septum, the superior bridging leaflet, the left ventricular free wall, and the length of the tendinous cords. Results: The circumference of the left ventricular outflow tract immediately underneath the aortic valve was not different from that at the middle part of the outflow tract. Hearts with the partial type defect, characterized by separate atrioventricular orifices, had a smaller outflow tract than those with the complete variety. Although the anatomic constituents that contribute to left ventricular outflow tract obstruction are complex, this study showed that a reduced width of the interventricular septum was most intimately related to narrowing immediately underneath the aortic valve. Obstruction at the middle part of the left ventricular outflow tract was largely caused by reduced width of the interventricular septum together with short tendinous cords. Conclusions: On the basis of these observations, we recommend detailed investigation of the anatomy of the left ventricular outflow tract immediately underneath the aortic valve, before surgical attempts to relieve outflow tract obstruction, because in some procedures the integrity of the aortic valve will be at stake.