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Pediatric Partial and Intermediate Atrioventricular Septal Defects Treatment & Management

  • Author: M Silvana Horenstein, MD; Chief Editor: P Syamasundar Rao, MD  more...
 
Updated: Mar 27, 2014
 

Medical Care

Treatment for congestive heart failure (CHF) is occasionally required if mitral regurgitation (MR) cannot be adequately surgically reduced.

Follow-up in patients with atrioventricular septal defect (AVSD) is determined on an individual basis, and the frequency depends on the persistence and severity of atrioventricular valve regurgitation or other abnormalities.

Chest radiography, ECG, and echocardiography should be performed, if the physical examination warrants.

Consultations

Obtain consultations with the following specialists:

  • Pediatric cardiologist
  • Cardiovascular surgeon
  • Geneticist, if an abnormality is suspected (eg, Down syndrome)
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Surgical Care

Management of partial atrioventricular septal defect (AVSD) is primarily surgical, and repair includes patch closure of the atrial septal defect (ASD), mitral valve annuloplasty, or cleft closure. Other defects (eg, left ventricular outflow tract [LVOT] obstruction, patent ductus arteriosus [PDA]) may require repair during the same operation.

Repair is usually electively performed in children aged 2-5 years, unless significant mitral regurgitation (MR) is present, in which case earlier repair is indicated. However, in the current era, repair of AVSD can be successfully performed in patients who weigh less than 5 kg.[11, 12, 13]

Surgical morbidity

Severe MR develops in a significant number of patients after correction of ASD. In fact, MR is the most common residual defect[14] and therefore, it is the most frequent indication for reoperation in patients after repair of both partial and complete AVSD.[15, 16, 17]

LVOT obstruction may not be evident for years after the initial repair. LVOT obstruction is the second most common indication for reoperation in patients with partial AVSD.[18, 19]

Preoperative severe left-sided atrioventricular valve regurgitation and associated valve malformations are important risk factors for postoperative development of MR.[15, 20]

According to another study, predictors for reoperation include postoperative MR, presence of major associated cardiac malformations, associated left atrioventricular valve malformations, partial or absent left atrioventricular valve cleft closure, and a weight of less than 5 kg.[11]

When the left-sided atrioventricular valve requires replacement because of unacceptable degrees of regurgitation, complete atrioventricular block (as well as higher mortality) are expected.[21]

Spontaneous regression of left-sided atrioventricular valve regurgitation after the immediate postoperative period has been described, thus avoiding the need for reoperation.[15]

Surgical mortality

Depending on the surgical series, early postoperative mortality rate is less than 3% in patients with mostly uncomplicated partial AVSD.[15, 22] However, a multicenter study showed that the current survival rate from all types of AVSD repairs (in which 21.5% of patients had partial AVSDs and almost 12% had intermediate AVSDs) was 98-99%, of which 96-97% have no major complications.[23]

Poorer survival was seen in patients with major associated cardiac malformations and pulmonary hypertension, with an early postoperative mortality of 8%.[11] Poorer survival was also observed in patients who required reoperation, regardless of whether the procedure entailed AV valve repair or replacement.[19]

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Contributor Information and Disclosures
Author

M Silvana Horenstein, MD Assistant Professor, Department of Pediatrics, University of Texas Medical School at Houston; Medical Doctor Consultant, Legacy Department, Best Doctors, Inc

M Silvana Horenstein, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Michael A Portman, MD, MD Professor, Department of Pediatrics, University of Washington School of Medicine; Director of Research, Division of Cardiology, Seattle Children's Hospital; Attending Physician, Seattle Children's Heart Center; Attending Physician, Cardiology Clinic, Providence Everett Medical Center

Michael A Portman, MD, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Physiological Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Alvin J Chin, MD Emeritus Professor of Pediatrics, University of Pennsylvania School of Medicine

Alvin J Chin, MD is a member of the following medical societies: American Association for the Advancement of Science, Society for Developmental Biology, American Heart Association

Disclosure: Nothing to disclose.

Chief Editor

P Syamasundar Rao, MD Professor of Pediatrics and Medicine, Division of Cardiology, Emeritus Chief of Pediatric Cardiology, University of Texas Medical School at Houston and Children's Memorial Hermann Hospital

P Syamasundar Rao, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Paul M Seib, MD Associate Professor of Pediatrics, University of Arkansas for Medical Sciences; Medical Director, Cardiac Catheterization Laboratory, Co-Medical Director, Cardiovascular Intensive Care Unit, Arkansas Children's Hospital

Paul M Seib, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Arkansas Medical Society, International Society for Heart and Lung Transplantation, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

References
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Partial atrioventricular septal defect (AVSD): The mitral and tricuspid annuli are separate. The cleft in the mitral leaflet is in the anterior position. This type of anatomy is usually associated with a primum atrial septal defect (ASD). Partial AVSD is more common than intermediate AVSD.
Intermediate atrioventricular septal defect (AVSD): A single valve annulus is present. The anterior and posterior bridging leaflets are fused (whereas in complete AVSD the anterior and posterior bridging leaflets are not fused). Therefore, the atrioventricular valve has a tricuspid and a mitral component. Intermediate AVSD is the least common type of AVSD.
Echocardiogram of the apical 4-chamber view demonstrating a partial atrioventricular septal defect (AVSD). Chambers are denoted by RA (right atrium), RV (right ventricle), and LV (left ventricle).
Echocardiogram with subcostal view demonstrates an atrioventricular septal defect (AVSD). A portion of the ostium secundum atrial septum is also missing, just superior to the ostium primum defect.
Color Doppler demonstrates left-to-right shunting through the partial atrioventricular septal defect (AVSD) shown in the following images.
Left superior axis deviation in the frontal plane and rR' pattern in right precordial leads.
 
 
 
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