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Clinical

Investigation
Discrete
Subaortic Stenosis
Surgical Outcomes and Follow-Up Results
Osman Tansel Darcin, MD Discrete subaortic stenosis, which is an obstructing lesion of the left ventricular outflow
Tahir Yagdi, MD tract, remains a surgical challenge. The recurrence rate is high despite sufficient conven-
Yuksel Atay, MD
tional resection.
Cagatay Engin, MD
Erturk Levent, MD We retrospectively reviewed the results of surgery for discrete subaortic stenosis at
Suat Buket, MD our institution from September 1995 through March 2001. Twenty-one patients with
Emin Alp Alayunt, MD this lesion underwent surgical treatment during this period. Excision of the fibromus-
cular membrane with myectomy was performed in all of the patients. Follow-up in all
patients ranged from 7 to 67 months (mean follow-up period, 39.57 ± 15.46 months).
The mean systolic gradient between the left ventricle and the aorta decreased from
59.23 ± 35.38 mmHg preoperatively to 9.47 ± 9.91 mmHg postoperatively. There was
no instance of heart block that required a permanent pacemaker, nor of bacterial en-
docarditis. There was no early or late postoperative death. A 22nd patient, who had 3+
aortic regurgitation, required aortic valve replacement and was excluded from the
study. Two of the patients (9.5%) underwent reoperation because of recurrent gradi-
ent and residual ventricular septal defect.
Our results suggest that fibromuscular membrane excision combined with myecto-
my in patients with discrete subaortic stenosis produces sufficient relief of obstruction
with low morbidity. (Tex Heart Inst J 2003;30:286-92)

C
ongenital obstruction of the left ventricular outflow tract (LVOT) affects
approximately 3% to 10% of individuals with congenital heart disease,
and discrete subaortic membrane accounts for 8% to 10% of all cases of
LVOT obstruction in children.1-3 This last condition presents as a membranous or
fibromuscular ring below the aortic valve, either in isolation or in association with
Key words: Aortic valve other congenital anomalies such as ventricular septal defect, patent ductus arterio-
stenosis/surgery; cardiac sus, coarctation of the aorta, bicuspid aortic valve, abnormal left ventricular (LV)
surgical procedures; heart
septal defects, ventricular;
papillary muscle, atrioventricular septal defect, and persistent superior left vena
myectomy; retrospective cava. The condition is rarely diagnosed antenatally or in infancy but often mani-
studies; ventricular outflow fests in the 1st decade of life with features of progressive LVOT obstruction, LV hy-
obstruction/surgery
pertrophy and dysfunction, or aortic regurgitation. The jet from the narrowed
subaortic tract damages the aortic cusps and causes regurgitation; this damage may
From: Departments of also render the aortic valve prone to infective endocarditis.4
Cardiovascular Surgery
(Drs. Darcin, Yagdi, Atay,
Treatment is usually surgical. Despite adequate resection, there is a substantial re-
Engin, Buket, and Alayunt) currence rate among patients who have undergone operation for discrete membra-
and Pediatric Cardiology nous subaortic stenosis (DSS). Although membranectomy, with or without septal
(Dr. Levent), Ege University
Hospital, Izmir, Turkey
myotomy or myectomy, has been the accepted method of treating fixed subaortic
stenosis, there are still controversies concerning operative methods and uncertain-
ties concerning the recurrence of subaortic obstruction and the development of
Address for reprints:
Yuksel Atay, MD,
aortic insufficiency after repair. Our usual approach to DSS is membrane excision
Ege University Medical with resection of the septal myocardium. In this study, we aimed to evaluate our
Faculty, Department of surgical results.
Cardiovascular Surgery,
Bornova–Izmir 35100,
Turkey Patients and Methods

E-mail:
Data Collection. All patients who underwent surgical treatment of DSS at our in-
yatay @med.ege.edu.tr stitution from September 1995 through March 2001 were included in this study.
Patients with significant valvular aortic stenosis, tunnel LVOT obstruction, or idio-
© 2003 by the Texas Heart ®
pathic hypertrophic cardiomyopathy were excluded. One patient who underwent
Institute, Houston aortic valve replacement combined with aortoventriculoplasty was excluded from

286 Discrete Subaortic Stenosis: Surgical Outcomes Volume 30, Number 4, 2003
the study. All patients were evaluated preoperatively ta); 2, mild (slightly broader jet limited to the LVOT,
and monitored for variable periods postoperatively. no ventricular enlargement, minimal or no retrograde
All patients or their families signed informed consents flow in the descending aorta, pressure half time = 400
for investigation during the study period. The case ms); 3, moderate (broad regurgitant jet extending into
histories of all patients, including patient and primary left ventricle, mild ventricular enlargement, holodia-
physician interviews and medical records, were exam- stolic retrograde aortic flow in the descending aorta,
ined retrospectively. We compiled information on pressure half time 200–400 ms); and 4, severe (wide
each patient’s age, sex, previous cardiac operation or regurgitant jet extending deep into the left ventricle,
coexisting cardiac anomaly (if any), physical signs and marked left ventricular enlargement, holodiastolic
symptoms, electrocardiography, chest radiography, retrograde flow in the descending aorta, pressure half
echocardiography, and cardiac catheterization. Echo- time <200 ms). Cardiac catheterization was per-
cardiography was performed preoperatively and at formed in 9 patients in whom no satisfactory images
regular postoperative intervals (Fig. 1). All complica- could be obtained on echocardiography. The peak
tions and reoperations were noted. gradient across the left ventricle–aorta was measured
All echocardiographic and angiocardiographic stud- by catheter pull-back and by monitoring pressures in
ies were conducted by the same pediatric cardiologist both chambers.
(EL). The maximal instantaneous gradient across the Surgical Procedure. Indications for surgery varied
LVOT was calculated from the peak spectral Doppler but included left ventricle–aorta gradient that exceed-
velocity using the modified Bernoulli equation.5 Aor- ed 30 mmHg, coexisting cardiac lesions that required
tic regurgitation was characterized as follows: 0, no operation, and echocardiographic or angiographic ev-
aortic regurgitation; 1, trivial (thin regurgitant jet seen idence of new or progressive aortic regurgitation. All
at the valve leaflets, no left ventricular distention or operations were performed by the same pediatric car-
diastolic retrograde aortic flow in the descending aor- diac surgeon (EAA) at the department of cardiac sur-
gery in Ege University Hospital. All operations were
performed with the patient on standard cardiopulmo-
A nary bypass under moderate systemic hypothermia.
Myocardial protection was achieved by means of cold
blood cardioplegia—antegrade, retrograde, or both.
After cardiopulmonary bypass was instituted, the aor-
ta was opened by an oblique aortotomy that was ex-
tended into the noncoronary sinus. After carefully
retracting the leaflets of the aortic valve, surgeons
could see the subaortic membrane (Fig. 2). They cir-
cumferentially excised both the obstructing discrete
membrane and the adjacent hypertrophied muscle.
Great care was exercised to avoid injury to the con-
duction tissue between the right and noncoronary
cusps and the anterior leaflet of the mitral valve, to
which the membrane occasionally adheres. The mean
B cardiopulmonary bypass time was 68 ± 41 minutes,
and the mean cross-clamp time was 30 ± 17 minutes.
Statistical Analysis. Results are expressed as a range,
with the mean ± SE. Group means were compared
with Student’s t-test on SPSS software (SPSS Inc.;
Chicago, Ill); a P value of less than 0.05 was consid-
ered significant.

Results
Preoperative Data. From September 1995 through
March 2001, 21 patients with DSS underwent resec-
tion of discrete subaortic stenosis alone or as part of a
Fig. 1 A) Parasternal long-axis view of the left ventricular
outflow tract shows a subaortic discrete membrane (arrow).
more comprehensive surgical procedure. The group
B) Postoperative parasternal long-axis view in the same comprised 9 female and 12 male patients who ranged
patient demonstrates relief of the subaortic stenosis. in age from 27 months to 61 years (mean age, 12.64
± 16.19 years). Three patients (14.3%) had under-

Texas Heart Institute Journal Discrete Subaortic Stenosis: Surgical Outcomes 287
persistent LSVC and the mild mitral insufficiency
A were corrected concomitantly at the time of DDS
surgery. The 2 patients with mild mitral insufficiency
did not require concomitant surgical correction. The
remaining 7 patients (33.3%) had isolated DSS, as
summarized in Table I.
Postoperative Findings. The patients underwent
postoperative follow-up that included physical exami-
nation and echocardiography. Follow-up results were
available for all patients, and length of follow-up
ranged from 7 to 67 months (mean, 39.57 ± 15.46
months). Two patients (9.5%) developed nonfatal
cardiac arrhythmia during the perioperative period
and were treated successfully. One patient (4.8%) de-
veloped acute pancreatitis during the postoperative
B period and was treated medically with complete re-
covery. Bundle branch block developed in 8 patients
during the postoperative period. No patient devel-
oped endocarditis or heart block that required a pace-
maker. There were no early or late postoperative
deaths. The early postoperative echocardiographic re-
sults showed that the membrane was completely re-
moved in all patients. At late follow-up, the systolic
gradient between the left ventricle and the aorta
ranged from 0 to 38 mmHg (mean gradient, 9.47 ±
9.91 mmHg), which was significantly lower than the
preoperative values (P <0.001) (Fig. 3). Aortic regur-
Fig. 2 Intraoperative views of A) subaortic discrete mem- gitation was also evaluated by means of echocardi-
brane (arrow) and B) left ventricular outflow tract after ography during the postoperative period. It decreased
membranectomy. in 8 patients (38.1%) and progressed in 4 patients
(19%). The aortic competence in the remaining 9 pa-
tients (42.9%) was unchanged. Two patients (9.5%)
required reoperation: 1 patient had recurrent DSS,
gone a previous cardiac surgical procedure: ventricular and 1 patient required closure of a recurrent ventricu-
septal defect (VSD) closure in 1; coexisting VSD clo- lar septal defect, which had been repaired at the time
sure and right ventricular outflow tract (RVOT) ste- of DSS resection.
nosis repair in 1; and coexisting atrial septal defect Symptoms of the patients were relieved completely
(ASD) and VSD closure in 1. during the early postoperative period, except for pal-
Eight patients (38.1%) were noted to be sympto- pitation in 1 patient, which resolved with medical
matic: 4 patients showed diminished exercise toler- therapy.
ance, 1 had palpitations, and 1 had syncopal episodes.
The remaining 13 patients (61.9%) were asympto- Discussion
matic. On physical examination, all 21 patients re-
vealed systolic ejection murmurs, and 15 had diastolic Discrete subaortic stenosis is a manifestation of a geo-
murmurs of aortic regurgitation. The left ventricle– metric anatomic alteration in the LVOT. This endo-
aorta gradient ranged from 14 to 155 mmHg (the cardial abnormality involves not only the subaortic
mean gradient was 59.23 ± 35.38 mmHg). Eleven ridge but also the leaf lets of the adjacent valves.1
patients had 1+ aortic regurgitation, and 4 patients Although substantial pressure gradient and aortic re-
had 2+ aortic regurgitation. Two patients had mild gurgitation are the main indications for surgery, con-
mitral insufficiency. No patient had endocarditis pre- troversy persists about the timing of surgical repair
operatively. and the surgical technique.3,5
Of the 21 patients, 15 (71.4%) had coexisting car- Unlike valvular aortic stenosis, DSS seems to be ac-
diac lesions. Of these, 6 patients had a VSD, 3 had quired, because it is almost never present at birth. It is
RVOT stenosis, 2 had a patent foramen ovale (PFO), believed that obstruction in this instance is a conse-
2 had persistent left superior vena cava (LSVC), and 2 quence of some abnormality of ventricular motion,
had mild mitral insufficiency. All conditions but the growth, hypertrophy, or a combination of these fac-

288 Discrete Subaortic Stenosis: Surgical Outcomes Volume 30, Number 4, 2003
TABLE I. Summary of Patient Data

Preoperative Data Postoperative Data

LV–Ao LV–Ao Grad. at


Pt. Gradient Associated Follow-Up Late Follow-Up Endo-
No. Age/Sex (mmHg) AI Procedures (mo) (mmHg) AI carditis Reoperation

1 4 y 3 mo/M 14 1+ VSD closure, 7 0 1+ No Yes (recur-


resection, rent DSS)
RVOT stenosis

2 5 y/M 85 1+ PDA ligation 52 38 2+ No No

3 12 y/F 51 1+ PFO closure 52 11 1+ No No

4 6 y/M 46 0 None 42 0 0 No No

5 2 y 3 mo/F 18 0 VSD closure 47 7 1+

6 7 y/F 62 1+ VSD closure 63 10 0

7 4 y/M 90 1+ Resection, 21 5 0 No No
RVOT stenosis

8 5 y/F 65 0 None 58 15 1+ No No

9 11 y/M 35 1+ None 31 0 0 No No

10 19 y/M 95 2+ None 38 0 2+ No No

11 5 y/F 73 2+ Persistent LSVC 42 12 1+ No No

12 5 y/F 15 2+ VSD closure 27 5 2+ No No

13 56 y/M 120 1+ None 67 30 0 No No

14 4 y/F 60 1+ None 42 13 0 No No

15 9 y/M 38 1+ VSD closure, 27 0 0 No Yes (recur-


resection, rent VSD)
RVOT stenosis

16 5 y/M 35 1+ PDA ligation 48 10 1+ No No

17 5 y/M 50 0 Persistent LSVC 24 10 1+ No No

18 61 y/F 55 2+ None 33 10 2+ No No

19 25 y/M 22 0 VSD closure 56 5 0 No No

20 5 y/M 60 1+ None 24 0 0 No No

21 10 y/F 155 0 PFO closure 30 18 0 No No

AI = aortic insufficiency; Ao = aorta; DSS = discrete subaortic stenosis; F = female; Grad. = gradient; LSVC = left superior vena
cava; LV = left ventricle; M = male; PDA = patent ductus arteriosus; PFO = patent foramen ovale; RVOT = right ventricular out-
flow tract; VSD = ventricular septal defect

tors.1,3,4,6 -8 An abnormal angle between the muscular myopathic component. In the vast majority of cases,
and conical ventricular septum appears to be an im- LV hypertrophy regresses after relief of the outflow
portant causative factor, but a definitive cause has not obstruction, as would be expected in a patient with
been established.9-11 valvular aortic stenosis. We are convinced that DSS
Various theories about the cause of DSS—congeni- has multifactorial causes.
tal, inflammatory, genetic, and acquired—have been Discrete subaortic stenosis is sometimes associated
proposed.3,12 Some investigators have considered the with various other cardiac malformations1- 4, 7,8 that
disease to be a form of cardiomyopathy,13 and there must be monitored and treated surgically when neces-
are patients with DSS who develop an unusually pro- sary. Chung and colleagues14 reviewed the cases of 8
found LV myocardial hypertrophic response. More patients, aged 1 to 8 years, who had VSD in combi-
often, however, there appears to be no global cardio- nation with various other cardiac lesions, but no evi-

Texas Heart Institute Journal Discrete Subaortic Stenosis: Surgical Outcomes 289
be progressive. The aortic regurgitation appears to be
due to thick fibrous tissue on the left ventricular sur-
face of the valve leaf lets. The fibrosis is caused by
repetitive trauma from a jet of blood through the
stenosis or by the proliferation of the fibroelastic
membrane itself. This fibrous tissue can play an im-
portant role in the retraction of the valve leaflets.17 Al-
though an important study found no benefit in early
surgery and a higher prevalence of aortic regurgitation
in surgically treated patients,18 we think that early sur-
gery may preserve the integrity of the aortic valve in
such a manner as to avoid later valve replacement.
Aortic insufficiency can progress postoperatively de-
Fig. 3 Postoperative changes in left ventricle–aorta (LV–Ao) spite relief of the LVOT stenosis of DSS, but our op-
peak gradient. erative results and early follow-up tend to support the
conclusion that worsening of the regurgitation in DSS
can be slowed or stopped with adequate resection of
DSS. This has been affirmed by various other stud-
dence of DSS. They operated on 6 of these patients ies.3-5,15,16
for the associated lesions, but none required closure of Although DSS has been treated surgically for many
the VSD. In 6 of the 8 patients, the VSD closed spon- years,1, 7 the optimal operative management and the
taneously, and in the remaining 2 there was a small timing of surgery remain controversial.5,12 Many au-
residual VSD. Subsequent serial echocardiography thors have suggested surgery for patients who have left
showed evidence of a subaortic membrane, which was ventricle–aorta gradients that exceed 30 mmHg or a
confirmed by catheterization and then by surgical re- coexisting cardiac defect that requires surgical correc-
section in 5 patients. They concluded that DSS might tion,1,5,8 while others advocate surgical resection for
develop in patients with small or spontaneously closed DSS of any degree because of concerns about the de-
VSDs. Rayburn and associates3 recorded 3 cases of velopmental role that subaortic stenosis may play in
VSD in their DSS patients and closed all of the de- aortic insufficiency.12,18 This earlier intervention for
fects. We encountered 6 cases of VSD in our patients DSS can prevent the development of abnormal mus-
who had DSS, and we closed all of the ventricular cular hypertrophy and can reduce the occurrence of
defects during resection of the fibromuscular mem- aortic regurgitation. It also protects patients from bac-
brane. We also resected 3 stenoses of the RVOT, li- terial endocarditis.1-3,5, 7
gated 2 patent ducti arteriosi (PDAs), and closed 2 The optimal surgical method for patients with DSS
PFOs. Discrete subaortic stenosis can sometimes re- is debatable.3,5 Although some surgeons prefer enu-
quire direct procedures to enlarge the LVOT, especi- cleation of the discrete membrane and in selected pa-
ally when DSS coexists with the diffuse type of LVOT tients its fibromuscular ridge,8 many others believe
stenosis. Such a procedure is generally conducted as that a routine myectomy is adequate to eliminate re-
an aortoventriculoplasty.1,15 We performed it in the currence. The latter, however, confirm that surgery is
patient who underwent aortic valve replacement and not sufficient without resection of hypertrophied
was subsequently excluded from this study. muscle.5,19 We too resected adjacent hypertrophied
Although the most common symptom in patients muscle during resection of fibrous membrane in all of
with DSS is diminished exercise tolerance, they may our patients. Limited septal muscle resection can re-
also have syncope or angina pectoris.1,3,4 It should be lieve obstruction of the LVOT in some patients, but a
remembered that most patients are asymptomatic, more aggressive approach must be taken when the
even in the presence of important gradients that in- pathologic condition requires it. Some of the residual
dicate surgery.1,3,8 Rayburn and colleagues3 confirmed perioperative left ventricular–aortic gradients in pa-
that 70% of their patients had no symptoms, but the tients with discrete subaortic stenosis undergoing
proportion varies from series to series. Kuralay and co- repairs are dynamic and transient, and are probably
workers16 reported that 64.4% of their patients had related to increased sympathetic activity following
exertional dyspnea. In our series, 8 patients (38.1%) surgery. However, persistent dynamic obstruction was
were noted to be symptomatic, and the remaining 13 found in 44% of patients after removal of discrete
(61.9%) were asymptomatic. subaortic obstruction.13 Several groups have reported
Apart from congenital cardiac abnormalities, ac- the need for repeat myectomy to relieve obstruction
quired aortic insufficiency is the most common lesion after the successful removal of subaortic membrane.
found in association with DSS, and it can of course Because the fibrous tissue that retracts the aortic valve

290 Discrete Subaortic Stenosis: Surgical Outcomes Volume 30, Number 4, 2003
leaflets remains, there can be no improvement in the that have used only membranectomy. However, our
aortic regurgitation after surgery. Radical excision of follow-up period was relatively short, and our con-
all diseased tissue, which attains a minimal early post- cept has never been tested in a prospective, random-
operative gradient, may reduce the occurrence of late ized trial. Due to the infrequent occurrence of this
aortic regurgitation.20 However, this more aggressive disease, our conclusions are drawn from retrospective
approach increases the risk of iatrogenic damage to study. We must await the long-term results in these
the conduction tissue, ventricular septum (VSD), and same patients before our approach can be justified. In
mitral valve. Kuralay and coworkers16 have reported conclusion, we believe that a larger number of pa-
fewer complications, such as conduction tissue injury, tients, longer follow-up by the pediatric cardiologist,
when myectomy is guided by transesophageal echo- and close collaboration with the pediatric cardiac sur-
cardiography. We believe that the risk of developing geon will be necessary to support this management.
heart block that requires permanent pacing is mini-
mal when the surgeon takes great care to avoid injury
to the conduction tissue between the right and non- References
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292 Discrete Subaortic Stenosis: Surgical Outcomes Volume 30, Number 4, 2003