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HomePediatrics: Cardiac Disease and Critical Care MedicinePediatric Unbalanced Atrioventricular Septal Defects

Pediatric Unbalanced Atrioventricular Septal Defects

Background

Atrioventricular (AV) septal defects comprise a broad spectrum of lesions, from partial or intermediate forms with no shunting at the ventricular level to complete AV septal defects with large atrial septal defects, large ventricular septal defects (VSDs), and a single common atrioventricular valve (AVV) orifice. Instead of separate mitral and tricuspid valve inlets, a common AVV has a single inlet (orifice) into the ventricular chambers. When this common AVV opens predominantly toward one ventricle or the other, an unbalanced AV canal (AVC) or AV septal defect forms, as shown below.

Echocardiogram image revealing a left ventricular

Echocardiogram image revealing a left ventricular dominant atrioventricular (AV) canal defect.

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If the common AVV predominantly opens into the morphologic left ventricle, the defect is termed a left ventricular (LV)–type or LV-dominant AV septal defect (canal). If the common AVV opens predominantly into the morphologic right ventricle, the defect is termed a right ventricular (RV)–type or RV-dominant AV septal defect (canal). The degree of unbalance varies from mildly unbalanced with 2 nearly normal-sized ventricles to severely unbalanced with a single dominant ventricle and a second hypoplastic ventricle. This results in essentially single-ventricle physiology. Importantly, the ventricles, not the common AVV, are unbalanced. The development of the ventricles is unbalanced with hypoplasia of the inlet and outlet septum, resulting in hypoplasia of the chamber with malalignment of the ventricular septum.

Embryology

AV septal defects occur at the embryonic age of 34-36 days when fusion of the endocardial cushions fails. This occurs when the endocardial cushion fibroblasts fail to migrate normally to form the septum of the AVC. As a result, a deficiency of the primum atrial septum, the ventricular septum, the septal leaflet of the tricuspid valve, and the anterior leaflet of the mitral valve occurs. The position of the AVVs becomes lower than normal. The anterior leaflet of the AVV extends across the ventricular septum and is shared between the left and right ventricles. If the leaflet opens preferentially toward either ventricle, blood flow is limited to the other ventricle, causing hypoplasia of that ventricle and creating unbalance between the 2 ventricles.

Anatomy

Please see Atrioventricular Septal Defect, Complete and Atrioventricular Septal Defect: Surgical Perspective for general anatomic principles common to all patients with AV septal defects.

As noted above, 2 major types of unbalanced AV septal defects (canals) are recognized (ie, LV-dominant, RV-dominant). Generally, concomitant hypoplasia of the left-sided structures (LV, aortic) or the right-sided structures (RV, pulmonary artery [PA]) also occurs. Although a considerable spectrum of ventricular dominance occurs, the term unbalanced AV septal defect generally implies hypoplasia of one ventricle and its associated outflow tract with essentially single-ventricle physiology. RV-dominant AV septal defects occur more commonly than LV-dominant AV septal defects. The LV or RV is severely hypoplastic in approximately 7% of patients born with complete AVC defects.

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