Modified Konno Procedure

Modified Konno Procedure

In some patients, the left ventricular outflow tract is narrow and local tissue resection alone is inadequate to relieve the obstruction. A modified Konno procedure can be used in this diverse group of patients, which includes tunnel-like stenosis, stenosis in patients after total repair of complete atrio-ventricular AV canal, and some cases of hypertrophic cardiomyopathy. The geometry of the outflow tract is altered by full thickness resection of the ventricular septum working through a right...

Valved Conduit Repair

What Arteries Comes From Posterior Aorta

Operations are carried out with cardiopulmonary bypass, moderate hypothermia, aortic clamping, cardioplegia, and profound local cardiac cooling. In most cases, repair is performed with a valved conduit placed in the right of the heart otherwise residual pulmonary hypertension that may be present after surgery may result in significant pulmonary regurgitation and right heart failure. 17-1-1. Repair with Porcine-Valved Conduit These conduits are readily available in various sizes however, the...

Double Switch Operation

Eustachian Valve

When a VSD is present, the double-switch operation is becoming popular for anatomic repair of corrected transposition. With both a venous switch procedure and a ventriculoarterial connection switch, the morphologic left ventricle is placed in the systemic circulation and the morphologic right ventricle in the pulmonary circulation. I prefer the Senning operation for the venous switch over the Mustard procedure in that the former uses natural landmarks to position various suture lines. This...

Obstruction of Bulboventricular Foramen

Damus Procedure

In the presence of single ventricle with d- or 1-transposition of the great arteries and obstruction of a bulboventricular foramen that separates the ventricle and aorta, ventricular hypertension occurs that must be relieved to preserve ventricular function. Two techniques are used. In the first, the proximal-divided main pulmonary is attached to the ascending aorta Damus procedure , creating a double outlet ventricle to bypass the obstruction. With the second technique, subaortic obstruction...

Arterial Switch Jatene Operation

Aortic Dissection Right Coronary Artery

Arterial switch repair is the preferred operation for d-transposition of the great arteries without severe anatomic left ventricular outflow tract narrowing or when such narrowing can be treated with resection. Other surgical repairs are rarely performed. The traditional contraindication to its use is the presence of an abnormal pulmonary valve, which would become the aortic valve after repair, although today one would consider combining a form of the Ross procedure and arterial switch...

Pulmonary Artery Banding and Band Removal at Subsequent Total Repair

Pulmonary Artery Banding Surgery

In the presence of a large left-to-right shunt, pulmonary artery banding may be indicated to protect the lungs and to avoid development of pulmonary vascular obstructive disease when total repair of intracardiac anomalies is not possible or should be delayed until an older age. Banding can be performed through a left or right thoracotomy or median sternotomy, regardless of the position of the great vessels. Ideally, it is carried out through a fourth interspace lateral thoracotomy on the side...

Pulmonary Vein Stenosis

Cor Triatriatum Repair

This rare anomaly occurs at the entrance of pulmonary veins to the left atrium. Because of the severe consequences of pulmonary venous hypertension, including congestive heart failure and or pulmonary vascular obstructive disease, surgery to repair this lesion is indicated immediately after discovery, regardless of the age of the patient. Direct repair of the pulmonary vein is performed in the presence of mild-to-moderate stenosis. An alternative repair is sutureless with stitches placed in...

Aortic Root Enlargement Procedures

Konno Procedure

With cardiopulmonary bypass, aortic clamping, and cardioplegia with profound local cardiac cooling, a proximal ascending aortotomy is made. A bicuspid stenotic and dysplastic valve is seen. After it is determined that valvuloplasty is not possible, the valve leaflets are excised. Figure 14-47. With cardiopulmonary bypass, aortic clamping, and cardioplegia with profound local cardiac cooling, a proximal ascending aortotomy is made. A bicuspid stenotic and dysplastic valve is seen....

Ventricular Septum

Pulmonary Valve Atresia

Infants born with this anomaly have inadequate pulmonary blood flow caused by pulmonary valve atresia and severe right ventricular hypertension, unless tricuspid insufficiency allows decompression of the ventricle. Initial resuscitation includes maintenance of ductus arteriosus patency with prostaglandin E Right ventricular size may vary from severe hypoplasia to a near normal size, depending on when in fetal development the pulmonary valve became atretic. If it was late in cardiac development,...

Palliation and Repair of Tetralogy of Fallot with Absent Pulmonary Valve Syndrome

Superior Vena Cava Syndrome

Infants born with this rare syndrome may develop aneurysmal dilatation of the main pulmonary artery and or its branches this may cause tracheal and bronchial obstruction resulting in severe respiratory distress. In the rare case when totally corrective surgery cannot be undertaken, airway obstruction may be relieved by translocating the offending right or left pulmonary artery from the posterior to the anterior mediastinum. This operation is largely of historic interest but emphasizes the...

Repair of Shunts

Picture Left Pulmonary Arter

Previously constructed systemic-to-pulmonary artery shunts must be closed at the time of total corrective surgery. 9-5-1. Classic Right Blalock-Taussig Shunt Figure 9-51. The subclavian artery trunk of the right Blalock-Taussig shunt is usually easy to identify medial to the superior vena cava while working within the pericardial space. Figure 9-51. The subclavian artery trunk of the right Blalock-Taussig shunt is usually easy to identify medial to the superior vena cava while working within...

First Stage Fontan Procedure

Atrial Septectomy

Before cardiopulmonary bypass, extensive dissection is performed. The ascending aorta and main pulmonary artery are freed from surrounding tissue to allow division of the proximal main pulmonary artery. The left pulmonary artery is mobilized, and the right pulmonary artery is dissected to facilitate the superior vena cava-right pulmonary arterial anastomosis. The entire superior vena cava is dissected to near the inominate vein, allowing high caval cannulation and lower caval exposure for the...

Late Pulmonary Valve Placement after Tetralogy Repair with a Transannular Patch

Transanular Patch

Placement of a transannular patch is necessary in some patients during tetralogy repair but this results in pulmonary regurgitation. Although many patients tolerate this indefinitely, 30 to 40 will require later valve placement. A pulmonary homograft valved conduit is the replacement of choice. Indications for surgery include progressive right ventricular dilatation and dysfunction, paradoxical septal motion, and flattening of the septum, which may result in left ventricular dysfunction and or...

Isolated Secundum Atrial Septal Defect

Cavoatrial Junction Images

The child has been placed on cardiopulmonary bypass, and a mid right atriotomy is made. The region of the cavoatrial junction is spared to avoid injury to the sinoatrial S A node. A large secundum atrial septal defect can be seen in the region of the fossa ovalis. A metal sucker is in the defect. Because the septal tissue that surrounds the ASD is substantial, it can be closed primarily. It is important to inspect the atrial chambers to rule out other anomalies and the orifices of...

Total Anomalous Pulmonary Venous Connection

Left Atrial Appendage Anatomy

Total repair is carried out soon after establishing the diagnosis and medical stabilization of the patient. The procedure can be emergent shortly after birth when there is obstruction of the common pulmonary venous channel as with a subdiaphragmatic connection , or in the early days of life when there is obstruction at the atrial septal level supracardiac or intracardiac connection . When there is no obstruction to pulmonary venous return, surgery is required in the early weeks of life because...

Total Repair of Simple Tetralogy of Fallot Transventricular

Anterior Muscular Vsd

Surgery is carried out with cardiopulmonary bypass, moderate hypothermia, aortic clamping with cardioplegia, and profound local cardiac cooling. Repair of pulmonary stenosis and the ventricular septal defect VSD are performed through a short high right ventriculotomy in the infundibulum, which is positioned to avoid division of coronary branches. If the pulmonary valve annulus is restrictive and a transannular patch is anticipated, a longitudinal or oblique ventriculotomy is made that is...

Infundibular Stenosis and Double Chamber Right Ventricle

Right Ventricular Infundibulum Resection

Repair is performed with cardiopulmonary bypass, aortic clamping, cardioplegic arrest, and profound local cardiac cooling. Figure 7-3. In this patient, after cardiopulmonary bypass is established, a proximal main pulmonary arteriotomy is made. There are three leaflets with stenotic commissures, and the valve is dysplastic. All leaflets are fibrous with limited mobility. Incising the stenotic commissures alone will not relieve the obstruction, because the leaflets are bulky and will not...

Palliative Shunts and Outflow Tract Reconstruction

Branches The Subclavian Artery

Classic Blalock-Taussig Subclavian Artery to Pulmonary Artery Shunt This operation is rarely performed because most surgeons prefer the more predictable modified Blalock shunt. It may still be useful in cases when the shunt is the end point of treatment because the subclavian artery trunk will grow with the patient. This procedure is ideally performed by working through a lateral fourth intercostal space thoracotomy on the side ipsilateral to the innominate artery. Postoperative...

Subpulmonary Ventricular Septal Defect

Pledget Sutures

Subpulmonary ventricular septal defects are located high in the ventricular septum and immediately below the pulmonary valve. Myocardial relaxation with cardioplegic arrest allows the upper septum to be retracted inferiorly, so that many subpulmonary defects can be closed completely through the transatrial approach. In many cases, an aortic valve cusp is intimate with the rim of this ventricular defect and care must be used to avoid damage to the valve. If exposure through the atrium is not...

Repair of Hypoplastic Right Ventricular Outflow Tract

Pictures Plastic Pulimonary Arteries

Although there are advantages and disadvantages of outflow tract patching across the pulmonary valve annulus, adequate relief of outflow tract blockage is an important component of total repair operations for tetralogy of Fallot. A competent pulmonary valve with minimal or no residual outflow tract blockage is ideal. Significant residual pulmonary stenosis results in increased morbidity and mortality, so that a transanular patch is indicated when the valve annulus is severely restrictive....

Complete Atrioventricularis Communis or Atrio Ventricular Canal

Intracardiac Repair For Vsd

Ventricular septal defect beneath AV valve leaflets Figure 4-15. Exposure is through a right atriotomy. A primum ASD is in the lower or caudad part of the atrial septum, and it is in continuity with a high VSD located beneath the flaccid AV valve leaflets. In this child, a secundum ASD is also present. ventricular septal defect beneath AV valve leaflets Figure 4-15. Exposure is through a right atriotomy. A primum ASD is in the lower or caudad part of the atrial septum, and it is in continuity...

Common Atrium

Close Cleft Mitral Valve

The child has been placed on cardiopulmonary bypass, and the view is looking through a right atriotomy. There is no atrial septum, and the orifices of the left atrial appendage and right pulmonary veins are seen in the posterior wall of the common atrial chamber. The mitral valve is anterior to the left atrial appendage. Figure 4-8. The child has been placed on cardiopulmonary bypass, and the view is looking through a right atriotomy. There is no atrial septum, and the orifices of...