Complete Atrio Ventricular Canal and Tetralogy of Fallot

The surgical challenge of this uncommon anomaly is related to aortic overriding and the resulting necessity to place the VSD patch more anteriorly and around the aortic valve annulus in order to construct an unobstructed left ventricle to aorta tunnel. I prefer using a two-patch technique for this repair. With such, the dimensions of the VSD patch of appropriate size and shape are more easily predicted. In most cases the complete repair can be performed working only through a right atriotomy while retracting AV valve leaflets. If the cephalad end of the VSD is difficult to repair through this exposure, a high right ventriculotomy should be performed for completion of the repair. When there is right ventricular outflow tract hypoplasia, a transannular outflow tract patch is used rather than the placement of a homograft valved conduit even though early after surgery ventricular performance may be somewhat compromised by pulmonary insufficiency. This disadvantage is offset by avoiding the need for homograft valve exchange due to patient growth, which would be necessary in most patients. If right ventricular dilatation and failure occur some years later, a valve can be placed at this time.

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main pulmonary artery aorta

Figure 4-55. In this anomaly, the aorta is located more anteriorly than normal and overrides the ventricular septum. The pulmonary valve and main pulmonary artery here are moderately hypoplastic.

Septal Defect

atrial septal defect common anterior AV valve leaflet ventricular septal defect

Figure 4-56. After cardiopulmonary bypass is established, and cardiac standstill achieved with aortic clamping and cardioplegia, a right atriotomy is made. The common anterior AV valve leaflet is free floating and undivided (Rastelli Type C), which is the usual case in this anomaly. A high VSD is in continuity with a low primum ASD.

atrial septal defect common anterior AV valve leaflet ventricular septal defect

Figure 4-56. After cardiopulmonary bypass is established, and cardiac standstill achieved with aortic clamping and cardioplegia, a right atriotomy is made. The common anterior AV valve leaflet is free floating and undivided (Rastelli Type C), which is the usual case in this anomaly. A high VSD is in continuity with a low primum ASD.

Determing Type Canal

common posterior AV valve leaflet caud

Figure 4-57. The common posterior AV valve leaflet is well formed and undivided. It is attached to the upper margin of the ventricular septum by multiple chordae.

common posterior AV valve leaflet caud

Figure 4-57. The common posterior AV valve leaflet is well formed and undivided. It is attached to the upper margin of the ventricular septum by multiple chordae.

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Complete Canal Leaflet Anatomy

ventricular septum

Figure 4-58. The common anterior AV valve leaflet is retracted. The VSD is located in the upper ventricular septum. With overriding of the aorta, the aortic valve is located, in part, over the right ventricle.

ventricular septum caud

Figure 4-58. The common anterior AV valve leaflet is retracted. The VSD is located in the upper ventricular septum. With overriding of the aorta, the aortic valve is located, in part, over the right ventricle.

Overriding Sutures

ventricular septal defect closure stitches

Figure 4-59. Interrupted multifilament mattress sutures with Teflon® felt pledgets are placed along the upper margin of the ventricular septum. Posteriorly, stitches are more superficial and slightly remote from the VSD to avoid the area of conductive tissue, which is located in this region. Anteriorly, stitches are placed as far as the exposure will allow. The final VSD closure stitches at the anterior extreme of the VSD will subsequently be placed working through a high right ventriculotomy.

ventricular septal defect closure stitches caiid

Figure 4-59. Interrupted multifilament mattress sutures with Teflon® felt pledgets are placed along the upper margin of the ventricular septum. Posteriorly, stitches are more superficial and slightly remote from the VSD to avoid the area of conductive tissue, which is located in this region. Anteriorly, stitches are placed as far as the exposure will allow. The final VSD closure stitches at the anterior extreme of the VSD will subsequently be placed working through a high right ventriculotomy.

Tetralogy Fallot Repair Images

common anterior AV valve leaflet patch closing ventricular septal defect common posterior AV valve leaflet

Figure 4-60. The VSD repair stitches have been placed in a Dacron® patch and tied. This patch is wider and more redundant at the anterior end beneath the common anterior AV valve leaflet, which is necessary because the anterior end of the VSD incorporates the aortic valve. Additional patch material is needed to stitch around the annulus of the valve that is located in the right ventricle.

common anterior AV valve leaflet patch closing ventricular septal defect common posterior AV valve leaflet caud

Complete Canal Leaflet Anatomy

Figure 4-61. Sutures are then passed through the upper rim of the VSD patch adjacent to the AV valve leaflets. The stitches are passed through the valve to separate this into separate mitral and tricuspid components.

caud stitches from upper rim of VSD patch passed through AV valve leaflets

Figure 4-61. Sutures are then passed through the upper rim of the VSD patch adjacent to the AV valve leaflets. The stitches are passed through the valve to separate this into separate mitral and tricuspid components.

Complete Canal Leaflet Anatomy

valve separating sutures cleft in new anterior mitral valve leaflet

Figure 4-62. A cleft is now created by approximating adjacent mitral portions of the common anterior and common posterior AV valve leaflets, respectively. The VSD patch is seen beneath the valve leaflets while the valve separating sutures pass through the AV valve leaflets.

valve separating sutures cleft in new anterior mitral valve leaflet

Figure 4-62. A cleft is now created by approximating adjacent mitral portions of the common anterior and common posterior AV valve leaflets, respectively. The VSD patch is seen beneath the valve leaflets while the valve separating sutures pass through the AV valve leaflets.

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Stitch Close Vsd

repaired cleft

Figure 4-63. Multiple stitches are used to close the cleft in the new anterior mitral leaflet.

repaired cleft ceph

Figure 4-63. Multiple stitches are used to close the cleft in the new anterior mitral leaflet.

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Tetralogy Fallot Patch

Figure 4-64. A second Dacron® patch is cut to conform to the ASD. The AV valve separating stitches are placed in the base of this patch and tied. Additional stitches are placed beneath the coronary sinus and then passed through the posterior margin of the new patch. These stitches are placed superficially and in tissue nearer the adjacent mitral valve leaflet in order to avoid the His' bundle.

VSD patch

ASD patch stitches beneath coronary sinus

Figure 4-64. A second Dacron® patch is cut to conform to the ASD. The AV valve separating stitches are placed in the base of this patch and tied. Additional stitches are placed beneath the coronary sinus and then passed through the posterior margin of the new patch. These stitches are placed superficially and in tissue nearer the adjacent mitral valve leaflet in order to avoid the His' bundle.

Coronary Sinus Asd
ASD patch

stitches beneath coronary sinus caud

Figure 4-65. The aortic cross-clamp is removed and warming commenced. After sinus rhythm is observed, the stitches beneath the coronary sinus are tied. If these injure the His' bundle, tissue heart block will be observed immediately on the electrocardiogram (EKG) tracing and the stitches are replaced. The upper rim of the ASD patch is then stitched to the margin of the ASD.

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Figure 4-65. The aortic cross-clamp is removed and warming commenced. After sinus rhythm is observed, the stitches beneath the coronary sinus are tied. If these injure the His' bundle, tissue heart block will be observed immediately on the electrocardiogram (EKG) tracing and the stitches are replaced. The upper rim of the ASD patch is then stitched to the margin of the ASD.

stitches beneath coronary sinus

Main Pulmonary Artery

main pulmonary artery ventriculotomy

Figure 4-66. In this child, it was not possible to repair the anterior and cephalad end of the VSD working through the atriotomy. In addition, the right ventricular outflow tract was restrictive due to infundibular muscle obstruction and a small pulmonary valve annulus, so a high right ventriculotomy is made.

main pulmonary artery ventriculotomy

Figure 4-66. In this child, it was not possible to repair the anterior and cephalad end of the VSD working through the atriotomy. In addition, the right ventricular outflow tract was restrictive due to infundibular muscle obstruction and a small pulmonary valve annulus, so a high right ventriculotomy is made.

Tetralogy Fallot Patch
Figure 4-67. The upper end of the VSD patch is seen and additional stitches are placed to attach this end of the patch to the ventricular septum.
Infundibular Vsd Patch Picture

main pulmonary artery tissue outflow tract patch

Figure 4-68. The right ventricular outflow tract is restrictive above the infundibulum and the ventriculotomy is extended across the pulmonary valve annulus and proximal main pulmonary artery. A pericardial patch is used here to suture over the right ventricular outflow tract for reconstruction. Currently, a Gore-Tex® patch or a homograft pulmonary artery wall patch is preferred in this position.

main pulmonary artery tissue outflow tract patch

Figure 4-68. The right ventricular outflow tract is restrictive above the infundibulum and the ventriculotomy is extended across the pulmonary valve annulus and proximal main pulmonary artery. A pericardial patch is used here to suture over the right ventricular outflow tract for reconstruction. Currently, a Gore-Tex® patch or a homograft pulmonary artery wall patch is preferred in this position.

Right Ventricle Homograft

Figure 4-69. The completed outflow tract reconstruction is shown with the placed over the upper right ventricle and proximal main pulmonary artery.

patch in outflow tract

Figure 4-69. The completed outflow tract reconstruction is shown with the placed over the upper right ventricle and proximal main pulmonary artery.

tissue patch

Ventricular

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