Complete Atrioventricularis Communis or Atrio Ventricular Canal

Ventricular Septal Defect

primum atrial septal defect ventricular septal defect beneath AV valve leaflets secundum atrial septal defect

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.

primum atrial septal defect ventricular septal defect beneath AV valve leaflets caud

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.

secundum atrial septal defect

Chemistry Septum

common anterior leaflet of AV valve chord attaching common anterior leaflet to ventricular septum ventricular septum tricuspid orifice mitral orifice common posterior leaflet of AV valve

Figure 4-16. The common anterior leaflet of the AV valve or anterior bridging leaflet extends over the tricuspid and mitral valve orifices. Similarly, the common posterior leaflet or posterior bridging leaflet of the AV valve extends over both valve orifices. There is no fibrous annular continuity of the mitral and tricuspid valves. Here, there are chordae that attach the common anterior leaflet to the ventricular septum (Type A AV Canal by the Rastelli classification).

common anterior leaflet of AV valve chord attaching common anterior leaflet to ventricular septum ventricular septum tricuspid orifice

Figure 4-16. The common anterior leaflet of the AV valve or anterior bridging leaflet extends over the tricuspid and mitral valve orifices. Similarly, the common posterior leaflet or posterior bridging leaflet of the AV valve extends over both valve orifices. There is no fibrous annular continuity of the mitral and tricuspid valves. Here, there are chordae that attach the common anterior leaflet to the ventricular septum (Type A AV Canal by the Rastelli classification).

mitral orifice common posterior leaflet of AV valve caud

Rastelli Operation

right ventricular papillary muscle

Figure 4-17. In this child, there are chordal attachments from the common anterior leaflet only to a papillary muscle in the right ventricle (Type B AV Canal by the Rastelli classification).

chorda I attachments of common anterior leaflet of AV valve are only to RV papillary muscle right ventricular papillary muscle caud

Figure 4-17. In this child, there are chordal attachments from the common anterior leaflet only to a papillary muscle in the right ventricle (Type B AV Canal by the Rastelli classification).

Complete Canal Leaflet Anatomy

ventricular septum free floating common anterior leaflet of AV valve without chordal attachments to ventricular septum ventricular septum

Figure 4-18. The common anterior leaflet is free floating with no chordal attachments to the ventricular septum (Type C Complete AV Canal by the Rastelli classification).

Figure 4-18. The common anterior leaflet is free floating with no chordal attachments to the ventricular septum (Type C Complete AV Canal by the Rastelli classification).

4 Endocardial Cushion Defects 47 4-4-1. Complete Atrio-Ventricular Canal: Patch Repair

Endocardial Cushion Defect

undivided common anterior leaflet

Figure 4-19. The common anterior leaflet of the AV valve is undivided. When the one-patch technique for repair is used, this leaflet is surgically divided to the annulus, leaving slightly more tissue on the mitral valve portion of the leaflet.

undivided common anterior leaflet

Figure 4-19. The common anterior leaflet of the AV valve is undivided. When the one-patch technique for repair is used, this leaflet is surgically divided to the annulus, leaving slightly more tissue on the mitral valve portion of the leaflet.

Mitral Valve Cleft

common anterior leaflet of AV valve

Figure 4-20. The common anterior leaflet of the AV valve in this child is naturally divided. The cleft or division in this valve may be used in the one-patch repair. If the mitral valve is deficient, the natural cleft may be closed in favor of a surgically created division toward the tricuspid valve portion of the leaflet so as to enlarge the mitral portion of the leaflet.

common anterior leaflet of AV valve

Figure 4-20. The common anterior leaflet of the AV valve in this child is naturally divided. The cleft or division in this valve may be used in the one-patch repair. If the mitral valve is deficient, the natural cleft may be closed in favor of a surgically created division toward the tricuspid valve portion of the leaflet so as to enlarge the mitral portion of the leaflet.

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Anterior Posterior Repair

common anterior leaflet of AV valve common posterior leaflet of AV valve

Figure 4-21. The common posterior leaflet of the AV valve may be naturally divided (less common) or in this case surgically divided to near the posterior annulus. The common anterior leaflet was also surgically divided. This is the first step in the one-patch repair of complete AV canal.

common anterior leaflet of AV valve common posterior leaflet of AV valve caud

Figure 4-21. The common posterior leaflet of the AV valve may be naturally divided (less common) or in this case surgically divided to near the posterior annulus. The common anterior leaflet was also surgically divided. This is the first step in the one-patch repair of complete AV canal.

Complete Canal

mitral portion of common anterior leaflet mitral portion of common posterior leaflet

Figure 4-22. The mitral portions of the common anterior leaflet and common posterior leaflet, respectively, have been approximated with interrupted sutures placed at the extremes of the mitral leaflet repair. Ideally the mitral valve is closed to the free margin of the new leaflet, and the proposed mitral orifice is measured with sizers after repair to prevent iatrogenic mitral stenosis.

caud mitral portion of common anterior leaflet mitral portion of common posterior leaflet

Figure 4-22. The mitral portions of the common anterior leaflet and common posterior leaflet, respectively, have been approximated with interrupted sutures placed at the extremes of the mitral leaflet repair. Ideally the mitral valve is closed to the free margin of the new leaflet, and the proposed mitral orifice is measured with sizers after repair to prevent iatrogenic mitral stenosis.

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Anterior Posterior Repair

mitral portion of common anterior leaflet mitral portion of common posterior leaflet

Figure 4-23. The mitral leaflet repair is completed with simple interrupted sutures. The newly constructed anterior mitral valve leaflet is now free floating. The new mitral orifice must be carefully measured using sized dilators. The opening is compared to a normal valves based on body surface area to avoid excessive closure of the valve, which may result in iatrogenic mitral stenosis.

mitral portion of common anterior leaflet caud

Figure 4-23. The mitral leaflet repair is completed with simple interrupted sutures. The newly constructed anterior mitral valve leaflet is now free floating. The new mitral orifice must be carefully measured using sized dilators. The opening is compared to a normal valves based on body surface area to avoid excessive closure of the valve, which may result in iatrogenic mitral stenosis.

mitral portion of common posterior leaflet

Ventricular Septal Defect Surgery

new anterior mitral leaflet ventricular septum ventricular septal defect

Figure 4-24. The new anterior mitral leaflet is lifted to expose the ventricular septal defect beneath. To close the VSD, felted horizontal mattress sutures will be placed on the right ventricular surface of the upper rim of the ventricular septum.

new anterior mitral leaflet ventricular septum ventricular septal defect

Figure 4-24. The new anterior mitral leaflet is lifted to expose the ventricular septal defect beneath. To close the VSD, felted horizontal mattress sutures will be placed on the right ventricular surface of the upper rim of the ventricular septum.

Knitted Dacron

region of His' bundle sutures beneath coronary sinus

Figure 4-25. A knitted Dacron® patch is cut to conform to the size and shape of the VSD and primum ASD. Stitches previously placed in the upper rim of the ventricular septum are placed in the lower rim of the Dacron® patch and tied. The most posterior ventricular septal defect stitches are near the His' bundle and should be placed slightly remote from the rim of the ventricular septum. Additional felted mattress sutures are placed superficially in the tissue beneath the coronary sinus. These sutures are in the region of the His' bundle and are tied after the aortic cross-clamp is removed and the heart is beating in sinus rhythm. If the His' bundle is damaged by these sutures, heart block will occur when they are tied. In this event, the sutures are removed and placed again.

knitted Dacron patch felted mattress sutures in ventricular septum region of His' bundle

Figure 4-25. A knitted Dacron® patch is cut to conform to the size and shape of the VSD and primum ASD. Stitches previously placed in the upper rim of the ventricular septum are placed in the lower rim of the Dacron® patch and tied. The most posterior ventricular septal defect stitches are near the His' bundle and should be placed slightly remote from the rim of the ventricular septum. Additional felted mattress sutures are placed superficially in the tissue beneath the coronary sinus. These sutures are in the region of the His' bundle and are tied after the aortic cross-clamp is removed and the heart is beating in sinus rhythm. If the His' bundle is damaged by these sutures, heart block will occur when they are tied. In this event, the sutures are removed and placed again.

caud sutures beneath coronary sinus

Dacron Patch Asd

reconstructed anterior mitral leaflet ventricular septal defect closed by lower part of Dacron patch stitches beneath coronary sinus

Figure 4-26. The Dacron® patch is retracted anteriorly to expose the ventricular septal defect beneath the new anterior mitral leaflet. Felted mattress sutures will be placed in the base of this leaflet near the Dacron® patch. Chordae of this leaflet are left intact. The sutures will be passed through the Dacron® patch at an appropriate level on the patch to mimic the position of the mitral leaflet in its natural position during ventricular systole. Care must be exercised to avoid positioning the leaflet too far cephalad on the patch, which might result in a tented and immobile leaflet. It is better to err on the side of attaching the leaflet nearer the ventricular septum. These valve-fixing sutures can also be passed through the adjacent tricuspid leaflets on the right ventricular surface of the patch.

reconstructed anterior mitral leaflet ventricular septal defect closed by lower part of Dacron patch stitches beneath coronary sinus caud

Cardio Patch Dacron

retracted

Dacron patch stitches beneath coronary sinus

Figure 4-27. The new anterior mitral leaflet is attached to the Dacron® patch by felted mattress sutures that have been tied.

mitral leaflet attached to patch by felted mattress sutures retracted

Dacron patch

Figure 4-27. The new anterior mitral leaflet is attached to the Dacron® patch by felted mattress sutures that have been tied.

caud stitches beneath coronary sinus

Tricuspid Valve Anterior Leaflet

tricuspid valve leaflet attached to Dacron patch stitches beneath coronary sinus

Figure 4-28. The right atrial surface of the patch is seen. Mitral valve sutures passed through the patch have also passed through the tricuspid valve leaflets, and the stitches are tied. Stitches beneath the coronary sinus are now passed through the adjacent patch and the aortic clamp is removed to commence rewarming. When conducted rhythm is observed, the coronary sinus stitches are tied. If the His' bundle is damaged when these stitches are tied, heart block is seen immediately. In that event offending sutures are removed and replaced.

tricuspid valve leaflet attached to Dacron patch

Figure 4-28. The right atrial surface of the patch is seen. Mitral valve sutures passed through the patch have also passed through the tricuspid valve leaflets, and the stitches are tied. Stitches beneath the coronary sinus are now passed through the adjacent patch and the aortic clamp is removed to commence rewarming. When conducted rhythm is observed, the coronary sinus stitches are tied. If the His' bundle is damaged when these stitches are tied, heart block is seen immediately. In that event offending sutures are removed and replaced.

stitches beneath coronary sinus

Primum Atrial Septal Defect

upper part of Dacron patch stitched over primum atrial septal defect ceph

caud

Figure 4-29. While rewarming continues, the upper part of the Dacron® patch is stitched to the atrial septum with a continuous suture. The right atriotomy is closed, and a left atrial pressure monitoring line is placed in the ventricular vent site near the right upper pulmonary vein shortly before discontinuing cardiopulmonary bypass.

Figure 4-29. While rewarming continues, the upper part of the Dacron® patch is stitched to the atrial septum with a continuous suture. The right atriotomy is closed, and a left atrial pressure monitoring line is placed in the ventricular vent site near the right upper pulmonary vein shortly before discontinuing cardiopulmonary bypass.

Dacron Patch Asd

Dacron patch closing atrial septal defect reconstructed tricuspid valve leaflets

Figure 4-30. In this child, 2.5 months after corrective surgery, the Dacron® patch is endothelialized, depicting the fate of the Dacron® material used in this repair.

Dacron patch closing atrial septal defect reconstructed tricuspid valve leaflets

Figure 4-30. In this child, 2.5 months after corrective surgery, the Dacron® patch is endothelialized, depicting the fate of the Dacron® material used in this repair.

4-4-2. Complete Atrio-Ventricular Canal: Double-Patch Repair

Currently this is my preferred repair. Iatric incisions in the bridging leaflets are avoided and there is less risk of valve repair breakdown following surgery. This is especially important because most AV repairs today are performed in young small infants with more fragile valvular tissue.

Figure 4-31. The exposure is through a right atriotomy after the infant is placed on cardiopulmonary bypass. The high VSD is in continuity with the low primum ASD. There is a single intracardiac AV valve comprised of common anterior and common posterior leaflets that span across the septal defects from left heart to right heart. Stay sutures have been placed in these valve leaflets for optimum exposure.

Primum Atrial Septal Defect

common anterior leaflet ventricular septal defect common posterior leaflet primum atrial septal defect

Figure 4-31. The exposure is through a right atriotomy after the infant is placed on cardiopulmonary bypass. The high VSD is in continuity with the low primum ASD. There is a single intracardiac AV valve comprised of common anterior and common posterior leaflets that span across the septal defects from left heart to right heart. Stay sutures have been placed in these valve leaflets for optimum exposure.

common anterior leaflet ventricular septal defect common posterior leaflet primum atrial septal defect

Complete Canal Leaflet Anatomy

common anterior leaflet chords at free margin of proposed new anterior mitral leaflet common posterior leaflet

Figure 4-32. The leaflets are carefully inspected and in most patients a fibrous rim of jet lesion demarks the point where the leaflets naturally come together during systole. This fibrous tissue is useful during the valve repair to close the new cleft because of its substance and ability to hold sutures. Both valve leaflets are inspected in order to identify the point where chordae attach to what will be the new free margin of the new anterior mitral leaflet. Great care is taken at this point in the operation to precisely define the point where the common anterior and common posterior leaflets will meet to form the new anterior mitral leaflet to avoid asymetric apposition. The surgeon can also inject saline under pressure in the ventricular chambers to open the valve leaflets to help identify the proper alignment for repair.

common anterior leaflet chords at free margin of proposed new anterior mitral leaflet common posterior leaflet

Figure 4-32. The leaflets are carefully inspected and in most patients a fibrous rim of jet lesion demarks the point where the leaflets naturally come together during systole. This fibrous tissue is useful during the valve repair to close the new cleft because of its substance and ability to hold sutures. Both valve leaflets are inspected in order to identify the point where chordae attach to what will be the new free margin of the new anterior mitral leaflet. Great care is taken at this point in the operation to precisely define the point where the common anterior and common posterior leaflets will meet to form the new anterior mitral leaflet to avoid asymetric apposition. The surgeon can also inject saline under pressure in the ventricular chambers to open the valve leaflets to help identify the proper alignment for repair.

Mitra Valve Leafs

common anterior leaflet marking stitch at free margin of new anterior mitral leaflet common posterior leaflet

Figure 4-33. When the point on the anterior and posterior leaflets near the left atrium and near the chordal insertions has been identified, a marking suture is placed to bring these points together. This posterior marking stitch is left in place during subsequent of the repair.

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Marking Stitch

marking stitch at free margin of new anterior mitral leaflet

Figure 4-34. Marking sutures are then placed at the more anterior extreme of the proposed anterior leaf mitral valve cleft and these are tied. These markers are left in place but do not impede exposure during the repair prior to cleft closure.

common anterior leaflet marking stitch at free margin of new anterior mitral leaflet caud marking stitches at base of new anterior mitral leaflet cleft marking stitch at free margin of new anterior mitral leaflet

Figure 4-33. When the point on the anterior and posterior leaflets near the left atrium and near the chordal insertions has been identified, a marking suture is placed to bring these points together. This posterior marking stitch is left in place during subsequent of the repair.

common posterior leaflet

Figure 4-34. Marking sutures are then placed at the more anterior extreme of the proposed anterior leaf mitral valve cleft and these are tied. These markers are left in place but do not impede exposure during the repair prior to cleft closure.

ceph j l

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Dacron Patch Closure Vsd

Dacron patch for VSD repair ventricular septal stitches

Figure 4-35. The felted mattress sutures are placed along the right ventricular surface of the upper margin of the ventricular septum adjacent to the ventricular septal defect. Posteriorly, these sutures are placed more superficially and somewhat remotely from the rim of the VSD in order to avoid the bundle of His' located in this region. Sutures are then passed through a knitted Dacron® patch that is cut to the size and shape of the VSD. Although the upper rim of the patch here is shown to be flat, that edge is often scalloped to allow a better fit for the new valve leaflets that will be attached here.

Dacron patch for VSD repair ventricular septal stitches ceph j l

caud

Figure 4-35. The felted mattress sutures are placed along the right ventricular surface of the upper margin of the ventricular septum adjacent to the ventricular septal defect. Posteriorly, these sutures are placed more superficially and somewhat remotely from the rim of the VSD in order to avoid the bundle of His' located in this region. Sutures are then passed through a knitted Dacron® patch that is cut to the size and shape of the VSD. Although the upper rim of the patch here is shown to be flat, that edge is often scalloped to allow a better fit for the new valve leaflets that will be attached here.

Intracardiac Repair For Vsd

stitches in upper rim of VSD patch

VSD repair patch

Figure 4-36. The VSD patch has been placed over the defect and the septal rim stitches tied. Nonfelted sutures are next passed through the upper rim of the patch. The size of the patch and the shape of the upper rim are such that after completing the repair the AV valve leaflets will rest on the patch in a position similar to that during end systole.

stitches in upper rim of VSD patch

VSD repair patch

Figure 4-36. The VSD patch has been placed over the defect and the septal rim stitches tied. Nonfelted sutures are next passed through the upper rim of the patch. The size of the patch and the shape of the upper rim are such that after completing the repair the AV valve leaflets will rest on the patch in a position similar to that during end systole.

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Diabetes And Kidney Disease

common anterior leaflet stitches passed through common anterior leaflet

VSD repair patch

Figure 4-37. The stitches in the upper rim of the VSD patch are passed through the common anterior and common posterior valve leaflets, respectively. The previously placed marking sutures indicate the line of these sutures so that the previously selected valve tissue can be placed appropriately on the mitral or tricuspid side of the patch. Generally, around two thirds of the undivided bridging leaflets are placed on the mitral valve side. If there is a natural division on the bridging leaflet, the transvalvular stitches can be placed in the base of the natural division of the leaflet.

caud common anterior leaflet stitches passed through common anterior leaflet

VSD repair patch

Figure 4-37. The stitches in the upper rim of the VSD patch are passed through the common anterior and common posterior valve leaflets, respectively. The previously placed marking sutures indicate the line of these sutures so that the previously selected valve tissue can be placed appropriately on the mitral or tricuspid side of the patch. Generally, around two thirds of the undivided bridging leaflets are placed on the mitral valve side. If there is a natural division on the bridging leaflet, the transvalvular stitches can be placed in the base of the natural division of the leaflet.

Vsd Patch Repair

VSD repair patch stitches repairing cleft in anterior mitral leaflet stitches through common posterior leaflet

Figure 4-38. Interrupted fine monofilament sutures are now used to close the cleft in the new anterior mitral leaflet. At this point the transvalvular stitches from the upper rim of the VSD patch are left untied. The new mitral valve orifice is measured carefully and the size compared with normal values in order to avoid excessive closure of the cleft and iatrogenic mitral stenosis.

VSD repair patch stitches repairing cleft in anterior mitral leaflet

Figure 4-38. Interrupted fine monofilament sutures are now used to close the cleft in the new anterior mitral leaflet. At this point the transvalvular stitches from the upper rim of the VSD patch are left untied. The new mitral valve orifice is measured carefully and the size compared with normal values in order to avoid excessive closure of the cleft and iatrogenic mitral stenosis.

stitches through common posterior leaflet

Atrial Septal Closure Patch

patch to close atrial septal defect

Figure 4-39. A second Dacron® patch is cut to conform to the size and shape of the primum ASD.

patch to close atrial septal defect

Figure 4-39. A second Dacron® patch is cut to conform to the size and shape of the primum ASD.

Primum Asd
Figure 4-40. The transvalvular stitches from the upper rim of the VSD patch are placed through the base of the ASD patch.
Pics Asd Repair Patch

ASD patch stitches beneath coronary sinus coronary sinus

Figure 4-41. The ASD patch has been lowered into position. Additional felted mattress sutures are placed superficially beneath the coronary sinus. If they can be placed toward the left atrium it is safer in order to avoid damage to the His' bundle which is in this region. The stitches are passed through the ASD patch. Next, the stitches along the base of the patch are tied leaving the few stitches beneath the coronary sinus untied. The aortic clamp is removed and rewarming is commenced. One must await the observation of sinus rhythm before proceeding. Only after observing sinus rhythm are the interrupted sutures near the coronary sinus tied. If they are too near the His' bundle, third-degree block will be observed immediately and the offending stitch is removed and replaced.

ASD patch stitches beneath coronary sinus caud

Figure 4-41. The ASD patch has been lowered into position. Additional felted mattress sutures are placed superficially beneath the coronary sinus. If they can be placed toward the left atrium it is safer in order to avoid damage to the His' bundle which is in this region. The stitches are passed through the ASD patch. Next, the stitches along the base of the patch are tied leaving the few stitches beneath the coronary sinus untied. The aortic clamp is removed and rewarming is commenced. One must await the observation of sinus rhythm before proceeding. Only after observing sinus rhythm are the interrupted sutures near the coronary sinus tied. If they are too near the His' bundle, third-degree block will be observed immediately and the offending stitch is removed and replaced.

coronary sinus

Asd Patch Repair

VSD repair patch

ASD repair patch

Figure 4-42. Stitches across the base of the ASD patch have been tied, as have the stitches beneath the coronary sinus. The upper rim of the patch is attached to the atrial septum with a continuous suture to complete the repair. A left atrial line is left through the ventricular vent site near the right upper pulmonary vein.

VSD repair patch

ASD repair patch

4-4-3. Complete Atrio-Ventricular Canal: Modified Single-Patch Repair

The concept of this complete AV canal repair includes obliteration of the VSD by attaching the AV valve leaflets directly to the top of the ventricular septum avoiding the need for placement of a patch beneath the AV valves. In theory this can be performed more rapidly than other repairs because the placement of the VSD patch is omitted. An additional advantage is avoiding a surgical incision in AV valve tissue (as in the standard one-patch technique), which is especially applicable in the small infant who may have fragile valve tissue. Of course, the same technique is also used in the classic two-patch repair. My bias is for use of the modified single-patch repair only in patients who have a very shallow VSD. Otherwise, the AV valve leaflets may be distorted by attaching them in an unnatural position to the top of the ventricular septum which may result in significant residual mitral regurgitation.

This operation is performed with moderate systemic hypothermia, aortic cross-clamping, cardioplegia, and profound local cardiac cooling.

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Tenting Mitral Valve

common anterior leaflet marking stitch in mitral valve cleft near free margin marking stitch in mitral valve cleft near ventricular septum common posterior leaflet

Figure 4-43. The child has been placed on cardiopulmonary bypass and cardioplegia delivered after applying the aortic cross-clamp. A right atriotomy is made. Initially the common anterior leaf and common posterior leaf are carefully evaluated to determine the appropriate position of the new cleft in the proposed new anterior mitral valve leaf. The first marking stitch is placed between the common anterior and common posterior leafs, respectively, near the free margin of each leaflet. The location of the new free margin can usually be identified by insertion of chords at this point. The proposed cleft in the new anterior mitral valve leaf is identified and appropriate marking stitches placed at the septal end of this cleft.

common anterior leaflet marking stitch in mitral valve cleft near free margin marking stitch in mitral valve cleft near ventricular septum caud

Figure 4-43. The child has been placed on cardiopulmonary bypass and cardioplegia delivered after applying the aortic cross-clamp. A right atriotomy is made. Initially the common anterior leaf and common posterior leaf are carefully evaluated to determine the appropriate position of the new cleft in the proposed new anterior mitral valve leaf. The first marking stitch is placed between the common anterior and common posterior leafs, respectively, near the free margin of each leaflet. The location of the new free margin can usually be identified by insertion of chords at this point. The proposed cleft in the new anterior mitral valve leaf is identified and appropriate marking stitches placed at the septal end of this cleft.

common posterior leaflet

Ventricular Septum Divisions

common anterior leaflet natural division in leaflet marking stitches in cleft near ventricular septum common posterior leaflet primum ASD rim

Figure 4-44. In this child, there is a natural division in the common anterior leaf. In order to enlarge the new mitral valve leaflet, this natural division will be closed so that the common anterior leaf can be divided by sutures nearer the tricuspid orifice.

common anterior leaflet natural division in leaflet marking stitches in cleft near ventricular septum

Figure 4-44. In this child, there is a natural division in the common anterior leaf. In order to enlarge the new mitral valve leaflet, this natural division will be closed so that the common anterior leaf can be divided by sutures nearer the tricuspid orifice.

caud common posterior leaflet primum ASD rim ceph R^L

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Pulmonary Vein Atrium Ventricle

felted stitches in ventricular septum for VSD repair shallow VSD

Figure 4-45. Felted mattress sutures are placed across the top of the ventricular septum on the right ventricular surface for the VSD repair. In this case, the VSD is shallow so that distortion of the valve should be minimal when these stitches are tied.

felted stitches in ventricular septum for VSD repair

Figure 4-45. Felted mattress sutures are placed across the top of the ventricular septum on the right ventricular surface for the VSD repair. In this case, the VSD is shallow so that distortion of the valve should be minimal when these stitches are tied.

ceph R^L

caud shallow VSD

Continuous Stitch Vsd Surgery

Figure 4-46. The VSD repair stitches have been passed through the AV valve leaflets in order to separate them into tricuspid and mitral components.

VSD repair stitches passed through

AV valve leaflets

Figure 4-46. The VSD repair stitches have been passed through the AV valve leaflets in order to separate them into tricuspid and mitral components.

Mitral Valve Cleft

natural division in common anterior leaflet marker stitches in cleft prim um ASD

Figure 4-47. The natural division in the common anterior leaf and the new cleft in the new anterior mitral leaf are exposed. The original marking sutures are used to align the leaflets properly.

natural division in common anterior leaflet marker stitches in cleft

Figure 4-47. The natural division in the common anterior leaf and the new cleft in the new anterior mitral leaf are exposed. The original marking sutures are used to align the leaflets properly.

prim um ASD

Anterior Mitral Leaflet Cleft

stitches closing natural division in common anterior leaflet cleft repair stitches

VSD repair stitches passed through A-V valve leaflets

Figure 4-48. Multiple simple sutures of fine polypropylene are placed to close the natural division in the common anterior leaflet and also to close the cleft in the new anterior mitral leaflet.

stitches closing natural division in common anterior leaflet cleft repair stitches

Figure 4-48. Multiple simple sutures of fine polypropylene are placed to close the natural division in the common anterior leaflet and also to close the cleft in the new anterior mitral leaflet.

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VSD repair stitches passed through A-V valve leaflets

Stitch Close Vsd

primum ASD

stitches beneath coronary sinus

Figure 4-49. Felted mattress sutures are placed beneath the coronary sinus for use in the ASD repair. These stitches are superficial and on the left atrial surface of atrial wall beneath the coronary sinus. Some of these stitches are placed in the annulus of the mitral valve because this is always remote from the His' bundle.

primum ASD

stitches beneath coronary sinus

Figure 4-49. Felted mattress sutures are placed beneath the coronary sinus for use in the ASD repair. These stitches are superficial and on the left atrial surface of atrial wall beneath the coronary sinus. Some of these stitches are placed in the annulus of the mitral valve because this is always remote from the His' bundle.

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Vsd And His Bundle

felted VSD

repair stitches

Figure 4-50. A patch cut to the size of the ASD is placed in the wound and the VSD repair sutures that pass through the AV valve leaflet tissue are now placed in this patch.

felted VSD

repair stitches caud

Figure 4-50. A patch cut to the size of the ASD is placed in the wound and the VSD repair sutures that pass through the AV valve leaflet tissue are now placed in this patch.

Dacron Vsd Repair

Figure 4-51. Stitches in the base of the Dacron® patch which pass through the AV valve leaflets are tied. With such the VSD is obliterated.

VSD repair stitches

Figure 4-51. Stitches in the base of the Dacron® patch which pass through the AV valve leaflets are tied. With such the VSD is obliterated.

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Asdvsd Patch Repair Operation

repaired division in common anterior leaf repaired anterior mi trat valve teaflet

ASD patch stitches beneath coronary sinus

Figure 4-52. Stitches placed beneath the coronary sinus are exposed and now these stitches will be placed in the Dacron® patch. The mitral valve cleft repair sutures are seen, as are the sutures that close the natural division in the common anterior leaf.

repaired division in common anterior leaf repaired anterior mi trat valve teaflet

ASD patch caud

Figure 4-52. Stitches placed beneath the coronary sinus are exposed and now these stitches will be placed in the Dacron® patch. The mitral valve cleft repair sutures are seen, as are the sutures that close the natural division in the common anterior leaf.

stitches beneath coronary sinus r ; if-(fx •

It / f felted stitches In upper rim of ventricular septum

Dacron patch on top of AV valves ceph caud stitches beneath coronary sinus

Figure 4-53. The ASD patch is in position and the stitches beneath the coronary sinus are placed in the Dacron® patch. The aortic cross-clamp is now removed and rewarming is commenced. Cardiac rhythm may initially be abnormal but usually complete heart block will then convert to sinus rhythm. While observing sinus rhythm, the coronary sinus stitches are tied. If they have injured the His' bundle, heart block will be seen immediately as they are tied. If such occurs the offending stitch is removed and replaced. Tying these sutures with a beating heart is safe because atrial tissue is not dynamic in contradistinction to tying ventricular septal stitches, which is almost always done with cardiac standstill.

Ventricular Standstill

Figure 4-54. To complete the repair, the upper rim of the Dacron® patch is attached to the atrial septum with a continuous suture. A left atrial line is left through the ventricular vent site near the right upper pulmonary vein.

ASD patch

Figure 4-54. To complete the repair, the upper rim of the Dacron® patch is attached to the atrial septum with a continuous suture. A left atrial line is left through the ventricular vent site near the right upper pulmonary vein.

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