Obstruction of Bulboventricular Foramen

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 is resected and/or septal tissue is removed to enlarge the bulboventricular foramen.

Damus Procedure
ascending aorta
What Bulboventricular Foramen

restrictive bulboventricular foramen post

Figure 6-45. This lateral view of a single ventricular injection shows the restrictive bulboventricular foramen that separates the ventricle from the subaortic chamber.

restrictive bulboventricular foramen post

Figure 6-45. This lateral view of a single ventricular injection shows the restrictive bulboventricular foramen that separates the ventricle from the subaortic chamber.

6-2-1. Damus Procedure caud

Pulmonary Artery Banding Surgery

Figure 6-46- The great vessels are transposed with an anterior ascending aorta and a posterior main pulmonary artery. The pulmonary artery band constricts the mid main pulmonary artery.

ascending aorta pulmonary artery banc caud

Figure 6-46- The great vessels are transposed with an anterior ascending aorta and a posterior main pulmonary artery. The pulmonary artery band constricts the mid main pulmonary artery.

Bulboventricular Foramen
Figure 6-47. Cardiopulmonary bypass is established, and the aorta is clamped. Profound local cardiac cooling and cardioplegia are used. The main pulmonary artery and its branches are dissected; the vessel is divided at the pulmonary artery band, and the band is removed.

caud

ascending aortotomy longitudina incision proximal main pulmonary artery

Figure 6-48. A longitudinal incision is made in the proximal main pulmonary artery segment to near the annulus and adjacent to the ascending aorta. The ascending aorta is opened proximally and then to a point more distal than the pulmonary artery segment.

ascending aortotomy longitudina incision

Figure 6-48. A longitudinal incision is made in the proximal main pulmonary artery segment to near the annulus and adjacent to the ascending aorta. The ascending aorta is opened proximally and then to a point more distal than the pulmonary artery segment.

caud proximal main pulmonary artery

Bulboventricular Foramen

ascending aorta

Gore-Tex hood ascending aorta

Gore-Tex hood proximal main pulmonary artery

Figure 6-49. A side-to-side anastomosis is constructed between the posterior margin of the proximal aortotomy and the proximal pulmonary arterotomy. A triangular shaped Gore-Tex® hood is stitched over the distal end of the main pulmonary artery segment and then attached to the distal aortotomy.

ceph i proximal main pulmonary artery

Figure 6-49. A side-to-side anastomosis is constructed between the posterior margin of the proximal aortotomy and the proximal pulmonary arterotomy. A triangular shaped Gore-Tex® hood is stitched over the distal end of the main pulmonary artery segment and then attached to the distal aortotomy.

caud

Proximal Pulmonary Artery

Gore-Tex hood

[ongitudina stitch transverse stitch

Figure 6-50. The anterior rim of the aortotomy is stitched to the anterior rim of the pulmonary artery to complete the repair.

Gore-Tex hood

[ongitudina stitch

Figure 6-50. The anterior rim of the aortotomy is stitched to the anterior rim of the pulmonary artery to complete the repair.

caud transverse stitch

6-2-2. Enlargement of Bulboventricular Foramen by Resection of Septal Tissue

This is an alternative technique to relieve ventricular outlet obstruction in patients with a single ventricle. A complication of this procedure is complete heart block caused by injury to conduction tissue during septal resection. In patients with d-looping, the His' bundle is located in septal tissue along the right and caudal margin of the bulboventricular foramen. In patients with 1-looping, the His' bundle is normally found along the cephalad and left margin of the bulboventricular foramen. Resection is carried out in the obstructing septum on the border of the foramen remote from conductive tissue.

Procedures are performed using cardiopulmonary bypass. In small infants, adequate exposure may be gained working through a small incision in the ventricular wall of the subaortic outflow chamber. The ventriculotomy is remote from the systemic ventricle and should not adversely affect ventricular performance. In older children, resection of septal tissue can be easily performed through a proximal ascending aortotomy while retracting the aortic valve or a right atriotomy while retracting the AV valve. It is useful to pass a large nerve hook or a right-angle clamp into the bulboventricular foramen for retraction, facilitating exposure of the area to be resected.

Bulboventricular Foramen

ascending aorta restrictive bulboventricular foramen ascending aorta restrictive bulboventricular foramen ceph

Bulboventricular Foramen

ventriculotomy

Figure 6-51. After placing the infant cardiopulmonary bypass with aortic cross-clamping and cardioplegic arrest, a short incision is made in the anterior wall of the subaortic chamber. In some cases it may be difficult to define the best location for the ventriculotomy. In this case, an aortotomy is made and a small clamp is passed into the subaortic chamber, pressing it against the anterior wall so the precise location for the ventriculotomy can be determined. The restrictive bulboventricular foramen is seen. Conductive tissue is near the right border of the bulboventricular foramen, and the area of resection is identified to the infant's left.

ceph

\ r caud ventriculotomy

Figure 6-51. After placing the infant cardiopulmonary bypass with aortic cross-clamping and cardioplegic arrest, a short incision is made in the anterior wall of the subaortic chamber. In some cases it may be difficult to define the best location for the ventriculotomy. In this case, an aortotomy is made and a small clamp is passed into the subaortic chamber, pressing it against the anterior wall so the precise location for the ventriculotomy can be determined. The restrictive bulboventricular foramen is seen. Conductive tissue is near the right border of the bulboventricular foramen, and the area of resection is identified to the infant's left.

Bulboventricular Foramen

Figure 6-52. The enlarged bulboventricular foramen is seen after resection of leftward septal tissue. The ventriculotomy is usually closed primarily. If the chamber is restrictive, muscle can be resected anteriorly in the subaortic area and the chamber can be enlarged by closing the ventriculotomy with an augmenting patch.

enlarged bulboventricular foramen

Figure 6-52. The enlarged bulboventricular foramen is seen after resection of leftward septal tissue. The ventriculotomy is usually closed primarily. If the chamber is restrictive, muscle can be resected anteriorly in the subaortic area and the chamber can be enlarged by closing the ventriculotomy with an augmenting patch.

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Responses

  • Tom
    What is Bulboventricular foramen obstruction?
    4 years ago
  • uwe maurer
    What is a Restrictive bulboventricular foramen?
    4 years ago
  • Osman Girma
    Where is the bulboventricular foramen located?
    3 years ago
  • asphodel burrows
    What is a Nonrestrictive bulboventricular foramen?
    1 year ago
  • abdul
    What happens with narrowing of the bulboventricular foramen?
    1 year ago

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