Perimembranous Ventricular Septal Defect

I prefer the transatrial approach to repair membranous VSD. There is usually excellent exposure of the entire defect, especially along the inferior and posterior rims, where conductive tissue is located.

Figure 5-1. The child has been placed on cardiopulmonary bypass and systemically cooled. The aorta is clamped and cardioplegia solution is infused. A right atriotomy is made, and the perimembranous VSD is exposed by retracting the tricuspid valve leaflets. To stabilize the exposure, stay sutures are placed in the atrial wall at the atriotomy and in the anterior and septal leaflets of the tricuspid valve.

Tricuspid Valve Leaflets

anterior tricuspid valve leaflet caud

Figure 5-1. The child has been placed on cardiopulmonary bypass and systemically cooled. The aorta is clamped and cardioplegia solution is infused. A right atriotomy is made, and the perimembranous VSD is exposed by retracting the tricuspid valve leaflets. To stabilize the exposure, stay sutures are placed in the atrial wall at the atriotomy and in the anterior and septal leaflets of the tricuspid valve.

anterior tricuspid valve leaflet ventricular septal defect septal tricuspid valve leaflet caud

Defect Septal Interventricular

ventricular septal defect septal leaflet of tricuspid valve anterior tricuspid valve leaflet attached to posterior rim of VSD

ventricular septal defect septal leaflet of tricuspid valve caud

Figure 5-2. Multiple interrupted multifilament mattress sutures with Teflon® felt pledgets are placed around the rim of the ventricular septal defect. When the septal tricuspid valve leaflet is attached to the margin of the VSD along the posterior and inferior rim of the defect, sutures are passed through the base of this leaflet to avoid conductive tissue. If there is no septal leaf attachment here, sutures are placed superficially and directly in the rim of the VSD rather than in septal tissue remote from the VSD rim. More anteriorly, along the inferior margin of the VSD, stitches are placed near the margin of the VSD in muscular septum. Generally, these stitches are placed through 25% of the thickness of the septum. Along the anterior margin of the VSD, stitches are placed in about 50% of the thickness of the septum on the right ventricular surface. Stitches along the cephalad rim of the ventricular septal defect are placed similarly, or they can be placed in the base of the anterior tricuspid valve leaflet when the latter is attached to this rim of the VSD. Care must be exercised to avoid injury to aortic valve cusps that are located in this area. The posterior margin of the VSD is usually in continuity with the base of the anterior tricuspid valve leaflet. Stitches here are passed through the base of this leaflet near the annulus.

Tricuspid Valve Anterior Leaflet

Figure 5-3. In some patients a fibrous remnant of the membranous septum is present in the posterior inferior corner of the VSD. When present, the corner stitch is placed in this remnant that is adjacent to but separate from the His' bundle.

fibrous remnant of membranous septum in posterior inferior corner

Figure 5-3. In some patients a fibrous remnant of the membranous septum is present in the posterior inferior corner of the VSD. When present, the corner stitch is placed in this remnant that is adjacent to but separate from the His' bundle.

Perimembranous Ventricular Septal Defect

anterior tricuspid valve leaflet attached to VSD posterior rim

Figure 5-4. The anterior tricuspid valve leaflet is attached to the posterior rim of the VSD. A small probe can identify the base of the leaflet near the annulus to identify the precise location for placement of the stitches.

anterior tricuspid valve leaflet attached to VSD posterior rim

Figure 5-4. The anterior tricuspid valve leaflet is attached to the posterior rim of the VSD. A small probe can identify the base of the leaflet near the annulus to identify the precise location for placement of the stitches.

aortic valve cusp adjacent to cephalad margin of VSD

Figure 5-5. The cephalad margin of the VSD is adjacent to the aortic valve. The aortic valve annulus is identified so that stitches can be placed in this structure or in adjacent right ventricular muscle and avoid damage to the aortic valve cusps. To identify the cusps, the aortic valve is observed in the closed position while cardioplegia solution is infused in the aortic root.

Perimembranous Vsd

anterior leaflet septal leaflet

Figure 5-6.

Stitches have been placed circumferentially in the rim of the VSD.

anterior leaflet septal leaflet

Figure 5-6.

Stitches have been placed circumferentially in the rim of the VSD.

Perimembranous Ventricular Septal Defect
Figure 5-7. Stitches are placed in a knitted Dacron® patch which is cut to conform to the size and shape of the VSD.
Vsd Closure

Dacron patch

Figure 5-8. Repair stitches placed in a Dacron® patch are tied. The integrity of the closure is checked with a 1-mm probe that is used to gently probe beneath the patch. Residual openings can usually be found and closed at this point in the operation.

Dacron patch

Figure 5-8. Repair stitches placed in a Dacron® patch are tied. The integrity of the closure is checked with a 1-mm probe that is used to gently probe beneath the patch. Residual openings can usually be found and closed at this point in the operation.

Figure 5-9. In another patient who was re-explored 7 years after VSD repair, the totally endothelialized patch is invisible beneath endocardial tissue, as seen through a right atriotomy.

Was this article helpful?

0 0
Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

Get My Free Ebook


Post a comment